The use of the 4AT for patients admitted to older adult wards

Introduction

Delirium is an acute, fluctuating syndrome causing disturbances in consciousness, attention, and cognition. It is common in older adults and associated with significant healthcare costs. The 4AT is an internationally recognised screen for delirium. The AMT-10 test is commonly used to assess cognition, however, does not account for fluctuating cognition, seen in delirium. The aim is to assess how often we are completing 4AT screens at identifiable checkpoints during admission.

Methods

A quality improvement project was conducted on a 22-bed older adult ward. 4AT and AMT-10 use at clerking and during inpatient stay was reviewed from clinical noting. Two PDSA (plan, do, study, act) cycles were undertaken. The interventions were: a teaching session to doctors about delirium and the 4AT; and empowering nursing staff to complete 4AT screens for new confusion. An initial grouping of confusion/delirium and 4AT/AMT-10 was refined to separate categories.

Results

At baseline, 15/22 patients had confusion or delirium; 40% received either 4AT or AMT‑10 (26.7% at clerking; 26.7% on ward). After the first intervention, 4AT use was 7% and 0% respectively, while AMT‑10 was 14% during clerking and 36% on the ward. After the second intervention, 4AT remained unchanged; AMT‑10 was 21% during clerking and 57% on the ward.

Conclusion

The interventions did not improve 4AT completion rates. Contributing factors likely included delirium being documented in the clerking impression - reducing perceived requirement for a 4AT; limited screening opportunities due to diverse presentations; and time pressures on the ward.

Barriers to 4AT use, particularly among nursing staff who often detect early behavioural changes, require further exploration. Further education is needed to embed delirium screening into routine practice and reinforce that the 4AT is the appropriate tool for acute confusion.