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4AT
The 4 'A's Test (4AT) is a bedside medical scale used to help determine if a person has positive signs for delirium. The 4AT also includes cognitive test items, making it suitable also for use as a rapid test for cognitive impairment. A 2025 study using large scale routine clinical data reported that 4AT scores were associated with dementia as well as delirium.
The 4AT is designed to be used as a delirium detection tool in general clinical settings, inpatient hospital settings outside of the Intensive Care Unit (ICU), or in the community. The 4AT is intended to be used by healthcare practitioners without the need for special training, and it takes around two minutes to complete. The test was first published online in 2011.
The 4AT has 32 published formal validation diagnostic test accuracy studies involving >6000 patients. It has been evaluated in several areas of practice including in the emergency department (ED), medical, surgical, community and palliative care settings. The 4AT is used internationally in both clinical practice and research. It is included in clinical guidelines, including the UK NICE Guidelines on Delirium, and policy documents. The 4AT is used as a tool for delirium and cognitive assessment in hip fracture registries.
Some evidence shows that the 4AT can be implemented at scale in real-world clinical practice and that it shows positive score rates at comparable levels to the expected delirium prevalence rates.
A 2022 two-center study in real-world clinical populations (total N=82,770) found that 4AT positive scores were aligned with expected delirium rates, and also were linked with important outcomes including 30-day mortality, one-year mortality, hospital length of stay, and days at home in the year following hospital admission. Notably, the 4AT was completed as part of usual care by a large number of different staff (mostly doctors and nurses) who had not received special training in use of the 4AT. This study therefore showed that the 4AT is feasible in large-scale practice and that it provides real-time delirium ascertainment with positive scores being linked to important short and longer-term outcomes.
The 4AT has 4 parameters:
The score range is 0–12, with scores of 4 or more suggesting possible delirium. Scores of 1-3 suggest possible cognitive impairment.
There are several indications of a positive score of 4 or more. Parameters [1] and [4] can each individually trigger a positive score. The rationale is that both altered arousal and acute change in mental functioning are highly specific indicators of delirium.
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4AT
The 4 'A's Test (4AT) is a bedside medical scale used to help determine if a person has positive signs for delirium. The 4AT also includes cognitive test items, making it suitable also for use as a rapid test for cognitive impairment. A 2025 study using large scale routine clinical data reported that 4AT scores were associated with dementia as well as delirium.
The 4AT is designed to be used as a delirium detection tool in general clinical settings, inpatient hospital settings outside of the Intensive Care Unit (ICU), or in the community. The 4AT is intended to be used by healthcare practitioners without the need for special training, and it takes around two minutes to complete. The test was first published online in 2011.
The 4AT has 32 published formal validation diagnostic test accuracy studies involving >6000 patients. It has been evaluated in several areas of practice including in the emergency department (ED), medical, surgical, community and palliative care settings. The 4AT is used internationally in both clinical practice and research. It is included in clinical guidelines, including the UK NICE Guidelines on Delirium, and policy documents. The 4AT is used as a tool for delirium and cognitive assessment in hip fracture registries.
Some evidence shows that the 4AT can be implemented at scale in real-world clinical practice and that it shows positive score rates at comparable levels to the expected delirium prevalence rates.
A 2022 two-center study in real-world clinical populations (total N=82,770) found that 4AT positive scores were aligned with expected delirium rates, and also were linked with important outcomes including 30-day mortality, one-year mortality, hospital length of stay, and days at home in the year following hospital admission. Notably, the 4AT was completed as part of usual care by a large number of different staff (mostly doctors and nurses) who had not received special training in use of the 4AT. This study therefore showed that the 4AT is feasible in large-scale practice and that it provides real-time delirium ascertainment with positive scores being linked to important short and longer-term outcomes.
The 4AT has 4 parameters:
The score range is 0–12, with scores of 4 or more suggesting possible delirium. Scores of 1-3 suggest possible cognitive impairment.
There are several indications of a positive score of 4 or more. Parameters [1] and [4] can each individually trigger a positive score. The rationale is that both altered arousal and acute change in mental functioning are highly specific indicators of delirium.