Talk:4AT

Reviewer Note

This is a type of conflict of interest that does not pose a danger to the integrity of the encyclopedia, and which should be accepted if the subject is notable. Robert McClenon (talk) 02:32, 16 May 2020 (UTC)

Regarding "This article may require copy editing for grammar, style, cohesion, tone, or spelling. (May 2020)" - can a more experienced editor advise on this?

Regarding "This article needs more links to other articles to help integrate it into the encyclopedia. (May 2020)" - the article now has a lot of links, and hard to see that many more could be added. — Preceding unsigned comment added by Avoreardon (talk • contribs) 07:21, 6 June 2020 (UTC)

COI edit request: source-led citation cleanup

Conflict-of-interest disclosure: I am Professor Alasdair MacLullich. I was involved in developing the 4AT, I am an author on some of the papers cited in this article, and I am connected with the official 4AT website. I am therefore not editing the article directly and ask an independent editor to assess this proposal under WP:COI and WP:MEDRS. I have no request that any source be retained merely because I authored it.

The article has carried an excessive-citations banner since July 2025. I do not think the banner should simply be removed. I have prepared a source-by-source cleanup proposal against revision 1356896714 and would be grateful if an independent editor could check and implement only the parts they consider appropriate.

The main proposed changes are:

1. remove the indirect SymptomFind citation and replace citation piles with systematic reviews and current national guidance;
2. merge duplicate source definitions (current refs 4/32, 5/45, 8/44 and 46/54);
3. retain the official 4AT site only for the form, scoring and translations, not as the principal source for biomedical recommendations;
4. replace the dynamic “32 studies/>6000 patients” claim with the 2020 systematic review and NICE's 2023 independent evidence review;
5. replace the six-study post-2019 validation pile with the NICE evidence review;
6. rewrite “Recommended use” to follow current NICE recommendations and the revised Australian Delirium Clinical Care Standard, removing the self-published Delirium Words citations and the unsupported “1–2 times per day” rule;
7. fix or remove the malformed `localhost:25512` URL in the current Korte citation; and
8. keep uniquely informative primary findings only with explicit single-study attribution (hospice validation, 82,770-admission outcomes, dementia association and recovery assessment).

Suggested high-level wording is set out below. The principal independent sources are:

• NICE CG103 recommendations 1.6.1–1.6.2: https://www.nice.org.uk/guidance/cg103/chapter/Recommendations#assessment-and-diagnosis
• NICE 2023 evidence review A: https://www.nice.org.uk/guidance/cg103/evidence/a-diagnostic-accuracy-of-tests-to-identify-delirium-pdf-11320715486
• Australian Delirium Clinical Care Standard (revised 2021): https://www.safetyandquality.gov.au/clinical-care-standards/delirium
• Tieges et al. systematic review/meta-analysis: https://doi.org/10.1093/ageing/afaa224
• Calf et al. systematic review/meta-analysis: https://doi.org/10.1093/ageing/afaa183
• Penfold et al. routine-practice systematic review: https://doi.org/10.1111/jgs.18751

1. Lead

The 4 'A's Test (4AT) is a brief bedside assessment used to identify possible delirium. It combines assessment of alertness and recent change or fluctuation with short tests of orientation and attention. The cognitive items mean that scores may also indicate cognitive impairment, although a positive 4AT result is not by itself a clinical diagnosis.

2. Description

The 4AT was first published online in 2011 and is designed for rapid use by healthcare practitioners in general hospital and community settings without special training. It is not the tool recommended by NICE for critical care or the recovery room after surgery. Systematic reviews and national evidence reviews have evaluated the 4AT across emergency, medical, surgical, stroke and long-term-care settings. A 2024 validation study also evaluated it in hospice inpatients. NICE recommends a 4AT assessment when indicators of delirium are identified, while the revised Australian Delirium Clinical Care Standard includes it among validated assessment tools. A 2025 scoping review found that national hip-fracture registries use delirium and cognitive assessments including the 4AT.

2. Description — real-world implementation

A 2024 systematic review found that delirium-detection tools, including the 4AT, had varying completion and positive-score rates when implemented in routine hospital practice. In a two-centre observational study of 82,770 emergency admissions, positive 4AT scores were associated with mortality, length of stay and days at home after admission.

3. Parameters

The total score ranges from 0 to 12. A score of 4 or more indicates possible delirium, while a score of 1–3 may indicate cognitive impairment. Altered alertness and acute or fluctuating change are central features in delirium assessment, which is why either of those 4AT items can by itself produce a score of 4. The cognitive items include an “untestable” option so the assessment can still be completed when verbal testing is not possible.

4. Psychometric properties

A 2020 systematic review and meta-analysis of 17 studies reported pooled sensitivity and specificity of 88% for delirium detection. NICE's 2023 evidence review, drawing on six reviews and 19 primary studies, reported median sensitivity of 87% and specificity of 88% and considered the evidence sufficient to recommend the 4AT when indicators of delirium are present. A multicentre prospective comparative diagnostic test-accuracy study found higher sensitivity and similar specificity for the 4AT compared with the Confusion Assessment Method. Large routine-data studies have also reported associations between 4AT score bands, later recorded dementia and adverse hospital outcomes; these observational associations do not establish causation.

5. Recommended use

NICE recommends using the 4AT when indicators of delirium are identified; in critical care or the recovery room after surgery it recommends CAM-ICU or ICDSC instead. If the assessment indicates delirium, a healthcare professional with relevant expertise should make the final diagnosis. A 2025 validation study reported that the 4AT can also be used to assess recovery from active delirium. The Australian Delirium Clinical Care Standard notes that some delirium assessment tools are not appropriate for repeated monitoring and lists DOS, RADAR, mRASS, SQiD and Nu-DESC as options for monitoring incident delirium.

5. Recommended use — comparison

The 4AT is one of several delirium-assessment tools, which differ in purpose, administration time, training requirements and diagnostic performance.

6. Languages

The official 4AT site provides translated versions of the instrument in multiple languages.

Please feel free to reject, modify or further reduce the proposed text and sources. In particular, I would welcome an independent judgment on whether the palliative-care, dementia-association and recovery studies add enough distinct encyclopaedic value to retain. I suggest leaving the maintenance banner in place until an uninvolved editor has completed the cleanup and reviewed the result. Avoreardon (talk) 14:21, 22 July 2026 (UTC)

AI-assistance disclosure: I used OpenAI Codex, a large language model, to help organise and draft this request from the source review. I authorised its submission. The request reflects the changes I am asking independent editors to consider; I ask editors to verify the cited sources and decide independently what, if anything, should be implemented. Avoreardon (talk) 15:20, 22 July 2026 (UTC)