UMEM Educational Pearls


A recent study was undertaken to validate the 4A's Test for the assessment of delirium in the elderly, with particular focus on inpatient geriatric patients; it revealed that the tool had high sensitivity in detecting delirium, particularly in those with dementia or language barriers, in whom this diagnosis can often be difficult to make.  Further studies would be useful in a similar demographic of emergency department geriatric patients to confirm that this straightforward test is generalizable to the emergency department geriatric patient population.


The 4A’s Test used for this study was accessed from (Free Access).

The 4AT consists of four items with a maximum achievable score of 12. 

Item 1 determines patient’s level of alertness by operator observation (maximum score 4). 

Items 2 and 3 screen cognition and attention with the use of the Abbreviated Mental Test-4 (AMT-4) (maximum score 2) and Months Backwards (maximum score 2).

Item 4 assesses for ?uctuation and acute changes in mental state (score 0 or 4).

A score of 0 indicates delirium or cognitive impairment is unlikely.

A score between 1 and 3 indicates possible cognitive impairment (corresponding to stand alone dementia screening tools).

A score of 4 and above is suggestive of delirium.


De J, Wand AFP, Smerdely PI, Hunt GE. Validating the 4A’s test in screening for delirium in a culturally diverse geriatric inpatient population. International Journal of Geriatric Psychiatry. 2017 Dec, 32(12): 1322-1329. doi: 10.1002/gps.4615.