Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and home time: two-centre study of 82,770 emergency admissions

Abstract

Background Studies investigating outcomes of delirium using large-scale routine data are rare. We performed a two-centre study using the 4 ‘A’s Test (4AT) delirium detection tool to analyse relationships between delirium and 30-day mortality, length of stay and home time (days at home in the year following admission). Methods The 4AT was performed as part of usual care. Data from emergency admissions in patients ≥65 years in Lothian, UK (n = 43,946) and Salford, UK (n = 38,824) over a period of $\sim$3 years were analysed using logistic regression models adjusted for age and sex. Results 4AT completion rates were 77% in Lothian and 49% in Salford. 4AT scores indicating delirium (≥4/12) were present in 18% of patients in Lothian, and 25% of patients in Salford. Thirty-day mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0/12 group in Lothian (adjusted odds ratio (aOR) 5.53, 95% confidence interval [CI] 4.99–6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98–3.87). Length of stay was more than double in patients with 4AT scores of 1–3/12 (indicating cognitive impairment) or ≥ 4/12 compared with 4AT 0/12. Median home time at 1 year was reduced by 112 days (Lothian) and 61 days (Salford) in the 4AT ≥4 group (P < 0.001). Conclusions Scores on the 4AT used at scale in practice are strongly linked with 30-day mortality, length of hospital stay and home time. The findings highlight the need for better understanding of why delirium is linked with poor outcomes and also the need to improve delirium detection and treatment.

Incidence and Long-term Functional Outcome of Neurologic Disorders in Hospitalized Patients With COVID-19 Infected With Pre-Omicron Variants

“…19 Long-term disability and death were more frequent than expected only for COVIDassociated cerebrovascular diseases and acute encephalopathy, compared with other known causes of the same disorders, in accordance with previous studies. [20][21][22] Diagnosis, treatment, data collection, and follow-up visits or calls were exclusively performed by neurologists who were involved in patient's management from hospital admission or were referred the patient by COVID physicians, intensivists, or infectious disease specialists at any time during the study period. This neurologist-centered approach of patient ascertainment had both advantages and limitations.…”

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review

“…Further, the 4AT may be advantageous to use in EDs as it is shorter and simpler compared with other recommended tests and does not require any special training 50 . This is supported by one recent large observational study examining 4AT outcomes in the ED, which found that screening using this tool was feasible in a large ‘real‐world’ ED setting 51 …”

“…50 This is supported by one recent large observational study examining 4AT outcomes in the ED, which found that screening using this tool was feasible in a large 'real-world' ED setting. 51 The second area of discrepancy pertains to pharmacological management. Two CPGs recommend against using antipsychotic medications, such as haloperidol, to treat delirium under any circumstance.…”

Delirium‐related psychiatric and neurocognitive impairment and the association with post‐intensive care syndrome—A narrative review

“…11 However, in clinical practice delirium can be difficult to diagnose and often goes unrecognized by clinicians, in up to 65% to 88% of cases. 2 Besides increased mortality, 12,13 delirium has also been associated with prolonged mechanical ventilations during ICU treatment, prolonged hospitalization and increased healthcare costs, 4,14,15 impaired physical functioning, [4][5][6]15 and cognitive disturbances and long-term cognitive decline. 7,14,16 Psychological symptoms such as anxiety, depression and posttraumatic stress have also been reported.…”