RN Tools
Alertness*
May ask patient to state name and address to help with rating
AMT 4*
Age, date of birth, place (name of the hospital or building), current year
Attention*
Instruct patient to list months in reverse order, starting at December
Acute change or fluctuating course*
Evidence of significant change or fluctuation in mental status within the last 2 weeks and still persisting in the last 24 hours
Delirium or severe cognitive impairment unlikely. Note that delirium is still possible if "acute change or fluctuating course" is questionable.
0
points
Diagnoses delirium in older patients.
Addition of the selected points:
|
Alertness |
Normal |
0 |
|
Mild sleepiness for <10 seconds after waking, then normal |
0 |
|
|
Clearly abnormal |
4 |
|
|
Age, date of birth, place (name of hospital or building), current year |
No mistakes |
0 |
|
1 mistake |
1 |
|
|
≥2 mistakes or untestable |
2 |
|
|
Attention* |
Lists ≥7 months correctly |
0 |
|
Starts but lists <7 months, or refuses to start |
1 |
|
|
Untestable (cannot start because unwell, drowsy, inattentive) |
2 |
|
|
Acute change or fluctuating course** |
No |
0 |
|
Yes |
4 |
*Instruct patient to list months in reverse order, starting at December.
**Evidence of significant change or fluctuation in mental status within the last 2 weeks and still persisting in the last 24 hours.
Interpretation:
|
4AT Score |
Level of impairment |
|
≥4 |
Possible delirium and/or cognitive impairment |
|
1–3 |
Possible cognitive impairment |
|
0 |
Delirium or severe cognitive impairment unlikely (but delirium still possible if “acute change or fluctuating course” information is incomplete) |
Patients admitted to geriatric wards, to screen for delirium.
If delirium is diagnosed, identify and treat underlying cause.