RN Tools
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.
Delirium or severe cognitive impairment unlikely. Note that delirium is still possible if "acute change or fluctuating course" is questionable.
0
points
Alertness*
AMT 4*
Attention*
Acute change or fluctuating course*