Evidence and implementation guide
The 4AT in guidelines
The 4AT is recommended in multiple guidelines, pathways and other guidance provided by governmental bodies and professional societies. This curated reference resource is under continuing review and links to guidance for a range of clinical settings.
This is not a systematic review. Entries are included where a source explicitly recommends, requires, lists or discusses the 4AT. Some sources recommend or require the 4AT directly; others include it among several validated tools. The labels below distinguish these relationships and do not imply that inclusion alone is a recommendation or evidence of implementation.
Evidence check: local source collection and current official web sources reviewed 26 July 2026.
International
Postoperative delirium
European Society of Anaesthesiology and Intensive Care Medicine
Update of the evidence-based and consensus-based guideline on postoperative delirium in adult patients (2024). The 4AT is included in Supplementary Table S2 on assessment tools.
Consensus group, Ethiopia
Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting. This evidence-based guideline addresses assessment and management of postoperative delirium in older people in low-resource settings, including use of the 4AT among assessment tools.
Emergency department
Geriatric Emergency Department Guidelines 2.0
Added in this review. The 2026 GRADE-based clinical practice guideline states that the 4AT, bCAM, CAM-ICU, mCAM, AMT-4 or RASS may be used to rule delirium in or out in older adults in the emergency department. This is a conditional, non-tool-specific recommendation based on very-low-certainty evidence. Read the guideline.
United Kingdom
General clinical guidance
National Institute for Health and Care Excellence (NICE)
Delirium: prevention, diagnosis and management in hospital and long-term care. In the 2023 update, NICE recommends that if indicators of delirium are identified, a competent health or social care practitioner should assess using the 4AT. In critical care or the recovery room after surgery, NICE recommends CAM-ICU or ICDSC instead.
Scottish Intercollegiate Guidelines Network (SIGN)
Risk reduction and management of delirium. 2019, updated 2022. SIGN recommends the 4AT for identifying probable delirium in emergency department and acute hospital settings. It may also be considered in community and other settings. CAM-ICU or ICDSC should be considered in intensive care.
NHS England standards and pathways
Model Acute Pathway: first 72 hours in hospital
New national standard, February 2026. Patients aged over 65 presenting to hospital as an emergency should be assessed by a competent clinical decision-maker within 30 minutes of arrival using the Clinical Frailty Scale and the 4AT. Read the NHS England standard.
Model discharge pathway
Published 7 July 2026. NHS England states that systems should embed consistent use of recognised tools across admission, review, discharge planning and handover, naming the 4AT as an example. It is therefore included here as pathway recognition rather than a tool-specific requirement. Read the model discharge pathway.
NHS Wales
Same Day Emergency Care Strategy, December 2024
Added in this review. NHS Wales recommends a triple assessment approach for older people living with frailty: Clinical Frailty Scale for people aged 65 and over, 4AT and NEWS2. It also recommends that front-door staff are trained to use all three and that scores are completed in all patients aged 65 and over within 60 minutes of arrival. Read the SDEC Strategy (PDF).
Emergency department
Royal College of Emergency Medicine
Care for Older People in the Emergency Department, Quality Improvement Programme 2023 to 2025 (PDF). For people aged 75 and over in participating type 1 emergency departments, its first individual-patient standard is delirium assessment using the 4AT.
Hip and femoral fracture
National Hip Fracture Database
Recommendations for hip fracture care. This annual-report link provides the wider National Hip Fracture Database context; the current, specific 4AT payment requirement is set out in the NHS England tariff entry below.
NHS England 2026/27 Best Practice Tariff
Current from 1 April 2026. The tariff criteria include a 4AT assessment before surgery with the score recorded in the National Hip Fracture Database, plus a repeat 4AT delirium assessment during the admission. Read Annex C: Guidance on best practice tariffs (PDF).
Palliative care
British Geriatrics Society
End of life care in delirium. This British Geriatrics Society chapter describes the 4AT as the preferred assessment test for delirium detection in clinical pathways.
Marie Curie
Delirium in palliative care. It describes the 4AT as a short delirium-detection tool for use when delirium is suspected or when people move between care settings, alongside clinical judgement and further assessment.
Policy and implementation reports
Delirium Matters: priorities and opportunities for health and social care policy in England
Added from the local source collection. This 2025 independent policy report recommends that the Department of Health and Social Care implement drivers to ensure that all people at risk are assessed for delirium on and during hospital admission using the 4AT. This is a policy recommendation rather than a current binding NHS standard. Read the report (PDF).
Ireland
General and emergency care
Health Service Executive
Early Identification and Management of Delirium in the Emergency Department/Acute Medical Assessment Unit (PDF). The pathway specifies 4AT assessment at triage or first contact after triage for adults aged 65 and over, and gives actions for positive scores.
Irish Association for Emergency Medicine
Management of Delirium in the Emergency Department (PDF). The current IAEM Clinical Guideline, version 1.0 (November 2024) includes assessment pathways for 4AT scores below 4 and of 4 or above.
Germany
Older adults across acute care
AWMF S3 Guideline: Delirium in Older Age
Added from the local source collection. The 2025 guideline gives Grade A recommendations for delirium assessment in emergency departments, older non-surgical inpatients and older surgical inpatients, with the 4AT included among the recommended instruments. For acute inpatients with dementia or cognitive impairment, it recommends the 4AT or a CAM algorithm. Read the full German guideline (PDF).
Italy
Hospital care
Italian intersociety consensus
Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons (PDF). The consensus proposes including the 4AT among admission assessment tools for older hospital patients and, where possible, incorporating it into nursing routine.
United States
General
American Psychiatric Association Practice Guideline
Added from the local source collection. The detailed 2025 guideline describes the 4AT, summarises its diagnostic accuracy and includes it in a table of assessment tools. It does not select one preferred delirium instrument, so this entry is labelled “included” rather than “recommended”. Read the detailed APA guideline (official pre-publication PDF) or view the published guideline statement.
American Nurses Association
Delirium: Prevent, Identify, and Treat. This American Nurses Association and American Delirium Society resource lists the 4AT as a validated tool for rapid assessment of delirium and cognitive impairment; it is not a tool-specific recommendation.
Perioperative care
American Society of Anesthesiologists Perioperative Brain Health Initiative
Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team. The review describes the 4AT as a commonly used, rapid tool that does not require specific training.
Canada
Emergency department
Canadian Association of Emergency Physicians
Care of Older People in Canadian Emergency Departments. The statement includes the 4AT among assessment tools for older people in Canadian emergency departments. It is included here as a position statement that names the 4AT, rather than as a tool-specific CAEP recommendation.
Community
Regional Geriatric Program of Toronto
Guidance on Delirium Care for Older Adults in the Community (PDF).
Australia
General
Australian Commission on Safety and Quality in Health Care
Australian Delirium Clinical Care Standard. The standard requires assessment using a validated delirium tool and lists the 4AT among the examples.
New Zealand
General
Health Quality & Safety Commission
Delirium | Mate kuawa. The guide recommends use of a delirium assessment tool and describes the 4AT as a quick, validated assessment tool that takes less than two minutes.
Scope and source-review notes
This page records documents that explicitly recommend, require, list or discuss the 4AT. The broader local source collection was also reviewed. Documents are not presented as 4AT endorsements when the examined text does not name a specific 4AT recommendation. Examples include the 2012 ACS/AGS preoperative guideline, the 2025 American Society of Anesthesiologists practice advisory and the 2025 SCCM PADIS focused update for intensive care. This boundary avoids implying endorsement where none was identified.