A 4AT score of 4 or more suggests possible delirium. It is not a diagnosis on its own. Three things should follow.
1. Urgent clinical assessment. A clinician with the right training decides whether delirium is present, using the history, information from someone who knows the person, and the whole clinical picture. The first step is to check for acute, life threatening causes.
2. A first nursing response. ACE-T is a free one page form for the first four hours after a positive screen. It prompts the nurse to look for acute triggers, attend to the patient’s experience, document delirium, and tell the team and the family. Urgent concerns need action straight away.
3. Treatment by the whole team. The guide to delirium treatment on this site describes eight parts of treatment, from finding causes to planning follow up.
Families can find plain English information at Delirium Support. Staff who want a 30 minute introduction can take Delirium in 30 at Delirium Academy.