Studies using the 4AT in routine practice

Examples of studies in which the 4AT has been used in routine clinical practice.

Penfold RS, Bowman E, Vardy ERLC, Sampson EL, Anand A, Guthrie B, MacLullich AMJ. Using scores from the 4AT delirium detection tool as an indicator of possible dementia: a study of 75 221 older adult hospital admissions. Age Ageing. 2025 May 31;54(6):afaf144. doi: 10.1093/ageing/afaf144.

Penfold RS, Farrow L, Hall AJ, Clement ND, Ward K, Donaldson L, Johansen A, Duckworth AD, Anand A, Hall DE, Guthrie B, MacLullich AMJ. Delirium on presentation with a hip fracture is associated with adverse outcomes : a multicentre observational study of 18,040 patients using national clinical registry data. Bone Joint J. 2025 Apr 1;107-B(4):470-478.

Penfold RS, Hall AJ, Anand A, Clement ND, Duckworth AD, MacLullich AMJ. Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services. Bone Jt Open. 2023 Jun 16;4(6):447-456.

Hawley S, Inman D, Gregson CL, Whitehouse M, Johansen A, Judge A. Risk Factors and 120-Day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD). J Am Med Dir Assoc. 2023 May;24(5):694-701.e7.

Ihle-Hansen H, Johnsen N, Jankowiak T, Hagberg G, Walle-Hansen MM, Landgraff I, Høvik G, Graven E, Myrstad M. Delirium screening in a stroke unit by nurses using 4AT: Results from a quality improvement project. Nurs Open. 2023 Nov;10(11):7431-7436.

Anand A, Cheng M, Ibitoye T, Maclullich AMJ, Vardy ERLC. 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. Age and Ageing. 2022 51 (3).

Beretta M, Uggeri S, Santucci C, Cattaneo M, Ermolli D, Gerosa C, Ornaghi M, Roccasalva A, Santambrogio P, Varrassi G, Corli O. Early Diagnosis of Delirium in Palliative Care Patients Decreases Mortality and Necessity of Palliative Sedation: Results of a Prospective Observational Study. Cureus. 2022 Jun 7;14(6):e25706.

Cullum S, Kubba Y, Varghese C, Coomarasamy C, Hopkins J. The evidence for introducing case-finding for delirium and dementia in older medical inpatients in a New Zealand hospital. Australas Psychiatry. 2022 Jun;30(3):303-307.

Myrstad M, Kuwelker K, Haakonsen S, Valebjørg T, Langeland N, Kittang BR, Hagberg G, Neerland BE, Bakken MS. Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study. Eur Geriatr Med. 2022 Feb;13(1):155-162.

Alhaidari AAO, Matsis KP. Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study. Eur Geriatr Med. 2021 Nov 16.

Matharu GS, Shah A, Hawley S, Johansen A, Inman D, Moppett I, Whitehouse MR, Judge A. The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland. BMC Med. 2022 Sep 26;20(1):319. doi: 10.1186/s12916-022-02517-8.

Myrstad M, Kuwelker K, Haakonsen S, Valebjørg T, Langeland N, Kittang BR, Hagberg G, Neerland BE, Bakken MS. Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis: a prospective cohort study. Eur Geriatr Med. 2021 Oct 8.

Tieges Z, Lowrey J, MacLullich AMJ. What delirium detection tools are used in routine clinical practice in the United Kingdom? Survey results from 91% of acute healthcare organisations. Eur Geriatr Med. 2021 May 18.

O'Shaughnessy Í, Romero-Ortuno R, Edge L, Dillon A, Flynn S, Briggs R, Shields D, McMahon G, Hennessy A, Kennedy U, Staunton P, McNamara R, Timmons S, Horgan F, Cunningham C. Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department. Eur J Intern Med. 2020 Nov 23:S0953-6205(20)30425-8.

Vardy E, Collins N, Grover U, et al. Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital. Age Ageing. 2020;49(4):672-678.

Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, Fluck D, Osmani A, Sharmin R, Sharma P, Fry CH, Han TS. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing. 2020 Apr 27;49(3):411-417.

Dormandy L, Mufti S, Higgins E, Bailey C, Dixon M. Shifting the focus: A QI project to improve the management of delirium in patients with hip fracture. Future Healthc J. 2019;6:215-219

Mossello E, Tesi F, Di Santo SG, Mazzone A, Torrini M, Cherubini A, Bo M, Musicco M, Bianchetti A, Ferrari A, Ferrara N, Trabucchi M, Morandi A, Bellelli G; Italian Study Group on Delirium. Recognition of Delirium Features in Clinical Practice: Data from the "Delirium Day 2015" National Survey. J Am Geriatr Soc. 2018;66:302-308

Bauernfreund Y, Butler M, Ragavan S, Sampson EL. TIME to think about delirium: improving detection and management on the acute medical unit. BMJ Open Qual. 2018 Aug 13;7(3):e000200

Morandi A, Di Santo SG, Cherubini A, Mossello E, Meagher D, Mazzone A, Bianchetti A, Ferrara N, Ferrari A, Musicco M, Trabucchi M, Bellelli G; ISGoD Group. Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study. Am J Geriatr Psychiatry. 2017; 25:1064-1071.

Baird L, Spiller JA. A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM? BMJ Open Qual. 2017; 6(2):e000153

Bellelli G, Morandi A, Di Santo SG, Mazzone A, Cherubini A, Mossello E, Bo M, Bianchetti A, Rozzini R, Zanetti E, Musicco M, Ferrari A, Ferrara N, Trabucchi M; Italian Study Group on Delirium (ISGoD). "Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool. BMC Med. 2016; 14:106

Morandi A, Han JH, Meagher D, Vasilevskis E, Cerejeira J, Hasemann W, MacLullich AM, Annoni G, Trabucchi M, Bellelli G. Detecting Delirium Superimposed on Dementia: Evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale. J Am Med Dir Assoc. 2016; 17:828-33