• Elizabeth Arnold, Anne M Finucane, Stacey Taylor, Juliet A Spiller, Siobhan O'Rourke, Julie Spenceley, Emma Carduff, Zoë Tieges, and Alasdair Mj MacLullich.
• Marie Curie Hospice Edinburgh, Edinburgh, UK.
• Palliat Med. 2024 May 1; 38 (5): 535545535-545.

BackgroundDelirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.AimTo determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.DesignA diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.Setting/ParticipantsTwo hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years.ResultsA total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).ConclusionThe results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings.Trial RegistryISCRTN 97417474.

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