Delirium screen
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NICE delirium 4AT screening recommendations
Use the 4AT for rapid delirium screening in most ward, emergency, and long-term care settings.
| 4AT item | Score |
|---|---|
| Alertness: normal = 0; clearly abnormal = 4 | 0 or 4 |
| AMT4: age, date of birth, place, current year. One error = 1; 2+ errors or untestable = 2 | 0-2 |
| Attention: recite months backward from December. 7+ correctly = 0; starts but scores <7 = 1; unable/refuses = 2 | 0-2 |
| Acute change or fluctuating course in alertness, cognition, or other mental function = 4 | 0 or 4 |
Interpretation
- 0: delirium or moderate-severe cognitive impairment unlikely, but not fully excluded.
- 1-3: possible cognitive impairment. Assess further.
- ≥4: possible delirium. Urgent clinical assessment for cause and management.
A positive screen is not the diagnosis. Confirm an acute change from baseline, obtain collateral history, review medications, vital signs, oxygenation, glucose, infection, pain, retention, constipation, withdrawal, and other reversible causes.
For ICU or immediate postoperative recovery, use CAM-ICU or ICDSC rather than 4AT, consistent with NICE delirium guidance. CAM is also a widely used validated tool; the textbook reports sensitivity around 94% and specificity above 85% for its diagnostic algorithm. Recent systematic reviews also support structured delirium instruments in ICU, postoperative, and emergency settings, including ICU screening evidence and ED diagnostic-accuracy evidence.
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