4AT score for Delirium Screening

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Evidence of significant change or fluctuation in mental status within the last 2 weeks and still persisting in the last 24 hours


4A's Score
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Table of Contents: Introduction > introduction What is 4A’s test? > what-is-4as-test How does the 4A’s test work? > how-does-the-4as-test-work Core Facts related to Delirium > core-facts-related-to-delirium What is Delirium? > what-is-delirium Types of Delirium > types-of-delirium Detection of Delirium through 4A’s test > detection-of-delirium-through-4as-test Presence of Delirium in older people > presence-of-delirium-in-older-people Delirium Symptoms > delirium-symptoms Delirium Causes > delirium-causes Treatment / Medication of Delirium > treatment-medication-of-delirium


The human mind is a complex organ and it controls all the functions which we perform physically. If the mind develops any abnormality, one or more physical functions can be completely distorted. The 4 A’s test is used for screening of delirium. In other words, this test is used to check whether delirium is present in your body or not.

What is 4A’s test?

When you develop a medical complication, certain tests are carried out to get assurance and confirmation that the problem is present. These tests have to be carried out before the medication is formally prescribed. For instance, if you have heart issues, the cardiologist would prescribe key tests including ECG before he prescribes medication or advises surgery. The 4 A’s test is used to get a confirmation about whether the patient is suffering from Delirium or not.

How does the 4A’s test work?

The 4A’s test includes various areas which are completed by the medical expert. The overall condition of the patient in relation to cognitive impairment is determined after the scores of all these individual areas have been calculated. The individual scores of all the areas would be added to get a total score.

The following key areas are examined

1. Level of Alertness

If someone is not alert mentally to an abnormal level, there is every chance that he may be facing a cognitive impairment issue. The first area examined through the 4A’s test is alertness. If you are a medical expert carrying out this test, this is the first score you have to calculate. The level of alertness has three benchmarks. If the user is completely normal and fully alert during the examination, he would be awarded with a zero score. Same is the case when he is sleepy for ten seconds after waking up and then becomes completely normal. However, if the abnormality is apparent, the user would be awarded with a score of 4. Once the level of alertness has been determined, the expert would move on to the next stage.

2. AMT 4 test

This is the second phase of the test completed by the medical expert. During this phase, the patient is questioned about his age, date of birth, place as well as the current year. If the patient makes no mistake, he is awarded with a zero score. On the other hand, if he makes one mistake, he is given a score of 1. Similarly, if he makes 2 or more mistakes, he is awarded with a score of 2. Some patients are also in the untestable phase and they are also awarded with a score of 2.

3. Attention checking

This is the third phase of the 4A’s test and it is used to check how attentive the patient is. As a medical expert, ask the patient to mention the months of the year in the reverse order. There are three benchmarks for awarding a score to the patient. If the patient pronounces 7 or more months in the reverse order without making any mistakes, he is awarded a score of 0. If he pronounces less than 7 month names properly, he is awarded with a score of 1. The worst case is when the patient is unable to proceed with the test due to drowsiness or lack of focus.

4. Fluctuation Course

Patients who suffer from delirium have hallucinations. In other words, they see things and hear sounds that do not exist in the first place. There are two rating options for this stage. If the patient has been having hallucinations for several weeks and the problem has continued in the last 24 hours as well, the medical expert would check the “yes” option. In other cases, the “no” option would be checked. If the “yes” option has been selected, the user would be awarded with a “4” score. On the other hand, if a “no” option has been selected, he would be awarded with a “0” score.

Test Result Interpretations

When all the four stages of the test have been completed, the score of each stage would be totalled to get the overall score. If the score is 4, you can reach the conclusion that the patient has delirium and the patient has to undergo further medical examination to gather more details. If the score is between 1 and 3, it can be said that the patient may not be suffering from delirium but the presence of cognitive impairment are high. Thus, further tests have to be carried out to gather more information. Even if the score is 0 which means that the patient has shown no signs of delirium, further medical examination is still advised.

There is no doubt that Delirium is a serious medical complication which can paralyze the life of an individual completely. According to most medical experts, people who suffer from this problem are unable to even complete basic tasks like writing a single line on a piece of paper.

Let us go into further details about this problem and the impacts it has.

What is Delirium?

In a nutshell, Delirium is a disturbed mental state. It affects the thinking abilities of an individual and hampers his concentration level. Patients of this disease are continuously in a state of confusion. They see people or things which practically do not exist. For instance, a delirium patient would talk to a person who does not exist in the first place. He may be a dead person as well. Delirium patients imagine a lot are mostly in a confused mental state. They fail to take decisions about the most basic things. They may even take hours to decide whether they have to begin a conversation with someone or not.

Types of Delirium

When a patient is suffering from a medical abnormality, it is not enough to know about the disease name only. Every medical abnormality has different types and Delirium is not an exception. Thus, patients who are suffering from delirium should know about the exact type that they have. This helps in better prescribed medication as well.
Here are the key Delirium types.

1. Delirium with Hyperactive Signs

Normally, patients show signs of uneasiness and restlessness when they are suffering from delirium. Such patients do not want to sit in once place or cooperate with someone they are talking to.

Patients who are restless are not easy to talk to and always in an agitated frame of mind. They are never relaxed and always want to get up and run. Irritation is one of the key signs as well. It is a fact that most people suffering from mental diseases face this issue but in case of delirium, the sign is more apparent. Delirium patients become impossible to manage for their family members when they are an extreme case of hyperactive delirium.


It is always good to go through an example when you want to clarity medical terminologies. Let us take the example of someone who is suffering from hyperactive delirium. As it is mentioned above, such people are very agitated and irritated. If you offer them something to eat, they might throw it away. Similarly, if someone interrupts their conversation, they might even start a physical fight. As compared to the normal level, the irritation level in such patients is much higher. This is the reason why they have to undergo medical treatments on an urgent scale.

2. Delirium with hypoactive signs

The chances of finding patients with hypoactive signs are lesser than coming across hyperactive patients. One of the key signs is drowsiness. People suffering from hypoactive delirium are unable to focus on things and have an overly sleepy attitude. They are lethargic and unable to concentrate on anything. For instance, if you ask them a simple question, they would not be able to focus on it.

Drowsiness is the key sign of people suffering from hypoactive delirium. Patients who suffer from this issue at the extreme level are even unable to stand. This is the key reason why they are also advised urgent medical care.

3. Delirium with Mixed signs

This category of patients is the hardest to handle because they have signs of both hypoactive and hyperactive delirium. Let us take an example. Someone who is suffering from mixed delirium may be super agitated at one time and completely exhausted with drowsiness at the other. Such patients undergo various tests including 4A’s test for better examination and treatment.

Detection of Delirium through 4A’s test

It is simply not possible for a medical expert to prescribe medication till the problem has been tested properly. 4A’s test is one of the best examination methods to check the intensity and presence of delirium. This test basically comprises of four stages and each stage is awarded a score. At the end of all four stages, the total is added to see the exact condition of the patient. Each of these stages has a different set of activities for examination. The score is awarded on the basis of how the patient performs.

Determination Delirium through four stages

As it is mentioned above delirium patients have to undergo four stages in the delirium test. After that the points of all the four stages are totaled to see exactly where the patient is standing. Let us go through some detailed points to extract more details.

  • The first stage called “alertness” is rated on the basis of three benchmarks called normal, mild sleepiness and clearly abnormal. If the patient is completely active like any other normal person without any agitation or irritation, he is rated as normal. In such cases, he is given a 0 score. Some patients are categorized in the mild sleepiness category. Such patients are sleep for the first 10 to 12 seconds after which they are awake and responsive throughout the test. Such patients are also given a zero score. Lastly, patients that do not wake up and respond are rated as clearly abnormal. They are given a score of 4.

  • When the alertness stage has been completed, the medical expert would move on to the next stage. This stage is called the AMT 4 stage and also has three benchmarks to rate the patient. In this stage, the patient is asked about his age, date of birth, place and the current year. He is awarded with a 0 score if he does not make any mistakes while giving the answers. If one mistake is made, he is awarded with a 1 score. Similarly, if he makes 2 or more mistakes, a score of 2 is given to him.

  • The third stage of the 4A’s test is called attention. During this stage, the patient is asked to pronounce the names of the month in the reverse order. This simply means that the patient has to start with December and move towards January. If the patient pronounces seven months without making any mistake, he is awarded with a 0 score. Similarly, if the patient does not start instantly or pronounces less than 4 months in a proper manner, he is awarded with a score of 1. The worst case is when the patient is not in a condition to start the test. Such patients are awarded a score of 2.

  • The fourth stage of the 4A’s test is called acute change. Unlike other stages, this final stage just has yes and no options. If the patient is paranoia or has been facing hallucinations from the last two weeks and the signs have not changed in the last day, he is placed in the “yes” category and given a score of 4. Patients who fall in the no category and provided with a score of 0.

Total and Test interpretation

When the test has been completed, the individual scores of all four stages are totaled so determine the exaction condition of the patient.

  • Score of 4

    If a patient has scored 4 after the test has been carried out, it can be counted as a confirmation that he is suffering from delirium. However, to get more details, it is always advisable to have further tests done. Thus, even if the patient ends up in the worst category, he would have to get further tests done.

  • Score of 1 to 3

    If the score of the patient is between 0 and 3 after the 4A’s test has been done, the patient would likely not be suffering from delirium but it would be counted as a case of cognitive impairment. Even if the patient is in this scenario, he should ideally go for more tests to get a clearer picture.

  • Score of 0

    According to the principles and logic of this test, it is a fact that patients with a zero score would not have cognitive impairment or delirium. Even then, further tests should be carried out to eliminate all kinds of doubts. Delirium is a complex and sensitive medical condition so getting a test done is always the best way out.

Presence of Delirium in older people

There is no doubt that ageing itself is a disease which cannot be avoided in any manner. When you talk about the presence of delirium in old people, the percentage is quite high.

Elderly People have higher chances of Delirium
When you catch up on age, the potential to battle medical complications obviously decrease. Someone who is 30 years of age would have much lesser chances of getting hit by delirium as compared to an individual who is 50 years old. Normally, when an elderly person shows signs of irritation, people around him get the perception that the reason is nothing but ageing. However, this may not be the case at all times. If you see other signs like hallucinations or drowsiness at all times, it is important to get proper tests done. Taking these signs lightly would obviously result in the condition worsening.


Delirium Symptoms

Every professional medical expert would analyse the symptoms of a disease and then prescribe medications accordingly. There are various symptoms which medical professionals check before reaching the conclusion that a patient is suffering from this disease. Some of the core ones are listed below.

Lack of Environmental awareness

People suffering from this medical issue find it very hard to keep a track on what is happening in their environment. Let us go through an example. A delirium patient would not be able to notice people sitting around him and talking about something or performing a physical task. Similarly, when you are communicating with such patients, they are unable to move from one conversational topic to the other.

Thinking and coordination patients

Delirium patients have memory losses on a serious scale. In other words, they are not even able to remember the basic things. For instance, if you ask a dementia patient about what he ate a day before, he would be blank about it. Along with that, these patients are unable to read and write properly due to lack of orientation. If they are told to read a simple sentence, they would be unable to connect between words. In a nutshell, people suffering from delirium have focus and coordination problems.

Hallucinations and withdrawals

Most delirium patients have hallucination problems. They start seeing things and hearing sounds which practically do not exist. Along with that, such patients also have withdrawal signs. You would not see such people mixing with other humans including their family members. Thus, if you someone having hallucinations or withdrawal signs, do not delay a medical check as the patient may be suffering from delirium.

Delirium Causes

Like any other disease, delirium has its own causes and reasons. Some of them are listed below.

Usage / withdrawal of alcohol and drugs

One of the key problems which drug and alcohol consumers go through is hallucination. At times, this problem goes away when the effect of drugs / alcohol is over but this may not be the case at all times. In some cases, people continue getting hallucinations and drowsiness even when they have stopped consuming alcohol / drugs. The key reason is that such people suffer from delirium. Consumption as well leaving drugs suddenly can drag the patient into delirium.

Insomnia and Distress

Insomnia is a serious medical normality and most people suffering from it do not take it seriously. Insomnia or lack of sleep drags a patient into delirium. If you have a look at most patient who have been suffering chronic insomnia, you would notice that they have other signs of delirium including hallucinations and drowsiness. If all these signs are present, it is strongly advisable to get hold of a medical expert at the earliest.

Treatment / Medication of Delirium

The intensity of delirium can increase in a rapid manner and condition of the patient can worsen at a fast pace. The correct medication / treatment of delirium is listed below.

Mental Assessments

The treatment phase basically begins with the testing phase. A number of tests are carried out to check delirium patients. One of the common ones is 4A’s test which checks the patient in four different areas. Along with that blood and urine tests are carried out from time to check for medical examination purposes.

Eliminating the triggering factor

When a patient is suffering from a serious mental illness like delirium, no treatment would work until the factor triggering these disturbances is eliminated. For instance, if a delirium patient is living in an environment where his irritation would increase, his medical treatment would not produce any positive results. In most cases, a complete change in environment is suggested by medical experts.

Summing It Up

When you talk about mental disorders and serious illnesses related to the human mind, a very careful approach needs to be adopted. For instance, a lot of patient care takers make the mistake or ignoring or overlooking symptoms. If you see that an elderly person you know is always drowsy and unable to focus, it may not be natural ageing only. It is important to keep your eyes open for signs of Delirium and other serious mental disorders.

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