The 4AT, cognitive impairment and age-friendly care
Commentary. These are the author’s interpretations of the cited evidence. Disclosures.
A delirium assessment can also reveal cognitive difficulty. That should lead to the right follow-up.
The 4AT includes brief tests of orientation and attention as well as assessment of alertness and acute change. These cognitive items can identify difficulty that deserves further assessment. They cannot, by themselves, distinguish dementia from delirium, other acute illness or another cause of poor performance.
Penfold et al. (2025) studied 75,221 emergency admissions of older adults. A 4AT was recorded for 62,188 admissions, representing 33,625 people. Higher scores were associated with a recorded clinical dementia diagnosis. The study used linked routine records, rather than a new specialist dementia assessment for every participant. It supports further evaluation of how routine 4AT results might help identify possible unrecognised cognitive impairment. It does not validate the 4AT as a standalone dementia diagnostic test. A correction was published in 2026 and is linked below.
A score of 1–3 can indicate cognitive impairment. A score of 4 or more suggests possible delirium, with or without underlying cognitive impairment. A low score does not exclude either condition when other evidence causes concern. Acute illness, language and sensory difficulties also need consideration. Persistent difficulty after the acute illness should prompt an appropriate clinical history and further assessment.
For delirium detection, specificity can be lower in people with dementia. A recent review in Dementia & Neuropsychologia pooled five studies and reported sensitivity of 88% and specificity of 79% in the dementia subgroup, with wide uncertainty around specificity (Keane et al., 2026). This is a reason to interpret positive scores with the history of acute change. It does not remove the value of assessing for delirium in this group.
The 4Ms of age-friendly care are What Matters, Medication, Mentation and Mobility. I think the 4AT shows promise as one part of a Mentation process: it addresses delirium while providing brief cognitive observations that can prompt further assessment. It does not cover depression, all cognitive assessment, or the other Ms. Neither this commentary nor the dementia study establishes that using the 4AT alone meets an age-friendly recognition or regulatory measure.
The practical opportunity is to connect information already collected with a useful response. Assess suspected delirium promptly. Document cognitive concerns and arrange follow-up where needed. Study whether this improves recognition and care, rather than assume that an extra recorded score is enough.
References
Institute for Healthcare Improvement (accessed 4 September 2026) Age-Friendly Health Systems and the 4Ms.
Keane, A. et al. (2026) 4AT screening for delirium in dementia: meta-analysis of diagnostic performance. Dementia & Neuropsychologia, 20, e20250378.
Penfold, R.S. et al. (2025) Using scores from the 4AT delirium detection tool as an indicator of possible dementia: a study of 75,221 older adult hospital admissions. Age and Ageing, 54, afaf144. Published correction (2026).
The 4AT (accessed 4 September 2026) Clinical user guide.
Disclosure: I am a co-developer of the 4AT and a co-author of the Penfold study.