Alasdair MacLullich

A delirium tool that also finds dementia?

New study: n=75,221 older adult admissions


↳ 4AT score ≥1: • 87% sensitive for clinical dementia diagnosis

↳ The 4AT isn't just for delirium anymore.



#Delirium #Dementia #4Ms

Penfold et al, Age Ageing 2025

🧠 Delirium is the only dedicated delirium journals

👍100% open access.

👍Ultra-low fees ($20 submission, $280 publication).

👍All study types welcome & rapid 4-week peer review.


#delirium

The sooner you diagnose #delirium, the sooner you can proactively relieve your patient's distress.

"My dad has dementia but was doing ok. Suddenly he became aggressive and was seeing spiders on the wall. We were terrified. It turned out he had a raging UTI with no other symptoms." 

#delirium

When delirium causes hallucinations, they're not "just seeing things"

The picture is Redon's L'Araignée souriante (The Smiling Spider), 1881.

People who experienced delirium often state that these experiences were genuinely terrifying for them - "terror like you wouldn't believe."

#Delirium

"The hate and anger that was coming out of him. I'd be quite honest, I was scared stiff." 

- Wife describing her husband's #delirium.

A few years ago delirium barely featured in nursing curricula.

Now we're beginning to see it embedded as core competency.

Progress is slow, though, and this is bad for patients as well as nurses.

❓ What does delirium training look like at your institution?



#nursingeducation

More than 1 in 3 older inpatients in this study were dehydrated.

Dehydrated patients: 13% higher odds of falling (OR 1.13, P=.002).

↳ Dehydration is cheap to fix - but easy to miss.



💧💧💧💧💧💧💧💧



⇉ Do you check fluid status on every ward round?

"He saw ships sailing through the sky, and heard voices from the sea."

Seven Samurai (Movie), Akira Kurosawa

#delirium

Reorientation tip in #delirium: Instead of repeatedly asking "Do you know where you are?" (which can increase frustration), provide orientation information naturally in conversation.

Delirium develops over hours/days, dementia over months/years.

"Dad was fine yesterday, today he's a different person" = think delirium, not dementia progression.

That familiar feeling when a positive 4AT screening test vanishes into the EHR ether.

It's good that we are doing more tests - but it's only half the job.


𝟒𝐀𝐓 +𝐯𝐞 ➡️ "𝐝𝐞𝐥𝐢𝐫𝐢𝐮𝐦" 𝐢𝐧 𝐭𝐡𝐞 𝐧𝐨𝐭𝐞𝐬 + 𝐚𝐧 𝐚𝐜𝐭𝐢𝐨𝐧 𝐩𝐥𝐚𝐧.


#Delirium #MedTwitter

Explain delirium in accessible terms: "The brain isn't processing information normally right now."

This helps families understand why repeating basics about what is going on, as well as being reassuring over and over again, can help the person experiencing #delirium.

“We had no structured training. It felt like guesswork, not clinical care.”

-- a nurse commenting on providing care to people with #delirium

➡️ Good quality delirium education is the single most important change we need to make to improve care.

Mrs Smith, 78, hip fracture patient, described as "confused & aggressive"

Ward round note: "?UTI. Start antibiotics." No mention of "delirium"

My reaction: What about her distress - untreated pain? Dehydration? Medication review? Telling the family the diagnosis? Etc.

Why we need Delirium 8 👇

The 4AT can be scored in patients who cannot speak or are too unwell to undergo cognitive testing. No patients are Unable To Assess (UTA) with the 4AT. This improves uptake and accuracy in diagnosis.

See the 4AT website for more details.

We all should be using tools to detect #delirium.

But not all tools perform well in practice - some show much lower rates of detection in the real-world than in practice.

-- check tool performance -- it's not enough to implement & achieve good completion rates.

Health tips for older adults.

#medtwitter

When speaking to person describing delusional beliefs, listen without interrupting or dismissing their experiences. Instead of immediately correcting them, say something calm and neutral like:

“That must be very frightening for you.”'

#delirium

When a person in hospital is restless then it often means they are experiencing #delirium.


→ Look carefully at their facial expressions - see if they might be seeing things that are not real.

→ Sometimes asking them - "are you seeing anything strange or frightening?" can help.

All these informal terms - avoiding saying "delirium" - makes care FAR less effective.

Use #DELIRIUM.

"You can't properly assess for delirium when someone already has dementia."


Wrong.


New meta-analysis (Keane et al. 2026): 4AT shows 88% sensitivity, 79% specificity in dementia populations.


5 studies. 1,304 patients. International data.


#delirium #dementia

🧠 Delirium = the only dedicated delirium journals.

👍100% open access.

👍Ultra-low fees ($20 submission, $280 publication).

👍All study types welcome & rapid 4-week peer review.


#delirium #medtwitter

Haloperidol is a very poor treatment for urinary retention.

When a person looks agitated, systematically check for direct causes of distress.

#delirium

A quote from a family member of a patient with delirium: "grieving for someone who's still alive."

Caring for loved ones with delirium, especially if it is persistent, can be stressful & exhausting.

Professionals should provide support to families as well as patients.

"I see her, she’s talking to me, she’s alive!" (Hallucinating under medication)

Taxi Driver, Martin Scorcese

“Nobody used the word delirium. I thought I’d lost my mind.”

— Delirium survivor


➡️ Always provide clear information, including telling the patient they have delirium, during the episode. Then explain & de-brief afterwards.

Always, always ask: Why is this person delirious? If they are showing agitation - always check for pain, retention, constipation, thirst, etc.


#Delirium #PatientSafety #Geriatrics #MedEd #Pain #Hospitalist #EmergencyMedicine #InternalMedicine #Dementia

More than 1 in 3 older inpatients in this study were dehydrated.

Dehydrated patients: 13% higher odds of falling (OR 1.13, P=.002).

↳ Dehydration is cheap to fix - but easy to miss.



💧💧💧💧💧💧💧💧



⇉ Do you check fluid status on every ward round?

“He has had some fearful shock - so says our doctor - and in his #delirium his ravings have been dreadful, of wolves and poison and blood, of ghosts and demons, and I fear to say of what.”


Bram Stoker - Dracula (1897)