Clinical Utility and Performance of the Traditional Chinese Version of the 4-As Test for Delirium Due to Traumatic Brain Injury

Background: Delirium is a common symptom following a traumatic brain injury (TBI) that is often overlooked by healthcare professionals. Early detection of post-traumatic delirium is crucial to improving patient outcomes and quality of life. The four As Test (4AT: alertness, attention, abbreviated mental test-4, and acute mental changes) is a brief and rapid tool for delirium assessment with acceptable reliability and validity. However, the 4AT has not yet been translated for use in the Taiwanese population.

Objective: To translate the 4AT into Traditional Chinese (TC-4AT), assess its reliability and validity, and explore the clinical effects of delirium in patients with TBI.

Methods: This prospective observational study was conducted at the neurosurgery wards of two Taiwanese hospitals. Patients who were aged 20 years and older, were diagnosed with a TBI, and had a Glasgow Coma Scale score between 13 and 15 were included. Interrater reliability was assessed, and validity was verified using criterion-related comparisons with the Short Confusion Assessment Method (Short CAM). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria were employed to assess the sensitivity and specificity of the TC-4AT for screening post-TBI delirium.

Results: A total of 100 patients with an average age of 67 years were enrolled, of whom 10% were diagnosed with delirium based on the DSM-5 criteria. The interrater reliability of the TC-4AT was 1.00. Patients with delirium tended to have a longer hospital stay than those without delirium (13 days vs. 7 days) although the difference was nonsignificant (P = 0.28). In terms of criterion validity, patients diagnosed with delirium using the Short CAM had a significantly higher score on the TC-4AT than those not diagnosed with delirium (P < 0.001). The receiver operating characteristic curve indicated that the optimal cutoff point was 4, with sensitivity, specificity, and area under the characteristic curve of 0.90, 0.94, and 0.96, respectively.

Conclusion: The TC-4AT is an accurate tool for delirium assessment that aids early detection and informs decision-making in preventive care.