New Findings Underscore Gaps in Delirium Screening and Diagnosis

Delirium, a common but often underrecognized condition, poses significant risks for older adults, especially those with multiple chronic health issues. Although delirium screenings are routine for older patients admitted to the hospital or ICU, they are not yet commonplace in emergency departments (EDs), where time constraints and surging patient volumes often take precedence.

When overlooked, delirium can worsen existing cognitive impairment, increase mortality, precipitate long-term complications and lead to longer hospital stays, explains Cleveland Clinic geriatrician Saket Saxena, MD. Despite these dangers, he notes that older patients who present to the ED with acute conditions often wait hours or days to be fully evaluated for the condition.

“Although we know that recognizing delirium early can significantly improve patient outcomes, there are a number of barriers that have historically stood in the way of appropriate, timely screening,” he says.

Early detection is key

A new quality improvement (QI) project led by Dr. Saxena aims to address this diagnostic challenge by evaluating the consistency and effectiveness of two widely used screening tools.

Cleveland Clinic’s 14 geriatric EDs test for delirium using 4AT, a bedside screening tool that takes about 60 seconds to complete. The rapid test begins by asking the person accompanying the patient if they are concerned about or have noticed any changes in the patient’s mental status. If the caregiver answers yes, the assessment is completed by asking the patient “orientation” questions that evaluate their ability to understand today’s date, where they are, and their date of birth and age. Their attention span is measured by asking the patient to name the months of the year backwards.

Any patient who receives a score of four or more is flagged for delirium.

Patients with a positive 4AT screen are frequently admitted for further evaluation using the Confusion Assessment Method (CAM) or CAM-ICU, the standard of care for confirming delirium in inpatient and ICU settings.

Comparing the numbers

Dr. Saxena explains that he and his team initiated their study to explore the correlation between 4AT positivity and CAM/CAM-ICU positivity – a connection that may reveal how consistently delirium is detected across different care settings.

“By comparing how frequently both tests pointed to delirium, we hope to better understand the factors that influence our ability to diagnose the disorder, both in the ED and the inpatient setting,” he says.

The study, which was presented at the American Geriatrics Society 2025 Annual Scientific Meeting, revealed data from geriatric patients who presented to the ED within a one-month period (Sept. 1-30, 2024). Nearly 13% of the 1,500 high-risk geriatric patients who were screened in the ED using the 4AT were found to be positive, suggesting either delirium or abnormal cognitive function.

Among a sample of 4AT-positive patients who were admitted and received follow-up CAM testing, about 1 in 4 (27.2%) were positive for delirium, and 72.8% were negative. Patients who were admitted to the ICU underwent CAM-ICU assessments, 88.9% of whom tested positive for delirium and 11.1% of whom tested negative.

Dr. Saxena says the stark contrast between the results of the two screening methods raises questions about how delirium is presented and detected when transitioning from the ED to inpatient care.

“We initially expected to find a high concordance between 4AT positivity and CAM positivity; however, the data suggests a less-reliable correlation,” he says. “These findings highlight the importance of comprehensive delirium screening throughout the patient care journey, from the ED to the hospital floor and ICU.”

Looking ahead

Because dementia can present differently depending on the patient and clinical environment, Dr. Saxena stresses that future research is needed to better understand the reasons behind these observed diagnostic discrepancies.

“By refining and standardizing delirium screening methods, clinicians can improve outcomes, reduce complications and, ultimately, ensure that geriatric patients receive appropriate, timely care during critical episodes of illness,” he says. “We hope our work can help address the gaps that arise across care settings – and by doing so, improve our ability to reduce hospital stays, prevent avoidable complications and support safer transitions of care for vulnerable older adults."