Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis – a prospective cohort study

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The quick Sequential Organ Failure Assessment (qSOFA) is recommended as a tool to predict poor outcome in patients with suspected sepsis, but assesses cognitive function crudely. We aimed to study the feasibility of The 4 'A's test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission by nurses and doctors inexperienced with this tool, and to characterize patients aged ≥ 65 years admitted to the ED with suspected sepsis. Methods In this prospective cohort study, we included patients aged ≥ 65 years, admitted to the EDs of two Norwegian general hospitals, with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria. Results Out of the 196 patients included (mean age 81 years), 100 patients fulfilled the sepsis diagnosis criteria. Mean 4AT screening time was 2.5 minutes (median two minutes). While qSOFA identified 48 patients (24%) with altered mental status, 114 patients (58%) had a 4AT score ≥ 1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). The prevalence of delirium any time during the hospital stay was 44% in patients aged 65–80 years, 57% in patients aged ≥ 80 years, and 76% in patients aged ≥ 80 years with sepsis. Conclusions Delirium screening upon ED admission, with 4AT performed by nurses and doctors inexperienced with this tool, was feasible among patients aged ≥ 65 years admitted with suspected sepsis. Features of delirium were common upon ED admission, particularly in patients with sepsis. The prevalence of delirium anytime during the hospital stay was highest among patients aged 80 years and older with sepsis. Our findings suggest increased awareness of delirium in older patients admitted to the ED with suspected sepsis, but the added value of systematic delirium screening with 4AT needs to be addressed in future studies. Critical Care & Emergency Medicine Sepsis qSOFA delirium infection SOFA emergency department 4AT encephalopathy Background Sepsis is severe organ dysfunction caused by a dysregulated host response to infection [ 1 ], and is responsible for one out of five deaths worldwide [ 2 ]. Older people are more susceptible to severe infections and sepsis, probably due to multiple factors such as comorbidities, reduced physiological organ reserves, altered immune function, and institutionalization [ 3 , 4 ]. Yet, few studies have characterized old patients with sepsis in detail. Older people with acute illness more often present with discrete or atypical symptoms than younger, often leading to delayed diagnosis and treatment [ 5 ]. Cognitive impairment and delirium are highly prevalent among acutely ill older people, and might further complicate the diagnostic evaluation. The incidence of delirium increases with increasing age [ 6 – 9 ], and infections are among the most common precipitating factors [ 9 , 10 ]. Delirium refers to a clinical state characterized by an acute alteration in alertness and attention, with an additional disturbance in cognition (i.e., memory deficit, disorientation, perception or language) that develops over a short period of time. Delirium is a clinical manifestation of an acute encephalopathy or brain dysfunction [ 11 ], can be an important sign of clinical deterioration, and should prompt further evaluation and treatment of underlying causes. Furthermore, delirium is associated with increased mortality. Early recognition of delirium is important, because treatment can improve outcomes and general patient care. Although at least one out of ten patients admitted to Emergency Departments (EDs) are suffering from delirium [ 10 ], screening for this clinical entity is not performed routinely in many EDs, and delirium often remains undetected [ 12 ]. Clinical risk scores are extensively used in EDs to facilitate optimal management of patients. The quick Sequential Organ Failure Assessment (qSOFA) is a recommended tool to predict poor outcome in patients with infection [ 1 ]. Altered mental status is one of three clinical variables scored in the qSOFA. Thus, evaluation of cognitive function is a core component of emergency medicine. However, previous studies have demonstrated a relatively poor ability of qSOFA performed in the ED to predict sepsis and sepsis-related mortality [ 14 – 17 ], and qSOFA only offers a crude evaluation of cognitive function. The 4 'A's Test (4AT) is a rapid bedside delirium screening tool that assesses the major features of delirium; disturbed alertness, cognition and attention, and acute change or fluctuation in symptoms [ 18 ]. The 4AT has a high sensitivity and specificity to detect delirium, and has been validated for use among ED patients [ 12 ]. Yet, we are not aware of any studies that have evaluated the feasibility of the 4AT upon ED arrival, performed by nurses and doctors without any previous experience with this tool. We aimed to study the feasibility of 4AT performed upon ED admission, and to characterize older patients admitted to the ED with suspected sepsis, particularly concerning symptoms of cognitive impairment and features of delirium. Methods This was a prospective cohort study. We consecutively included patients aged 65 years and older with suspected sepsis (as judged by ED nurses or doctors), admitted to the EDs of two Norwegian general hospitals; Bærum Hospital (BH) Vestre Viken Hospital Trust in the Oslo region, and Haraldsplass Deaconess Hospital (HDH) in Bergen. Patients were included during the periods from October 23rd 2017 to May 14th 2018 at BH and June 18th to October 14th 2018 at HDH. Patients, for whom an International Classification of Diseases 10th Revision (ICD-10) code corresponding to an infectious disease was not registered for the current hospital stay, were excluded from the analysis. A list of the infectious disease ICD-10-codes used for this purpose, is provided as Supplementary material (Supplementary table 1). Assessments 4AT. The 4 'A's test assesses four core features of delirium [ 18 ]. A total 4AT score of 1–3 indicates possible cognitive impairment, and a score of four or above indicates possible delirum. In patients with a 4AT score of 0, delirium or severe cognitive impairment are unlikely. The 4AT consists of four subscores, with each representing one of the four ‘A’s; Alertness, Abbreviated Mental Test – 4 (AMT4), Attention, and Acute change or fluctuating course:1) Alertness (Is the patient fully alert and not markedly drowsy or agitated?). Patients with altered alertness during bedside assessment, are scored with four points. Patients who are not agitated, and fully alert, or have mild sleepiness for less than 10 seconds, are scored with 0 points. 2) AMT4. This abbreviated cognitive assessment tests if the patient is oriented. The patient is asked to tell her/his age, date of birth, the name of the hospital or building, and the current year. While one mistake is scored with one point, and two or more mistankes with two points, correct answers give a score of 0. 3) Attention. The patient is asked to list the months of the year in backward order. Patients who manages less than seven months, are scored with one point. Patients who are not testable due to drowsiness or disturbed attention, are scored with two points. Patients managing seven or more months correctly, are scored with 0. 4) Acute change or fluctuating course. If there is evidence of change or fluctuation in alterness, cognition or other mental functions that have arisen over the last two weeks and are still present within the last 24 hours, the patient is scored with four points. If not, the patient is scored with 0 points. This subscore often requires information from a next of kin. When performed by delirium experts or researchers, the 4AT detects delirium in acutely ill patients with a sensitivity of 76% and a specificity of 95% [ 12 ]. We used the Norwegian translation of the 4AT in this study [ 19 ]. 4AT was conducted by ED nurses and doctors without any previouis experience with the screening tool, except from a 45-minute introduction lecture. The screening was performed in the ED within two hours of admission. The operating nurse or doctor registered the number of minutes used on the delirium screening, and if they found the screening tool useful or not in each case. qSOFA. The qSOFA score assesses the risk of poor outcome in patients with infections. Systolic blood pressure ≤ 100 mm Hg, respiratory rate of ≥ 22/min, and altered mental status are scored with one point each. The most recent consensus on sepsis management (Sepsis-3) suggests that one point for altered mental status should be given when the Glasgow Coma Scale score is < 15 [ 1 ]. A qSOFA score ≥ 2 should prompt clinicians to further investigate for organ dysfunction, initiate sepsis therapy and consider increased monitoring. A recent meta-analysis reported that the qSOFA predicts mortality with a pooled sensitivity of 42% and a pooled specificity of 88% in ED patients with infections [ 17 ]. Delirium. We diagnosed delirium retrospectively during a thorough review of the patients’ hospital records, and according to The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 [ 20 ]. We used a chart-based method aiming to extract evidence for each of the diagnostic criteria, from hospital records, including daily notes by both doctors, nurses, and other staff. This method has been used in previous studies [ 21 ], and shows acceptable validity when performed by delirium experts or delirium researchers [ 22 , 23 ]. We classified cases with evidence of an acute change in altertness, cognition, or other mental functions, as delirium [ 11 ]. Sepsis . We defined sepsis according to existing guidelines, as an evident infection, based on the history and a thorough clinical evaluation, including laboratory and radiological findings, with an acute (within 24 hours) change in total Sequential Organ Failure Assessment (SOFA) score of ≥ 2 points consequent to the infection [ 1 ]. SOFA grades impairment by organ system in patients with infection, and accounts for clinical interventions [ 24 ]. A change in SOFA score ≥ 2 points indicates organ dysfunction [ 25 ]. Septic shock was defined as sepsis identified by SOFA with a mean arterial pressure less than 65 mm Hg despite vasopressor therapy, and hyperlactatemia (> 2 mMol/L, 18 mg/dL) after volume resuscitation [ 1 ]. We also registered ICD-10 codes for sepsis (A39.2, A40, A41, I33.0, G00, R65) given at discharge from the hospital. Infection diagnoses. Infections were defined based on ICD-10 codes from the actual hospital stay. Mortality. In-hospital mortality was defined as death from any cause during the hospital stay. Other measures. Age, length of hospital stay, and discharge destination were retrieved from hospital records. Statistical methods Continuous variables are presented as the mean ± standard deviation and categorical variables as a number (%). We used Student’s t test for means of continuous variables, and Pearson’s Chi-square test of independence for categorical variables to compare characteristics between patients with and without sepsis, patients of different age groups, and patients included at the two different study sites. A p-value < 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS version 25.0 (IBM, Armonk, NY, USA). Patient and public involvement Patient or public involvement in the design, execution or dissemination of results of the present study was not considered feasible or relevant. Ethical considerations This was a study without interventions that could harm the patients. Delirium screening with 4AT was rapid and did not delay sepsis treatment. The HDH part of the study was approved by the Regional Committee of Research Ethics in Western Norway (2018/909/REK vest). The BH part of the study was approved as a quality study by the hospital officer for data protection (16/00117 − 85). Since only routine clinical data were collected from the electronic health records, the requirement for informed consent was waived. A letter with information about the study was sent by post to all patients after discharge, allowing the patient to withdraw their data. The study complies with the Declaration of Helsinki. Results A total of 229 patients aged 65 years and older were included in the study. After exclusion of six patients who withdrew from the study, and 27 patients without an infectious disease (as defined by ICD-10 codes), 196 patients (mean age 81.1 years) were eligible for further analysis, 101 at BH and 95 at HDH, respectively. Characteristics of the study participants by study hospital are shown in Supplementary Table 2. Pneumonia was the most common diagnosis (45%), followed by urinary tract infection (34%), influenza (8%), skin infections (6%), abdominal infections (5%) and others (7%). In total, 100 patients (51%) fulfilled the criteria for sepsis, of whom three patients suffered septic shock. Table 1 shows the characteristics of patients with and without sepsis. Patients with sepsis were more likely to be men, and more often had renal failure and anemia, than patients without sepsis. Only 37 out of 100 patients (37%) were discharged with an ICD-code for sepsis. Table 1 Characteristics of patients aged 65 years and older admitted to two Norwegian Emergency Departments by sepsis diagnosis (n = 196). Sepsis (n = 100) No sepsis (n = 96) p-value Mean (SD) Mean (SD) Age (years) 81.3 (7.8) 80.9 (7.9) 0.75 Length of hospital stay (days) 8.1 (6.3) 6.9 (6.5) 0.18 C-reactive protein (mg/L) 1 177 (98) 153 (104) 0.10 n (%) n (%) Men 67 (67) 50 (52) < 0.05 Age group (years) 0.85 65–79 42 (42) 39 (41) ≥80 58 (58) 57 (59) Renal function (mL/min/1.73 m 2 ) 60 36 (36) 56 (56) eGFR < 30 24 (24) 5 (5) Hyponatremia 2 0.59 Mild 30 (31) 26 (27) Moderate 4 (4) 2 (2) Anemia 3 < 0.05 Moderate 83 (83) 66 (69) Severe 7 (7) 3 (3) Infection diagnosis 4 Pneumonia 41 (41) 46 (48) 0.33 Urinary tract infection 24 (25) 31 (32) 0.20 Influenza 9 (9) 6 (6) 0.47 Abdominal infection 7 (7) 3 (3) 0.22 Skin infection 5 (5) 7 (7) 0.50 Others 8 (8) 6 (6) 0.63 1 Maximum value during the hospital stay, 2 Mild hyponatremia, Serum Sodium 130–136 Mmol/L; Moderate hyponatremia, Serum Sodium 120–129 Mmol/L. 3 Moderate anemia, Hemoglobin < 12 g/dL for women and < 13 g/dL for men ; severe anemia, Hemoglobin < 8 g/dL, 4 Based on International Classification of Diseases-10 codes. SD, Standard Deviation; eGFR, estimated Glomerular Filtration Rate. The median time spent on the delirium screening with 4AT was two minutes (mean 2.5 minutes, registered in 164 (84%) patients). While qSOFA identified 48 patients with altered mental status, 114 patients (58%) had a 4AT score of at least one up on ED admission, indicating cognitive impairment. The operators valued the 4AT screening as useful in 77 out of 89 cases (78%) with cognitive impairment, and 43 out 68 cases (63%) without cognitive impairment (not reported in 30 cases). Table 2 shows qSOFA and 4AT scores in patients with and without sepsis. Sepsis patients more often had a 4AT score ≥ 4 upon ED admission, indicating delirium, than patients without sepsis (40% vs. 26%, p < 0.05). Disturbed attention (assessed with the Months Backwards Test) was the most common finding. Table 2 Quick Sequential Organ Failure Assessment scores and 4AT scores at Emergency Department admission by sepsis diagnosis in patients aged 65 and older admitted to two Norwegian Emergency Departments with suspected sepsis (n = 196). Sepsis (n = 100) No sepsis (n = 96) p-value Mean (SD) Mean (SD) qSOFA score 1 < 0.05 0 11 (11) 25 (26) 1 42 (42) 48 (50) 2 36 (36) 18 (19) 3 8 (8) 0 (0) Respiratory rate ≥ 22/min 81 (81) 56 (58) < 0.05 Systolic BP ≤ 100 mmHg 28 (28) 16 (17) 0.06 Altered mental status (GCS < 15) 1 31 (31) 17 (18) 0.08 4AT score 2 < 0.05 0 31 (31) 49 (52) 1–3 29 (29) 21 (22) ≥4 40 (40) 24 (26) 4AT subscores Reduced alertness 19 (19) 12 (13) 0.17 Cognitive impairment 56 (56) 27 (28) < 0.05 Disturbed attention 59 (59) 38 (40) < 0.05 Acute change or fluctuations 28 (28) 19 (21) 0.12 1 Altered mental status scored with one point when Glasgow Coma Scale score was < 15. Glasgow Coma Scale score and Quick Sequential Organ Failure Assessment score were missing in three patients with sepsis and five patients without sepsis, 2 4AT score was missing in two patients without sepsis. SD, Standard Deviation; SOFA, Sequential Organ Failure Assessment; GCS, Glasgow Coma Scale; BP, Blood Pressure; 4AT, 4 Assessment Test. Characteristics, qSOFA score and 4AT score in sepsis patients aged under 80 years and 80 years and older are shown in Table 3 . Older patients were more likely to have renal failure than younger sepsis patients, and were more often discharged to a nursing home. Although not statistically significant, older sepsis patients had lower values for C-reactive protein, stayed longer in hospital, and more often had symptoms of cognitive impairment at admission than younger sepsis patients. Table 3 Characteristics of patients with sepsis by age group (n = 100), among patients aged 65 and older admitted to two Norwegian Emergency Departments with suspected sepsis. Age ≥ 80 years (n = 58) Age < 80 years (n = 42) p-value Mean (SD) Mean (SD) Age (years) 86.9 (4.6) 73.6 (3.7) 22/min 48 (83) 33 (79) 0.60 Systolic BP < 100 mmHg 17 (29) 11 (26) 0.73 Altered mental status (GCS ≤ 14) 17 (31) 14 (33) 0.32 Renal function (mL/min/1.73 m 2 ) 2 60 12 (21) 24 (57) eGFR < 30 21 (36) 3 (7) Hyponatremia 2, 3 0.09 Mild 12 (21) 18 (43) Moderate 2 (3) 2 (5) Anemia 2, 4 0.68 Moderate 48 (83) 35 (83) Severe 5 (9) 2 (5) 4AT-score 0.37 0 15 (26) 16 (38) 1–3 17 (29) 12 (29) ≥4 26 (45) 14 (33) 4AT subscores Reduced alertness 11 (19) 8 (19) 0.99 Cognitive impairment 37 (64) 19 (45) 0.11 Disturbed attention 37 (64) 24 (52) 0.33 Acute change or fluctuations 19 (33) 9 (21) 0.30 Infection diagnosis 5 Pneumonia 18 (31) 23 (55) < 0.05 Urinary tract infection 15 (26) 9 (21) 0.61 Influenza 6 (10) 3 (7) 0.58 Abdominal infection 6 (10) 1 (2) 0.12 Skin infection 3 (5) 2 (5) 0.93 Others 6 (10) 2 (5) 0.31 Discharge destination < 0.05 Home 20 (35) 28 (67) Institution 29 (50) 11 (26) In-hospital mortality 8 (14) 1 (2) < 0.05 1 Highest value during the hospital stay, 2 Lowest value during the hospital stay, 3 Mild hyponatremia, Serum Sodium 130–136 Mmol/L; Moderate hyponatremia, Serum Sodium 120–129 Mmol/L, 4 Moderate anemia, Hemoglobin < 12 g/dL for women and < 13 g/dL for men ; severe anemia, Hemoglobin < 8 g/dL, 5 Based on International Classification of Diseases-10 codes. SD, Standard Deviation; SOFA, Sequential Organ Failure Assessment; qSOFA, quick SOFA; GCS, Glasgow Coma Scale; BP, Blood Pressure; eGFR, estimated Glomerular Filtration Rate; 4AT, 4 Assessment Test; SIRS, Systemic Inflammatory Response Syndrom; Mild hyponatremia, Serum Sodium 130–136 Mmol/L; Moderate hyponatremia, Serum Sodium 120–129 Mmol/L. A total of 102 patients (52%), had delirium anytime during the hospital stay. Out of these, 61 (60%) had a 4AT score ≥ 4 indicating delirium already upon ED admission. The prevalence of delirium anytime during the hospital stay was 44% in patients aged 65–80 years, and 57% in patients aged 80 years and older. Out of 100 patients with sepsis, 68 had delirium during the hospital stay. Patients aged 80 years and older with sepsis had the highest prevalence of delirium (44 out of 58, 76%). Ten patients (5%) died during their hospital stay; nine patients with sepsis and one patient without sepsis (in-hospital mortality 9% vs. 1%, p < 0.05). In-hospital mortality was 14% in sepsis patients aged ≥ 80 years and 2% in sepsis patients aged 65–79 years (p < 0.05). A qSOFA score ≥ 2 at ED admission predicted in-hospital mortality with a sensitivity and specificity of 50% and 68%, respectively. Discussion To our knowledge, this is the first study evaluating the feasibility of delirium screening with 4AT upon ED admission carried out by nurses and doctors without any previous experience with the 4AT. The use of 4AT was feasible, and compared to qSOFA, 4AT gave a more detailed characterization of cognitive impairment and features of delirium. In line with previous studies of acutely ill older patients, we found that symptoms of cognitive impairment or delirium were highly prevalent already at hospital admission [ 6 – 9 ]. In particular, many patients with sepsis had a 4AT-score of four or more, indicating delirium. Delirium features can represent clinical deterioration and delirium is associated with poor outcome [ 9 ]. The pathophysiological mechanisms explaining delirium in acutely ill patients are not full understood [ 26 ]. In patients with sepsis, however, both cerebral hypoperfusion, due to hypotension, and cerebral hypoxia could play a role. This study demonstrated a particulary high prevalence of delirium among patients with sepsis aged 80 years and older. It has been suggested that delirium screening should be implemented in routine practice in patients groups with a high risk of suffering delirium [ 7 , 12 ]. Our findings support that increased awareness of delirium in older patients acutely admitted to hospital with suspected sepsis is necessary, and indicate a high prevalence of delirium features already at ED admission. We believe that systematic screening is useful in this patient group, but this needs to be addressed in future studies. The 4AT has been characterized as rapid and practical tool that does not require special training. Validation studies of 4AT have demonstrated high sensitivity and specificity to predict delirium among ED patients [ 12 , 27 , 28 ]. In these studies, however, 4AT has been performed by delirium experts or trained research assistants, often many hours after hospital admission. The validity of the 4AT might be lower in other settings and dependent on both the operators and the timing of the assessment [ 21 ]. Hence, further studies are needed to assess its use in different settings. The risk of delayed sepsis treatment and the high workload in many EDs could be counterarguments to introducing a new diagnostic tool. However, in patients with cognitive impairment or delirium, a rapid screening with 4AT might provide important additional information. In this study, the median time spent on the 4AT assessment was only two minutes, and in line with a previous report, the nurses and doctors valued the delirium screening as useful in the majority of the cases [ 12 ]. Although the mean age of the patients in the current study was higher, the overall in-hospital mortality rate of 5% corresponds with previous studies. In a Norwegian study of patients admitted to the ED of a university hospital, the mortality after seven days was 7% [ 14 ]. The ability of qSOFA to predict in-hospital mortality was limited, with sensitivity and specificity comparable to previous studies [ 14 – 17 ]. Strengths and limitations Our study included old patients with symptoms of cognitive impairment and with delirium, patient groups that are often excluded from clinical studies. Furthermore, we investigated a delirium screening tool used upon ED admission, performed by nurses and doctors inexperienced with the tool, and without particular expertise in delirium diagnosis. Such an approach, together with the inclusion of patients at two general hospitals in different cities, might have improved the generalizability of our findings. On the other hand, differences in routine practice and seasonal differences in regards to patient inclusion might have introduced skewness in the data, with the risk of bias. Further limitations were the retrospective registration of sepsis and delirium diagnoses, and the lack of information about patients excluded from the study. Finally, the study did not assess inter-operator variability, and the results could be biased by the limited operator training prior to the study and the many operators involved in the study. Conclusions The delirium screening tool 4AT was feasible upon ED admission in patients aged 65 years and older with suspected sepsis, when performed by nurses and doctors inexperiencedwith this tool. Two out of three patients had at least one feature of delirium upon ED admission. Sepsis patients more often had a 4AT score ≥ 4, indicating delirium. More than half of the patients had delirium during the hospital stay. The prevalence of delirium was highest among the oldest patients and in patients with sepsis. Our findings suggest that increased awareness of delirium features among older patients with suspected sepsis is important. Future studies should further evaluate the added value of delirium screening with 4AT in different settings. Declarations Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available, but are available from the corresponding author upon reasonable request. Acknowledgements Thanks to Ida Wilson Landgraff for proof reading the manuscript. Funding KK’s work was financed by local quality project funds from the Western Norway Health Authority (HV1279). All other authors are employees at the Vestre Viken Hospital Trust or the Haraldsplass Diaconess Hospital. Contributions MM, KK, SH, NL, BK and MSB contributed to the data collection. MM and SN were responsible for the statistical analyses. MM drafted the manuscript. All authors reviewed and revised the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. All authors read and approved the final manuscript. Ethics declarations Ethics approval and consent to participate The Regional Committee of Research Ethicsand the Hospital Trust institutional review board approved the study as minimal risk as only routine clinical data were collected from the electronic health records. Hence, the requirement for informed consent was waived. However, a letter with information about the study was sent by post to all patients, enabling the patient to withdraw their data. Consent for publication The publication of the results from this study was approved by The Regional Committee of Research Ethicsand the Hospital Trust institutional review board Competing interests The authors declare that they have no competing interests related to this work. References Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–10. doi: 10.1001/jama.2016.0287 . Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395:200–11. doi: 10.1016/S0140-6736(19)32989-7 . Resnick NM, Marcantonio ER. How should clinical care of the aged differ? Lancet. 1997;350:1157–8. Knoop ST, Skrede S, Langeland N, Flaatten HK. 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Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies. Clin Microbiol Infect. 2018;24:1123–9. doi: 10.1016/j.cmi.2018.03.032 . Jiang J, Yang J, Mei J, Jin Y, Lu Y. Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2018;26:56. doi: 10.1186/s13049-018-0527-9 . https://www.the4at.com. Accessed 11 February 2021. Evensen S, Forr T, Al-Fattal A, de Groot C, Lonne G, Gjevjon ER, et al. New tool to detect delirium and cognitive impairment. Tidsskr Nor Laegeforen. 2016;136:299–300. doi: 10.4045/tidsskr.15.1334 . American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2018. Myrstad M, Watne LO, Johnsen NT, Børs-Lind E, Neerland BE. Delirium screening in an acute geriatric ward by nurses using 4AT: results from a quality improvement project. Eur Ger Med. 2019;10:667–71. doi: 10.1007/s41999-019-00215-y . Inouye SK, Leo-Summers L, Zhang Y, Bogardus ST Jr, Leslie DL, Agostini JV. A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method. J Am Geriatr Soc. 2005;53:312–8. Kuhn E, Du X, McGrath K, Coveney S, O’Regan N, Richardson S, et al. Validation of a consensus method for identifying delirium from hospital records. PLoS One. 2014;9:e111823. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ impairment/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707–10. doi: 10.1007/BF01709751 . Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:762–74. doi: 10.1001/jama.2016.0288 . Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, et al. Delirium Nat Rev Dis Primers. 2020;6(1):90. doi: 10.1038/s41572-020-00223-4 . O'Sullivan D, Brady N, Manning E, O'Shea E, O'Grady S. N OR, et al. Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees. Age Ageing. 2018;47:61–8. doi: 10.1093/ageing/afx149 . Gagné AJ, Voyer P, Boucher V, Nadeau A, Carmichael PH, Pelletier M, et al. Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department. CJEM. 2018;20:903–10. doi: 10.1017/cem.2018.367 . Supplementary Files Supplementarytable1.docx Supplementarytable2.docx Graphicalabstract.pdf Graphical abstract - Delirium screening with 4AT in the Emergency Department. Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2021 Read the published version in European Geriatric Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-267220","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Original research","associatedPublications":[],"authors":[{"id":13417026,"identity":"b3595590-a12b-4344-84f2-4d2a90bb2c7e","order_by":0,"name":"Marius 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AS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kanika","middleName":"","lastName":"Kuwelker","suffix":""},{"id":13417028,"identity":"175d1437-916f-4a7f-9ec7-44ec4d972c30","order_by":2,"name":"Sigurd Haakonsen","email":"","orcid":"","institution":"Baerum Hospital: Baerum sykehus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sigurd","middleName":"","lastName":"Haakonsen","suffix":""},{"id":13417029,"identity":"af7f0829-9b44-4bd9-a3ec-a20933005978","order_by":3,"name":"Therese Valebjørg","email":"","orcid":"","institution":"Baerum Hospital: Baerum sykehus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Therese","middleName":"","lastName":"Valebjørg","suffix":""},{"id":13417030,"identity":"6826b0c8-fa54-445e-84e8-5fbe2f70ef52","order_by":4,"name":"Bård Reiakvam Kittang","email":"","orcid":"","institution":"Haraldsplass Diakonale Sykehus AS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bård","middleName":"Reiakvam","lastName":"Kittang","suffix":""},{"id":13417031,"identity":"59647657-5c43-4db5-bd57-17d70850cd6e","order_by":5,"name":"Guri Hagberg","email":"","orcid":"","institution":"Baerum Hospital: Baerum sykehus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guri","middleName":"","lastName":"Hagberg","suffix":""},{"id":13417032,"identity":"4769d95d-dd0a-47dd-8721-68b122df3300","order_by":6,"name":"Bjørn Erik Neerland","email":"","orcid":"","institution":"Oslo Universitetssykehus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bjørn","middleName":"Erik","lastName":"Neerland","suffix":""},{"id":13417033,"identity":"fc71dbe1-290c-41f5-8980-b8190b8b8b8b","order_by":7,"name":"Marit Stordal Bakken","email":"","orcid":"","institution":"Haraldsplass Diakonale Sykehus AS","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marit","middleName":"Stordal","lastName":"Bakken","suffix":""}],"badges":[],"createdAt":"2021-02-22 14:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-267220/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-267220/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s41999-021-00558-5","type":"published","date":"2021-10-08T21:19:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":18456386,"identity":"1bf694ba-d8e3-4a28-b7c6-f8e86bb3dabe","added_by":"auto","created_at":"2022-02-21 21:19:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":371374,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-267220/v1/977b0e1e-95af-412a-904b-8d1424c07521.pdf"},{"id":6620365,"identity":"2715d918-3b09-496a-aa81-8b8e3002c516","added_by":"auto","created_at":"2021-03-04 20:49:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12536,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-267220/v1/c1e6fa78ba15bc7a2608ed32.docx"},{"id":6620644,"identity":"0717e082-1f4c-4e81-9fd4-9d2c6e2d6753","added_by":"auto","created_at":"2021-03-04 20:52:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19801,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-267220/v1/f3c3893cc880200cd1bbf8a1.docx"},{"id":6620367,"identity":"8494665e-5677-438d-9b31-24a72bb45392","added_by":"auto","created_at":"2021-03-04 20:49:46","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":462882,"visible":true,"origin":"","legend":"Graphical abstract - Delirium screening with 4AT in the Emergency Department.","description":"","filename":"Graphicalabstract.pdf","url":"https://assets-eu.researchsquare.com/files/rs-267220/v1/85fd6255747796e52df4c3d7.pdf"}],"financialInterests":"","formattedTitle":"Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis – a prospective cohort study","fulltext":[{"header":"Background","content":" \u003cp\u003eSepsis is severe organ dysfunction caused by a dysregulated host response to infection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and is responsible for one out of five deaths worldwide [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Older people are more susceptible to severe infections and sepsis, probably due to multiple factors such as comorbidities, reduced physiological organ reserves, altered immune function, and institutionalization [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Yet, few studies have characterized old patients with sepsis in detail. Older people with acute illness more often present with discrete or atypical symptoms than younger, often leading to delayed diagnosis and treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Cognitive impairment and delirium are highly prevalent among acutely ill older people, and might further complicate the diagnostic evaluation. The incidence of delirium increases with increasing age [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and infections are among the most common precipitating factors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Delirium refers to a clinical state characterized by an acute alteration in alertness and attention, with an additional disturbance in cognition (i.e., memory deficit, disorientation, perception or language) that develops over a short period of time. Delirium is a clinical manifestation of an acute encephalopathy or brain dysfunction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], can be an important sign of clinical deterioration, and should prompt further evaluation and treatment of underlying causes. Furthermore, delirium is associated with increased mortality. Early recognition of delirium is important, because treatment can improve outcomes and general patient care. Although at least one out of ten patients admitted to Emergency Departments (EDs) are suffering from delirium [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], screening for this clinical entity is not performed routinely in many EDs, and delirium often remains undetected [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical risk scores are extensively used in EDs to facilitate optimal management of patients. The quick Sequential Organ Failure Assessment (qSOFA) is a recommended tool to predict poor outcome in patients with infection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Altered mental status is one of three clinical variables scored in the qSOFA. Thus, evaluation of cognitive function is a core component of emergency medicine. However, previous studies have demonstrated a relatively poor ability of qSOFA performed in the ED to predict sepsis and sepsis-related mortality [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and qSOFA only offers a crude evaluation of cognitive function. The 4 'A's Test (4AT) is a rapid bedside delirium screening tool that assesses the major features of delirium; disturbed alertness, cognition and attention, and acute change or fluctuation in symptoms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The 4AT has a high sensitivity and specificity to detect delirium, and has been validated for use among ED patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Yet, we are not aware of any studies that have evaluated the feasibility of the 4AT upon ED arrival, performed by nurses and doctors without any previous experience with this tool.\u003c/p\u003e \u003cp\u003eWe aimed to study the feasibility of 4AT performed upon ED admission, and to characterize older patients admitted to the ED with suspected sepsis, particularly concerning symptoms of cognitive impairment and features of delirium.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThis was a prospective cohort study. We consecutively included patients aged 65 years and older with suspected sepsis (as judged by ED nurses or doctors), admitted to the EDs of two Norwegian general hospitals; B\u0026aelig;rum Hospital (BH) Vestre Viken Hospital Trust in the Oslo region, and Haraldsplass Deaconess Hospital (HDH) in Bergen. Patients were included during the periods from October 23rd 2017 to May 14th 2018 at BH and June 18th to October 14th 2018 at HDH. Patients, for whom an International Classification of Diseases 10th Revision (ICD-10) code corresponding to an infectious disease was not registered for the current hospital stay, were excluded from the analysis. A list of the infectious disease ICD-10-codes used for this purpose, is provided as Supplementary material (Supplementary table 1).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eAssessments\u003c/h2\u003e\u003cp\u003e\u003cem\u003e4AT.\u003c/em\u003e The 4 'A's test assesses four core features of delirium [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A total 4AT score of 1\u0026ndash;3 indicates possible cognitive impairment, and a score of four or above indicates possible delirum. In patients with a 4AT score of 0, delirium or severe cognitive impairment are unlikely. The 4AT consists of four subscores, with each representing one of the four \u0026lsquo;A\u0026rsquo;s; Alertness, Abbreviated Mental Test \u0026ndash; 4 (AMT4), Attention, and Acute change or fluctuating course:1) \u003cem\u003eAlertness\u003c/em\u003e (Is the patient fully alert and not markedly drowsy or agitated?). Patients with altered alertness during bedside assessment, are scored with four points. Patients who are not agitated, and fully alert, or have mild sleepiness for less than 10 seconds, are scored with 0 points. 2) \u003cem\u003eAMT4.\u003c/em\u003e This abbreviated cognitive assessment tests if the patient is oriented. The patient is asked to tell her/his age, date of birth, the name of the hospital or building, and the current year. While one mistake is scored with one point, and two or more mistankes with two points, correct answers give a score of 0. 3) \u003cem\u003eAttention.\u003c/em\u003e The patient is asked to list the months of the year in backward order. Patients who manages less than seven months, are scored with one point. Patients who are not testable due to drowsiness or disturbed attention, are scored with two points. Patients managing seven or more months correctly, are scored with 0. 4) \u003cem\u003eAcute change or fluctuating course.\u003c/em\u003e If there is evidence of change or fluctuation in alterness, cognition or other mental functions that have arisen over the last two weeks and are still present within the last 24 hours, the patient is scored with four points. If not, the patient is scored with 0 points. This subscore often requires information from a next of kin. When performed by delirium experts or researchers, the 4AT detects delirium in acutely ill patients with a sensitivity of 76% and a specificity of 95% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. We used the Norwegian translation of the 4AT in this study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. 4AT was conducted by ED nurses and doctors without any previouis experience with the screening tool, except from a 45-minute introduction lecture. The screening was performed in the ED within two hours of admission. The operating nurse or doctor registered the number of minutes used on the delirium screening, and if they found the screening tool useful or not in each case.\u003c/p\u003e\u003cp\u003e\u003cem\u003eqSOFA.\u003c/em\u003e The qSOFA score assesses the risk of poor outcome in patients with infections. Systolic blood pressure\u0026thinsp;\u0026le;\u0026thinsp;100 mm Hg, respiratory rate of \u0026ge;\u0026thinsp;22/min, and altered mental status are scored with one point each. The most recent consensus on sepsis management (Sepsis-3) suggests that one point for altered mental status should be given when the Glasgow Coma Scale score is \u0026lt;\u0026thinsp;15 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A qSOFA score\u0026thinsp;\u0026ge;\u0026thinsp;2 should prompt clinicians to further investigate for organ dysfunction, initiate sepsis therapy and consider increased monitoring. A recent meta-analysis reported that the qSOFA predicts mortality with a pooled sensitivity of 42% and a pooled specificity of 88% in ED patients with infections [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eDelirium.\u003c/em\u003e We diagnosed delirium retrospectively during a thorough review of the patients\u0026rsquo; hospital records, and according to The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We used a chart-based method aiming to extract evidence for each of the diagnostic criteria, from hospital records, including daily notes by both doctors, nurses, and other staff. This method has been used in previous studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and shows acceptable validity when performed by delirium experts or delirium researchers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We classified cases with evidence of an acute change in altertness, cognition, or other mental functions, as delirium [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eSepsis\u003c/em\u003e. We defined sepsis according to existing guidelines, as an evident infection, based on the history and a thorough clinical evaluation, including laboratory and radiological findings, with an acute (within 24 hours) change in total Sequential Organ Failure Assessment (SOFA) score of \u0026ge;\u0026thinsp;2 points consequent to the infection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. SOFA grades impairment by organ system in patients with infection, and accounts for clinical interventions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A change in SOFA score\u0026thinsp;\u0026ge;\u0026thinsp;2 points indicates organ dysfunction [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Septic shock was defined as sepsis identified by SOFA with a mean arterial pressure less than 65 mm Hg despite vasopressor therapy, and hyperlactatemia (\u0026gt;\u0026thinsp;2 mMol/L, 18 mg/dL) after volume resuscitation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. We also registered ICD-10 codes for sepsis (A39.2, A40, A41, I33.0, G00, R65) given at discharge from the hospital.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInfection diagnoses.\u003c/em\u003e Infections were defined based on ICD-10 codes from the actual hospital stay.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMortality.\u003c/em\u003e In-hospital mortality was defined as death from any cause during the hospital stay.\u003c/p\u003e\u003cp\u003e\u003cem\u003eOther measures.\u003c/em\u003e Age, length of hospital stay, and discharge destination were retrieved from hospital records.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical methods\u003c/h2\u003e\u003cp\u003eContinuous variables are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and categorical variables as a number (%). We used Student\u0026rsquo;s t test for means of continuous variables, and Pearson\u0026rsquo;s Chi-square test of independence for categorical variables to compare characteristics between patients with and without sepsis, patients of different age groups, and patients included at the two different study sites. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were conducted using SPSS version 25.0 (IBM, Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003ePatient and public involvement\u003c/h2\u003e\u003cp\u003ePatient or public involvement in the design, execution or dissemination of results of the present study was not considered feasible or relevant.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eEthical considerations\u003c/h2\u003e\u003cp\u003eThis was a study without interventions that could harm the patients. Delirium screening with 4AT was rapid and did not delay sepsis treatment. \u003cdiv class=\"Ethics-ToolTip\"\u003eThe HDH part of the study was approved by the Regional Committee of Research Ethics in Western Norway (2018/909/REK vest).\u003c/div\u003e\u003cdiv class=\"Ethics-ToolTip\"\u003eThe BH part of the study was approved as a quality study by the hospital officer for data protection (16/00117\u0026thinsp;\u0026minus;\u0026thinsp;85).\u003c/div\u003e\u003cdiv class=\"Ethics-ToolTip\"\u003eSince only routine clinical data were collected from the electronic health records, the requirement for informed consent was waived.\u003c/div\u003e A letter with information about the study was sent by post to all patients after discharge, allowing the patient to withdraw their data. The study complies with the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":" \u003cp\u003eA total of 229 patients aged 65 years and older were included in the study. After exclusion of six patients who withdrew from the study, and 27 patients without an infectious disease (as defined by ICD-10 codes), 196 patients (mean age 81.1 years) were eligible for further analysis, 101 at BH and 95 at HDH, respectively. Characteristics of the study participants by study hospital are shown in Supplementary Table\u0026nbsp;2. Pneumonia was the most common diagnosis (45%), followed by urinary tract infection (34%), influenza (8%), skin infections (6%), abdominal infections (5%) and others (7%).\u003c/p\u003e \u003cp\u003eIn total, 100 patients (51%) fulfilled the criteria for sepsis, of whom three patients suffered septic shock. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the characteristics of patients with and without sepsis. Patients with sepsis were more likely to be men, and more often had renal failure and anemia, than patients without sepsis. Only 37 out of 100 patients (37%) were discharged with an ICD-code for sepsis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients aged 65 years and older admitted to two Norwegian Emergency Departments by sepsis diagnosis (n\u0026thinsp;=\u0026thinsp;196).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo sepsis\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.3 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.9 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.1 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.9 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein (mg/L)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177 (98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153 (104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal function (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyponatremia\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection diagnosis\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluenza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003e Maximum value during the hospital stay, \u003csup\u003e2\u003c/sup\u003e Mild hyponatremia, Serum Sodium 130\u0026ndash;136 Mmol/L; Moderate hyponatremia, Serum Sodium 120\u0026ndash;129 Mmol/L. \u003csup\u003e3\u003c/sup\u003e Moderate anemia, Hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL for women and \u0026lt;\u0026thinsp;13 g/dL for men ; severe anemia, Hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;8 g/dL, \u003csup\u003e4\u003c/sup\u003e Based on International Classification of Diseases-10 codes.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, Standard Deviation; eGFR, estimated Glomerular Filtration Rate.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median time spent on the delirium screening with 4AT was two minutes (mean 2.5 minutes, registered in 164 (84%) patients). While qSOFA identified 48 patients with altered mental status, 114 patients (58%) had a 4AT score of at least one up on ED admission, indicating cognitive impairment. The operators valued the 4AT screening as useful in 77 out of 89 cases (78%) with cognitive impairment, and 43 out 68 cases (63%) without cognitive impairment (not reported in 30 cases). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows qSOFA and 4AT scores in patients with and without sepsis. Sepsis patients more often had a 4AT score\u0026thinsp;\u0026ge;\u0026thinsp;4 upon ED admission, indicating delirium, than patients without sepsis (40% vs. 26%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Disturbed attention (assessed with the Months Backwards Test) was the most common finding.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuick Sequential Organ Failure Assessment scores and 4AT scores at Emergency Department admission by sepsis diagnosis in patients aged 65 and older admitted to two Norwegian Emergency Departments with suspected sepsis (n\u0026thinsp;=\u0026thinsp;196).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo sepsis\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;96)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eqSOFA score\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate\u0026thinsp;\u0026ge;\u0026thinsp;22/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP\u0026thinsp;\u0026le;\u0026thinsp;100 mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAltered mental status (GCS\u0026thinsp;\u0026lt;\u0026thinsp;15)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4AT score\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4AT subscores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced alertness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisturbed attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute change or fluctuations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003e Altered mental status scored with one point when Glasgow Coma Scale score was \u0026lt;\u0026thinsp;15. Glasgow Coma Scale score and Quick Sequential Organ Failure Assessment score were missing in three patients with sepsis and five patients without sepsis, \u003csup\u003e2\u003c/sup\u003e 4AT score was missing in two patients without sepsis.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, Standard Deviation; SOFA, Sequential Organ Failure Assessment; GCS, Glasgow Coma Scale; BP, Blood Pressure; 4AT, 4 Assessment Test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCharacteristics, qSOFA score and 4AT score in sepsis patients aged under 80 years and 80 years and older are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Older patients were more likely to have renal failure than younger sepsis patients, and were more often discharged to a nursing home. Although not statistically significant, older sepsis patients had lower values for C-reactive protein, stayed longer in hospital, and more often had symptoms of cognitive impairment at admission than younger sepsis patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients with sepsis by age group (n\u0026thinsp;=\u0026thinsp;100), among patients aged 65 and older admitted to two Norwegian Emergency Departments with suspected sepsis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;80 years\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;80 years\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.9 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.6 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.4 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive Protein (mg/L)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164 (95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eqSOFA\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate\u0026thinsp;\u0026gt;\u0026thinsp;22/min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP\u0026thinsp;\u0026lt;\u0026thinsp;100 mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAltered mental status (GCS\u0026thinsp;\u0026le;\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal function (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR\u0026thinsp;\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyponatremia\u003csup\u003e2, 3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003csup\u003e2, 4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4AT-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4AT subscores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduced alertness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisturbed attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute change or fluctuations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection diagnosis\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluenza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge destination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003e Highest value during the hospital stay, \u003csup\u003e2\u003c/sup\u003e Lowest value during the hospital stay, \u003csup\u003e3\u003c/sup\u003e Mild hyponatremia, Serum Sodium 130\u0026ndash;136 Mmol/L; Moderate hyponatremia, Serum Sodium 120\u0026ndash;129 Mmol/L, \u003csup\u003e4\u003c/sup\u003e Moderate anemia, Hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;12 g/dL for women and \u0026lt;\u0026thinsp;13 g/dL for men ; severe anemia, Hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;8 g/dL, \u003csup\u003e5\u003c/sup\u003e Based on International Classification of Diseases-10 codes.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, Standard Deviation; SOFA, Sequential Organ Failure Assessment; qSOFA, quick SOFA; GCS, Glasgow Coma Scale; BP, Blood Pressure; eGFR, estimated Glomerular Filtration Rate; 4AT, 4 Assessment Test; SIRS, Systemic Inflammatory Response Syndrom; Mild hyponatremia, Serum Sodium 130\u0026ndash;136 Mmol/L; Moderate hyponatremia, Serum Sodium 120\u0026ndash;129 Mmol/L.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 102 patients (52%), had delirium anytime during the hospital stay. Out of these, 61 (60%) had a 4AT score\u0026thinsp;\u0026ge;\u0026thinsp;4 indicating delirium already upon ED admission. The prevalence of delirium anytime during the hospital stay was 44% in patients aged 65\u0026ndash;80 years, and 57% in patients aged 80 years and older. Out of 100 patients with sepsis, 68 had delirium during the hospital stay. Patients aged 80 years and older with sepsis had the highest prevalence of delirium (44 out of 58, 76%).\u003c/p\u003e \u003cp\u003eTen patients (5%) died during their hospital stay; nine patients with sepsis and one patient without sepsis (in-hospital mortality 9% vs. 1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In-hospital mortality was 14% in sepsis patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years and 2% in sepsis patients aged 65\u0026ndash;79 years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A qSOFA score\u0026thinsp;\u0026ge;\u0026thinsp;2 at ED admission predicted in-hospital mortality with a sensitivity and specificity of 50% and 68%, respectively.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eTo our knowledge, this is the first study evaluating the feasibility of delirium screening with 4AT upon ED admission carried out by nurses and doctors without any previous experience with the 4AT. The use of 4AT was feasible, and compared to qSOFA, 4AT gave a more detailed characterization of cognitive impairment and features of delirium. In line with previous studies of acutely ill older patients, we found that symptoms of cognitive impairment or delirium were highly prevalent already at hospital admission [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn particular, many patients with sepsis had a 4AT-score of four or more, indicating delirium. Delirium features can represent clinical deterioration and delirium is associated with poor outcome [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The pathophysiological mechanisms explaining delirium in acutely ill patients are not full understood [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In patients with sepsis, however, both cerebral hypoperfusion, due to hypotension, and cerebral hypoxia could play a role.\u003c/p\u003e \u003cp\u003eThis study demonstrated a particulary high prevalence of delirium among patients with sepsis aged 80 years and older. It has been suggested that delirium screening should be implemented in routine practice in patients groups with a high risk of suffering delirium [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our findings support that increased awareness of delirium in older patients acutely admitted to hospital with suspected sepsis is necessary, and indicate a high prevalence of delirium features already at ED admission. We believe that systematic screening is useful in this patient group, but this needs to be addressed in future studies.\u003c/p\u003e \u003cp\u003eThe 4AT has been characterized as rapid and practical tool that does not require special training. Validation studies of 4AT have demonstrated high sensitivity and specificity to predict delirium among ED patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In these studies, however, 4AT has been performed by delirium experts or trained research assistants, often many hours after hospital admission. The validity of the 4AT might be lower in other settings and dependent on both the operators and the timing of the assessment [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Hence, further studies are needed to assess its use in different settings.\u003c/p\u003e \u003cp\u003eThe risk of delayed sepsis treatment and the high workload in many EDs could be counterarguments to introducing a new diagnostic tool. However, in patients with cognitive impairment or delirium, a rapid screening with 4AT might provide important additional information. In this study, the median time spent on the 4AT assessment was only two minutes, and in line with a previous report, the nurses and doctors valued the delirium screening as useful in the majority of the cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the mean age of the patients in the current study was higher, the overall in-hospital mortality rate of 5% corresponds with previous studies. In a Norwegian study of patients admitted to the ED of a university hospital, the mortality after seven days was 7% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The ability of qSOFA to predict in-hospital mortality was limited, with sensitivity and specificity comparable to previous studies [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOur study included old patients with symptoms of cognitive impairment and with delirium, patient groups that are often excluded from clinical studies. Furthermore, we investigated a delirium screening tool used upon ED admission, performed by nurses and doctors inexperienced with the tool, and without particular expertise in delirium diagnosis. Such an approach, together with the inclusion of patients at two general hospitals in different cities, might have improved the generalizability of our findings. On the other hand, differences in routine practice and seasonal differences in regards to patient inclusion might have introduced skewness in the data, with the risk of bias. Further limitations were the retrospective registration of sepsis and delirium diagnoses, and the lack of information about patients excluded from the study. Finally, the study did not assess inter-operator variability, and the results could be biased by the limited operator training prior to the study and the many operators involved in the study.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThe delirium screening tool 4AT was feasible upon ED admission in patients aged 65 years and older with suspected sepsis, when performed by nurses and doctors inexperiencedwith this tool. Two out of three patients had at least one feature of delirium upon ED admission. Sepsis patients more often had a 4AT score\u0026thinsp;\u0026ge;\u0026thinsp;4, indicating delirium. More than half of the patients had delirium during the hospital stay. The prevalence of delirium was highest among the oldest patients and in patients with sepsis. Our findings suggest that increased awareness of delirium features among older patients with suspected sepsis is important. Future studies should further evaluate the added value of delirium screening with 4AT in different settings.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available, but are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks to Ida Wilson Landgraff for proof reading the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKK\u0026rsquo;s work was financed by local quality project funds from the Western Norway Health Authority (HV1279). \u0026nbsp;All other authors are employees at the Vestre Viken Hospital Trust or the Haraldsplass Diaconess Hospital. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM, KK, SH, NL, BK and MSB contributed to the data collection. MM and SN were responsible for the statistical analyses. MM drafted the manuscript. All authors reviewed and revised the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Regional Committee of Research Ethicsand the Hospital Trust institutional review board approved the study as minimal risk as only routine clinical data were collected from the electronic health records. Hence, the requirement for informed consent was waived. However, a letter with information about the study was sent by post to all patients, enabling the patient to withdraw their data.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe publication of the results from this study was approved by The Regional Committee of Research Ethicsand the Hospital Trust institutional review board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests related to this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSinger M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 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CJEM. 2018;20:903\u0026ndash;10. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/cem.2018.367\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sepsis, qSOFA, delirium, infection, SOFA, emergency department, 4AT, encephalopathy","lastPublishedDoi":"10.21203/rs.3.rs-267220/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-267220/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCognitive impairment is common among acutely ill older patients admitted to hospital. The quick Sequential Organ Failure Assessment (qSOFA) is recommended as a tool to predict poor outcome in patients with suspected sepsis, but assesses cognitive function crudely. We aimed to study the feasibility of The 4 'A's test (4AT), a rapid delirium screening tool, performed upon Emergency Department (ED) admission by nurses and doctors inexperienced with this tool, and to characterize patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years admitted to the ED with suspected sepsis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this prospective cohort study, we included patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years, admitted to the EDs of two Norwegian general hospitals, with suspected sepsis. ED nurses and doctors performed delirium screening with 4AT within two hours after ED admission, and registered the time spent on the screening in each case. Sepsis and delirium during the hospital stay were diagnosed retrospectively, according to recommended diagnosis criteria.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of the 196 patients included (mean age 81 years), 100 patients fulfilled the sepsis diagnosis criteria. Mean 4AT screening time was 2.5 minutes (median two minutes). While qSOFA identified 48 patients (24%) with altered mental status, 114 patients (58%) had a 4AT score\u0026thinsp;\u0026ge;\u0026thinsp;1, indicating cognitive impairment, upon ED admission. Sepsis patients more often had a 4AT score\u0026thinsp;\u0026ge;\u0026thinsp;4, indicating delirium, than patients without sepsis (40% vs. 26%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The prevalence of delirium any time during the hospital stay was 44% in patients aged 65\u0026ndash;80 years, 57% in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years, and 76% in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;80 years with sepsis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDelirium screening upon ED admission, with 4AT performed by nurses and doctors inexperienced with this tool, was feasible among patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years admitted with suspected sepsis. Features of delirium were common upon ED admission, particularly in patients with sepsis. The prevalence of delirium anytime during the hospital stay was highest among patients aged 80 years and older with sepsis. Our findings suggest increased awareness of delirium in older patients admitted to the ED with suspected sepsis, but the added value of systematic delirium screening with 4AT needs to be addressed in future studies.\u003c/p\u003e","manuscriptTitle":"Delirium screening with 4AT in patients aged 65 years and older admitted to the Emergency Department with suspected sepsis – a prospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-04 20:49:44","doi":"10.21203/rs.3.rs-267220/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"967e8159-84b2-4bae-9f2c-827fa3040db2","owner":[],"postedDate":"March 4th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":2770496,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2022-02-21T21:19:42+00:00","versionOfRecord":{"articleIdentity":"rs-267220","link":"https://doi.org/10.1007/s41999-021-00558-5","journal":{"identity":"european-geriatric-medicine","isVorOnly":false,"title":"European Geriatric Medicine"},"publishedOn":"2021-10-08 21:19:42","publishedOnDateReadable":"October 8th, 2021"},"versionCreatedAt":"2021-03-04 20:49:44","video":"","vorDoi":"10.1007/s41999-021-00558-5","vorDoiUrl":"https://doi.org/10.1007/s41999-021-00558-5","workflowStages":[]},"version":"v1","identity":"rs-267220","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-267220","identity":"rs-267220","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}