Comparison between 4AT and mini-mental state examination tools for cognitive assessment of palliative care patients: A quality improvement project

Abstract

Background and objective: Cognitive impairment, including delirium, is common among patients with advanced cancer receiving palliative care, yet it often goes undetected. For the past 14 years, the Mini-Mental State Examination (MMSE), a globally recognized and validated tool, has been used by palliative care physicians in Qatar to assess cognitive function at the time of patient acceptance into the palliative care program. The aim of the study was to enhance the initial assessment of delirium and cognitive function in patients with advanced cancer by evaluating the feasibility and clinical utility of the Assessment Test for Delirium and Cognitive Impairment (4AT) screening tool alongside the MMSE.

Methods: A quality improvement initiative was conducted using the Plan-Do-Study-Act (PDSA) methodology. Fifty-three patients with advanced cancer were assessed using both the MMSE and the 4AT tools (in Arabic and English) on the first day of acceptance into the palliative care program. Pre- and post-intervention surveys were used to capture palliative care physicians’ perceptions and experiences with both tools.

Results: Physicians reported that the 4AT tool was simpler and faster to administer (100%), effective in assessing cognitive status (75%), provided useful clinical information (62.5%), and was well accepted by patients (100%). While the MMSE remains a well-established assessment tool, the 4AT was viewed as a more practical option for routine use in busy clinical settings.

Conclusions: The 4AT tool demonstrates strong potential as a complementary or alternative approach to the MMSE for initial cognitive screening in palliative care. Its brevity, ease of use, and patient acceptability make it well-suited for routine clinical practice, particularly in settings requiring rapid cognitive assessment.

Keywords

Cognitive impairment / Cognitive screening tool / 4AT / MMSE / Palliative care

References

[1] Watt CL, Scott M, Webber C, et al. Delirium screening tools validated in the context of palliative care: A systematic review. Palliative Medicine. 2021 Apr; 35(4): 683-96. PMid:33588640 https://doi.org/10.1177/0269216321994730

[2] Fayers PM, Hjermstad MJ, Ranhoff AH, et al. Which mini-mental state exam items can be used to screen for delirium and cognitive impairment?. Journal of Pain and Symptom Management. 2005 Jul 1; 30(1): 41-50. PMid:16043006 https://doi.org/10.1016/j.jpainsymman.2005.05.001

[3] Hosie A, Agar M, Lobb E, et al. Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis. International Journal of Nursing Studies. 2017; 75: 123-129. PMid:28783489 https://doi.org/10.1016/j.ijnurstu.2017.07.007

[4] Recchia A, Rizzi B, Favero A, et al. Prevalence of Delirium in End-of-Life Palliative Care Patients: An Observational Study. Medical Principles and Practice. 2022; 31(2): 118-24. PMid:35038708 https://doi.org/10.1159/000521994

[5] Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research. 1975 Nov 1; 12(3): 189-98. PMid:1202204 https://doi.org/10.1016/0022-3956(75)90026-6

[6] Robinson J. Cognitive assessment of palliative care patients. Progress in Palliative Care. 1999 Jan 1; 7(6): 291-8. https://doi.org/10.1080/09699260.1999.11746854

[7] Hjermstad MJ, Loge JH, Kaasa S.Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research. Palliative medicine. 2004 Sep; 18(6): 494-506. PMid:15453620 https://doi.org/10.1191/0269216304pm920oa

[8] Devenney E, Hodges JR. The mini-mental state examination: pitfalls and limitations. Practical neurology. 2017 Feb 1; 17(1): 79-80. PMid:27903765 https://doi.org/10.1136/practneurol-2016-001520

[9] Monroe T, Carter M.Using the Folstein Mini Mental State Exam (MMSE)toexploremethodologicalissuesincognitiveagingresearch. European Journal of Ageing. 2012 Sep; 9: 265-74. PMid:28804426 https://doi.org/10.1007/s10433-012-0234-8

[10] Mudge AM, Lee-Steere K, Treleaven E, et al. Cognitive impairment in older hospital inpatients: prevalence, care needs and carer perceptions. Australian Health Review. 2021; 46(2): 244-250. PMid:34856117 https://doi.org/10.1071/AH20286

[11] Lees R, Corbet S, Johnston C, et al. Test Accuracy of Short Screening Tests for Diagnosis of Delirium or Cognitive Impairment in an Acute Stroke Unit Setting. Stroke. 2013; 44(11): 3078-3083. PMid:23988641 https://doi.org/10.1161/STROKEAHA.113.001724

[12] Arnold E, Finucane AM, Spiller JA, et al. Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study. AMRC Open Research [Internet]. 2021 Apr 26; 3: 16. PMid:35966135 https://doi.org/10.12688/amrcopenres.12973.1

[13] Tieges Z, Lowrey J, MacLullich AM.What delirium detection tools are used in routine clinical practice in the United Kingdom? Survey results from 91% of acute healthcare organisations. European Geriatric Medicine. 2021 Dec; 12(6): 1293-8. PMid:34008099 https://doi.org/10.1007/s41999-021-00507-2

[14] Baird L, Spiller JA.A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM? BMJ Open Quality [Internet]. 2017 Aug; 6(2): e000153. PMid:28959786 https://doi.org/10.1136/bmjoq-2017-000153

[15] Shenkin SD, Fox C, Godfrey M, et al. Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study. BMJ open. 2018 Feb 1; 8(2): e015572. PMid:29440152 https://doi.org/10.1136/bmjopen-2016-015572

[16] Bellelli G, Morandi A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised olderpeople. Age andAgeing[Internet]. 2014 Mar2; 43(4): 496-502. PMid:24590568 https://doi.org/10.1093/ageing/afu021

[17] Kuladee S, Prachason T. Development and validation of the Thai version of the 4 ‘A’s Test for delirium screening in hospitalized elderly patients with acute medical illnesses. Neuropsychiatric Disease and Treatment. 2016 Feb 24: 437-43. PMid:26966365 https://doi.org/10.2147/NDT.S97228

[18] De J, Wand AP, Smerdely PI, et al. Validating the 4A’s test in screening for delirium in a culturally diverse geriatric inpatient population. International Journal of Geriatric Psychiatry. 2017 Dec; 32(12): 1322-9. PMid:27766672 https://doi.org/10.1002/gps.4615

[19] Evensen S, Hylen Ranhoff A, Lydersen S, et al. The delirium screening tool 4AT in routine clinical practice: prediction of mortality, sensitivity and specificity. European Geriatric Medicine. 2021 Aug; 12: 793-800. PMid:33813725 https://doi.org/10.1007/s41999-021-00489-1

[20] Hasegawa T, Seo T, Kubota Y, et al. Reliability and validity of the Japanese version of the 4A’s Test for delirium screening in the elderly patient. Asian journal of psychiatry. 2022 Jan 1; 67: 102918. PMid:34798384 https://doi.org/10.1016/j.ajp.2021.102918