Alasdair Maurice Joseph MacLullich

Background: Presenting features of delirium can be difficult to distinguish from co-existing dementia phenomenology. While the 4 ‘A’s Test (4AT) is a well validated delirium screening tool across multiple patient populations and healthcare settings, how its diagnostic performance varies across different levels of baseline cognition is unclear. Methods: This study harmonises data from two prospective cohorts: the Delirium and Population Health Informatics Cohort (DELPHIC) and Delirium and Cognitive Impact in Dementia (DECIDE). Both cohorts were stratified into tertiles according to baseline cognition. Delirium was defined using DSM-IV (DELPHIC) and DSM-V (DECIDE). 4AT domain scores were operationalised from relevant delirium assessments within each study (MDAS, OSLA, months of the year backwards); item 4 was drawn from assessments of fluctuation. This process yielded an operationalised 4AT. Diagnostic accuracy of the operationalised 4AT was calculated using sensitivity, specificity, and receiver operating characteristics, with pooled estimates for each test domain. Results: Among 396 unique participants and 2468 assessments across both studies, pooled 4AT sensitivity and specificity were 0.73 and 0.89, respectively. Overall 4AT performance was consistent across cognitive tertiles (sensitivity: high 0.82, middle 0.73, low 0.71; specificity: high 0.91; middle 0.92; low 0.86). Conclusions: The operationalised 4AT showed good diagnostic performance in all three levels of baseline cognition. Sensitivity would likely have been higher had clinical information to inform 4AT item 4 been available. Overall, however, the findings support the value of bedside 4AT items in detecting delirium in hospitalised patients across the spectrum of baseline cognition.

Background: Delirium affects one-in-four hospitalized individuals aged 65-years or older, and is associated with serious complications, including post-traumatic stress disorder, prolonged hospitalization, and increased mortality. Healthcare professionals often lack insight into the distress that patients experience; this is known to undermine empathic care and timely detection. Virtual reality (VR) is emerging as a promising tool to enhance empathy and understanding of the patient experience due to its inherent immersive, embodied, and experience-based characteristics. Objective: To pilot and obtain preliminary subjective evidence on the usability, empathic impact, and educational value of a VR simulation grounded in qualitative evidence of patients’ delirium experiences. Methods: 23 university students completed a 7-minute VR delirium simulation and an immediate 42-item survey. This included usability items adapted from the System Usability Scale, items conceptually informed by different validated questionnaires, and study-specific items. Full instruments were not administered to minimize respondent burden and target context-specific elements. Spearman correlations explored response patterns. Open-ended items were summarized descriptively. Results: Twelve of 22 Likert items differed from neutrality (3) after correction. Participants found the simulation intuitive (M=4.30, SD=0.70, d=1.86) and its immersive nature engaging (M=4.22, SD=0.74, d=1.65), reporting increased empathy (M=4.39, SD=0.58, d= 2.39), improved understanding of delirium-related emotional distress (M=4.13, SD=0.81, d=1.48) and cognitive distortions (M=4.22, SD=0.60, d=1.81). They endorsed the integration of VR into health education and expressed interest in potential additional features. Qualitative responses highlighted VR’s value for empathy training and to improve doctor-patient communication, while calling for even greater realism and personalization. Conclusion: This pilot study suggests that VR simulations are perceived as effective, engaging tools for enhancing empathy and insight in delirium-related education and care training.

Aims: Periprosthetic femur fracture (PFF) data capture in national registries is recognised to be limited. The aim of this study was to use hospital level data to establish patient characteristics, describe PFF management and mortality (including standardized mortality rate (SMR)), and compare outcomes to native hip fractures (NHF) using Scottish Hip Fracture Audit (SHFA) data. Methods: A nationwide retrospective cohort study was conducted of all patients aged ≥ 50 years sustaining a PFF managed in 16 centres between 1 January and 31 December 2019. Data collected included patient demographic details, PFF, and management characteristics, along with outcomes including frailty and mortality. Comparison of PFF with NHF data was performed. Independent associations of PFF and mortality were evaluated with Cox regression survival analysis that were adjusted for confounders. Results: There were 328 PFFs (mean age 79 years (SD 10), 66% female (n = 217)). Compared with NHF, PFF patients were less frail (median Clinical Frailty Scale (CFS) 4 (IQR 3 to 5) vs 5 (IQR to 7); p < 0.001) and more likely to be home-dwelling (91% vs 76%; p < 0.001). The majority of PFFs were related to arthroplasty implants (n = 307 (93.5%) to: 228 hip (70%) and 79 knee (24%)). There were 175 patients (53%) managed with fixation, 99 (30%) with revision arthroplasty, and 50 (15%) managed nonoperatively. The one-year mortality rate and SMR were 20.8% (95% CI 16.2 to 25.0) and 2.74 (95% CI 2.10 to 3.40) for PFFs compared with 29% (95%CI 28.0-30.0) and 3.66 (95% CI 3.6 to 3.8) in NHFs, respectively. Factors independently associated with increased mortality risk were interprosthetic fractures (adjusted hazard ratio (aHR) 2.65 (95% CI 1.41 to 5.00); p = 0.003), male sex (aHR 1.76 (95% CI 1.11 to 2.78); p = 0.015), older age (per year aHR 1.07 (95% CI 1.04 to 1.11); p < 0.001), and higher pre-injury frailty (CFS 5 to 9: aHR 4.16 (95% CI 1.18 to 14.7); p = 0.027). Time to theatre and management strategy were not independently associated with increased mortality. Conclusion: PFFs are associated with an increased mortality risk, and result in functional decline. Coding limitations mean most PFFs are likely missed in arthroplasty registries, underestimating the true incidence. National registry integration and tailored multidisciplinary pathways, similar to those for NHF, are essential for improving outcomes and healthcare planning. Cite this article: Bone Joint J 2026;108-B(5):707–715.

Dementia diagnoses are captured across multiple routine data sources, but discrepancies between these may affect both care and research. This study determined the prevalence and overlap of recorded dementia across primary care, hospital and community prescribing data in a UK regional cohort, and examined whether outcomes differed by the setting in which dementia was first recorded. A retrospective cohort study of adults aged ≥65 years (n = 133 407) in a large Scottish health board. Dementia diagnoses recorded from 1 April 2016 to 1 April 2020 were identified across linked primary care, hospital discharge and prescribing records. Associations between source of first recorded dementia diagnosis and subsequent mortality and emergency hospitalisation were estimated using Cox proportional hazards and Fine–Gray competing-risks models. At baseline (1 April 2016), 7544/133407 individuals (5.7%) had recorded dementia: 95.1% in primary care, 73.3% in hospital and 54.3% in prescribing records. Over four years, 7359 of the remaining 125,863 individuals (5.8%) had newly recorded dementia: 70.2% in primary care, 22.2% in hospital and 7.6% in prescribing records. Only 35.9% of hospital-recorded diagnoses were coded in primary care within a year or at the time of death, if earlier. People first diagnosed in hospital were older, frailer, more socioeconomically deprived and had higher mortality than those first diagnosed in primary care [365 days: aHR 1.29, 95% CI 1.19–1.41]. Dementia is variably recorded across routine datasets, and the setting in which dementia is first recorded identifies groups with different prognoses. Improved data integration and scrutiny of hospital-based diagnostic pathways are needed to ensure diagnoses are reliably transferred and people with dementia receive timely, equitable postdiagnostic care.

Delirium is an aetiologically nonspecific cerebral syndrome characterised by disturbances in consciousness, attention, perception, cognition, memory, psych

Background: A crucial part of delirium care is assessing for recovery, yet there are no validated methods for this. The 4AT is a widely used delirium assessment tool, but its performance in assessing recovery remains unstudied. This study evaluated the 4AT’s performance in assessing recovery from delirium. Materials and methods: In this prospective diagnostic accuracy study, older hospitalised patients (≥70 years) with reference standard delirium on enrolment were assessed 2–4 times over ≤9 days. Paired researchers independently conducted blinded assessments of (i) a reference standard (Diagnostic and Statistical Manual for Mental Disorders, 5th edition), including the Delirium Rating Scale-Revised-98 and neuropsychological tests and (ii) the 4AT (index test, score ≥ 4 positive) plus brief measures of distress and psychotic symptoms. Results: A total of 120 people with delirium participated [median age 86.3, range 70–99, 67 (55.8%) female and 55 (45.8%) with dementia]. All of them completed the first two assessments, 103 (85.8%) completed three and 69 (57.5%) four. Reference standard delirium was present in 102/120 (85%), 72/103 (69.9%) and 53/69 (76.8%) cases at assessments two to four, respectively. In Receiver Operating Characteristic analyses, the 4AT’s sensitivity for detecting delirium was 0.95 (confidence interval 0.91–0.99), 0.96 (0.91–1) and 0.94 (0.88–1), and specificity was 0.67 (0.13–1), 0.88 (0.71–1) and 1 (1–1) at assessments two to four. In total 18 (15%) participants recovered from delirium. Distress was common in delirium and decreased with recovery. Conclusion: The 4AT maintains diagnostic accuracy on repeated admissions and may effectively assess delirium recovery in acute hospital settings. Fewer patients than expected recovered within 9 days, suggesting more studies on the natural history of delirium in different settings would be informative.

Introduction: Overall dementia diagnosis rates are substantially below true rates. Hospital admissions of older people involve cognitive and functional assessments relevant to dementia diagnosis. These assessments could be harnessed to contribute to identifying patients for further assessment. Yet relationships of inpatient cognitive tests with known dementia are unclear. The 4AT (www.the4AT.com) assesses for delirium (Scores 4–12) and also cognitive impairment via embedded cognitive tests (Scores 1–3). We investigated relationships between 4AT scores and clinical dementia diagnoses. Methods: We included participants aged ≥65 years admitted as a medical emergency to three hospitals from 1 April 2016 to 1 April 2020, who had the 4AT performed on admission. Clinical dementia diagnosis was ascertained from linked primary care, hospital discharge and community prescribing data. Results: Of 75 221 admissions, 62 188 (82.7%; 33 625 unique patients; mean age 80.2 years; 55.8% female) had a 4AT on admission. Of these, 9948 (16.0%) had a recorded clinical dementia diagnosis at the time of admission, with a further 1197 (1.9%) receiving a new diagnosis at discharge. Of admissions with dementia, 9669/11 145 (86.8%) had a 4AT score ≥1 on admission, compared to 14 994/51 043 (29.4%) without dementia. 4AT ≥1 had a sensitivity of 0.87 (95% CI 0.86–0.87) and a specificity of 0.71 (0.70–0.71) in relation to clinical dementia diagnosis. 4AT ≥4 showed sensitivity of 0.50 (0.50–0.51) and a specificity of 0.88 (0.88–0.88). Conclusions: 4AT scores were associated with clinically diagnosed dementia. These results suggest that routinely collected 4AT scores could be leveraged in conjunction with other clinical indicators to identify patients with possible undiagnosed dementia who could undergo further inpatient diagnostic assessment and/or post-discharge specialist follow-up.

Aims: Delirium is common in hip fracture patients, but large-scale routine data studies examining the prevalence and associations of delirium at the time of initial presentation with a hip fracture are rare. This study aimed to describe the prevalence and outcomes of delirium on initial presentation with a hip fracture in a large national population sample.Methods: This study analyzed routinely collected national clinical registry data for all people in Scotland aged 50 years and over presenting with a hip fracture between 1 July 2019 and 31 December 2021. Delirium was assessed prospectively by clinicians as part of routine care using the 4AT, a validated two-minute assessment tool. Associations of 4AT score with mortality and return home within 30 days were analyzed using logistic regression models, adjusted for confounders.Results: Of 18,040 patients (mean age 80 years (SD 10); 70% female (n = 12,594)), 16,476 (91%) had a 4AT assessment on presentation and of these, 3,386 (21%) had a score ≥ 4, suggestive of delirium. Patients with delirium were older, more likely residing in care homes, and had higher American Society of Anesthesiologists grades (all p < 0.001). Delirium was independently associated with a twofold increased risk of inpatient mortality (adjusted odds ratio (aOR) 2.26 (95% CI 1.79 to 2.84)) and one-year mortality (aOR 2.05 (95% CI 1.83 to 2.29)), and a lower likelihood of returning home within 30 days (aOR 0.27 (95% CI 0.24 to 0.30)).Conclusion: Delirium affects around 20% of patients presenting with a hip fracture, and is associated with important adverse outcomes. Integrating delirium assessment into the initial clinical assessment of hip fracture patients is feasible at national scale, and should be considered as part of care for all hip fracture patients.Cite this article: Bone Joint J 2025;107-B(4):470–478.