Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Laura L Kuensting, DNP, APRN, PCNS-BC, CPNP, CPEN


Carla Beckerle, DNP, APRN, AGNP-BC


Nancy Magnuson, DSN, FNP, RN



Delirium is a problem for many older adults who are acutely ill. Delirium often comes on suddenly, can be severe, and is often difficult to diagnose, especially in the presence of dementia. Missed delirium has a mortality rate of 30.8% and costs millions. What is the purpose of this study?

Methods The 4A’s Test screening instrument was implemented and evaluated in the Emergency Department of a rural Midwestern hospital from May 1, 2019 through August 31, 2019.

Results There were 122 participants in the study with 61 in each cohort. In 2018, three (5%) were diagnosed with delirium without a screening instrument. In 2019, 10 (6.1%) screened positive and were diagnosed with delirium. A Fisher’s exact test compared the 2018 and 2019 cohorts. The relationship between screening with or without a screening tool was statistically significant at the .05 level (p = 0.3227). A Fischer’s Exact Test was also performed on patients with and without previously diagnosed dementia. Twenty-two (36%) subjects had dementia and eight (13%) were positive with 39 (64%) subjects without dementia and seven (11.8%) screening positive. The relationship with and without a previous diagnosis of dementia was statistically significant at the 0.5 level (p= 0.2495).

Implications for Practice The study found an 11.5% increase in recognition of delirium in the ED in general psychiatric presenting patients and an 18.5% increase in recognition of delirium in the ED in psychiatric presenting patients with a previous diagnosis of dementia.