# Translation, Cultural Adaptation, and Validation of the Greek Version of the 4 ‘A’s Test for Delirium Screening in Elderly Patients with Hip Fracture

## TL;DR

This study translated and validated a quick delirium screening tool, the 4AT, for Greek-speaking elderly patients with hip fractures.

## Contribution

The study provides a culturally adapted and validated Greek version of the 4AT for delirium screening in hip fracture patients.

## Key findings

- The Greek 4AT showed 87.5% sensitivity and 91.1% specificity for delirium detection.
- The tool had an AUC of 0.94, indicating strong diagnostic accuracy.
- A cut-off score of ≥4 was optimal for screening delirium in this population.

## Abstract

Background: Delirium is a frequent and serious complication in elderly patients with hip fractures and is associated with adverse outcomes. Early identification requires a brief and reliable screening tool suitable for routine clinical practice. The 4 ‘A’s Test (4AT) is a rapid instrument for delirium detection that requires minimal training. Objective: To translate, culturally adapt, and validate the Greek version of the 4AT in elderly patients with hip fractures. Methods: A total of 103 patients aged ≥65 years who were admitted with hip fracture were enrolled. The 4AT was translated using a forward–backward translation process and culturally adapted according to established guidelines. Delirium diagnosis was established using DSM-5 criteria by trained clinicians, serving as the reference standard. The 4AT was administered independently within 3 h. Diagnostic accuracy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC). The optimal cut-off was determined using Youden’s index. Results: At a cut-off score ≥4, the Greek 4AT demonstrated a sensitivity of 87.5% and specificity of 91.1%, with PPV 75% and NPV 96%. The AUC was 0.94, indicating excellent diagnostic performance. Conclusions: The Greek version of the 4AT is a valid and reliable screening tool for detecting delirium in elderly patients with hip fractures.