Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Delirium, Dementia, and Amnestic and Other Cognitive Disorders “Cognitive Disorders Group”

Four Major Diagnoses: Delirium, Dementia, Amnestic, and Other Cognitive Disorders NOS

The core concept of these disorders is: • The presence of impairments in cognition, for example: • Language disturbance (aphasia) • Motor disturbance despite intact motor function (apraxia) • Failure to recognize or identify objects despite intact sensory function (agnosia) • Impairment in the capacity to plan and organize (executive functions), • In Delirium the client also has a disturbance in consciousness.

All of these cognitive disorders are presumed to be caused by one or more substances and/or general medical conditions (GMC). (In other words, none of these are caused by psychological issues.)

Which one of the diagnoses you choose is determined by what you think the cause of the disorder is due to (i.e., the etiology). For example, 293.0 Delirium Due to a General Medical Condition (p. 141) is used when you think a medical condition caused the delirium. Substance-Induced Delirium is used when you think the condition is due to a drug of abuse, a medication, or toxin exposure.

The impairments in cognition have to represent a significant change from a previous level of functioning.

Core Criteria for each of the four major diagnoses in the Cognitive Disorders Groups Delirium, Dementia Amnestic, and Cognitive Disorder NOS

Core Criteria for Delirium A delirium is distinguished by: disturbance of consciousness. Delirium = Disturbance of Consciousness and Disturbance of Consciousness = Delirium (The person is not unconscious)

What is a “disturbance of consciousness” (or a “delirium”)? It is a rapidly developing, fluctuating state of reduced awareness in which the following are true: • Delirium often starts with reduced clarity or awareness of the environment; i.e., with reduced ability to focus, sustain, or shift attention, and • The client has at least one deficit of memory, orientation, language, or perception, and • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

Delirium: Four types of diagnoses • 293.0 Delirium Due to … [Indicate the General Medical Condition] Delirium can be caused by trauma to the brain, infections, epilepsy, endocrine disorders, toxicity from medications, poisons, and various other diseases throughout the body. Be sure to check out coding notes. p. 143

Delirium: Types of diagnoses (con’t.) • Substance-Induced Delirium. Alcohol and other sedative drugs of abuse, as well as nearly every class of street drug, including medications can cause delirium. Types a. Substance Intoxication Delirium, p. 145 b. Substance Withdrawal Delirium, p. 146

Delirium: Types of diagnoses (con’t.) • Delirium Due to Multiple Etiologies. This diagnosis is used when more than one cause for delirium is identified in the same client, p. 147. • Delirium NOS. This category is used when you don’t know the cause of a client’s delirium. 780.09 Delirium NOS. Used for a delirium that does not meet criteria for any specific types of described in the DSM section. (Be sure to look at examples, p. 147.)

Treatment for Delirium • Unlikely MFTs will have to treat someone with delirium; however, a new or on-going client with delirium could arrive in your office. • First priority is to keep the client alive and prevent brain damage: Quickly identify a delirium and call 911 and/or refer to a physician. • History from family, friends, etc. or your records may reveal similar confused periods with a known cause (e.g., hypoglycemia in diabetes or drug overdose, which suggests delirium and the cause.)

Core Criteria for Dementia Dementia is an impairment in memory with associated cognitive disturbances. • Dementia means “loss,” so there must be a decline from a previous level of functioning – usually a gradual decline. • In addition to memory loss, client must show at least one other cognitive deficit: aphasia, apraxia, agnosia, or loss of executive functioning. • Dementia cannot be diagnosed if the symptoms occur only when the client is delirious • Dementia may be caused by a nonpsychiatric medical condition, a substance, or a mixture of the two problems. • Be sure to look at Coding Notes.

Dementia differs from delirium in several ways • To diagnose a dementia, multiple cognitive deficits must be present • With dementia, impairment in the ability to focus or shift attention is not prominent • The cause of dementia is usually found within the central nervous system; the cause of delirium is often found elsewhere in the body • Dementia is relatively fixed (unchanging), as compared to delirium. • Although a client occasionally recovers from dementia, this is not usual.

Dementia: Five (5) Types of Diagnoses • Dementia of the Alzheimer’s Type, p. 154 a. Most common cause of senility b. Begins gradually and usually progresses relentlessly c. More than 50% all dementias are Alzheimer’s type • Vascular Dementia, p. 158 a. Due to vascular brain disease b. A stepwise process, with relatively sudden onset and a fluctuating course c. About 10-20% of dementias are vascular

Dementia: Types of Diagnoses • Dementia Due to … HIV disease, Head Trauma, Parkinson’s Disease, Huntington’s Disease, Pick’s Disease, Creutzfeldt-Jakob disease (infection by a slow virus), and Other GMC, p.162-168. Most common toxins causing dementia are those resulting from kidney and liver failure.

Dementia: Types of Diagnoses • Substance-Induced Persisting Dementia. 5-10% are related to prolonged use of alcohol, inhalants, or sedatives, 168. • Dementia Due to Multiple Etiologies. Use this category when client has more than one of the causes above, 179. • Dementia NOS. Use this category when you know the client is demented, but you don’t know why, 171.

Amnestic Disorders Amnestic is just a fancy was of saying “amnesia.” Main features: • Reduced ability to focus or shift attention is not required • Memory is affected far more than any other function - sometimes to the extent that conversations taking place only a few minutes earlier will be forgotten. • In some cases, clients with an amnestic disorder will try to hide a loss of memory by making up (confabulating) experiences.

Core Criteria for Amnestic Syndrome • The core criteria include one element - the development of memory impairment as manifested by: • The inability to learn new information, or • The inability to recall previously learned information. • The core criteria are the same for each of the 3 etiologies or diagnoses under Amnestic syndrome.

Amnestic Disorder:Types of Diagnoses 1. Amnestic Disorder Due to a General Medical Condition. Symptoms are similar to Korsakoff’s syndrome, but there is a medical cause, such as hypoxia, stroke, head trauma, or herpes simplex encephalitis. • Substance-Induced Persisting Amnestic Disorder. Popularly known as Korsakoff’s syndrome. Most often occurs in an alcoholic client who suffers from thiamine (vitamin B1) deficiency. 3. Amnestic Disorder NOS. For clients who have severe memory problems, but little else in the way of cognitive disability and the underlying cause is unknown.

Other Causes of Cognitive Symptoms • Age-Related Cognitive Decline. Older clients who report trouble remembering, names, telephone numbers, or places they put things may, upon testing, have a memory problem that is consistent with age and not pathological.

Other Causes of Cognitive Symptoms • Dissociative Disorders. Profound, temporary loss of memory may occur in persons who suffer from: • Dissociative Amnesia, p. 520 • Dissociative Fugue, p. 523 • Dissociative Identity Disorder, p. 526 • Pseudodementia • Some clients seem to have severe memory loss and other symptoms of dementia, but actually are severely depressed. • Accounts for 5% of clients referred for a dementia evaluation • Found only in the elderly.

Other Causes of Cognitive Symptoms • Malingering. Some clients intentionally exaggerate or falsify cognitive symptoms to obtain funds (insurance, worker’s compensation) or to avoid punishment or military service. • Factitious Disorder With Predominantly Psychological signs and Symptoms. Some clients feign cognitive symptoms, but not for direct gain. Their motive is to be hospitalized or otherwise cared for.

Making a Diagnosisof “Delirium” Ask yourself these questions: • Does the client have a disturbance of consciousness? If the answer is “yes,” then the diagnosis is “delirium.” • Is the client unconscious? Then the diagnosis is not “delirium.” • Is the client aware of his/her reduced attention (i.e., disturbed consciousness)? If the client is unaware, then the diagnosis is very likely “delirium,” caused by a general medical condition or substance. • Can the client offer some explanation for his/her reduced attention, such as preoccupation with other worries? If the client can offer an explanation, then most likely the diagnosis is not “delirium.”

Making a Diagnosis Question: Does the client have an impairment in cognition? If cognitive impairment is only a memory disturbance and the client is fully conscious, the diagnosis is one of the following Amnestic Disorders: • Amnestic Disorder due to a General Medical Condition • Substance-Induced Persisting Amnestic Disorder • Amnestic Disorder Not Otherwise Specified. (continued)

Making a Diagnosis (con’t.) Same Question: Does the client have an impairment in cognition? If the cognitive impairment is a disturbance of consciousness and the impairment tends to fluctuate during the day, the diagnosis is one of the following deliriums: • Delirium Due to a General Medical Condition • Substance-Induced Delirium • Delirium Due to Multiple Etiologies • Delirium Not Otherwise Specified. If the cognitive impairment is a memory disturbance and an aphasia, apraxia, agnosia, or disturbance in executive functioning without a disturbance of consciousness, the diagnosis is: • Dementia.

Making a Diagnosis Question: What is the temporal basis of the client's disturbance? • If the client's cognitive impairment develops slowly (usually weeks or months) and remains stable with little fluctuation during the day, the diagnosis is Dementia. • If the client's cognitive impairments develop rapidly (usually hours or days) or worsen rapidly and fluctuate during the course of the day, the diagnosis is Delirium.

Making a Diagnosis Question: What if there is not an identifiable general medical condition or substance etiologically related to the disturbance? • The diagnosis of a specific Delirium, Dementia or Amnestic Disorder (with the exception of Dementia of the Alzheimer's Type) requires the identification of one or more general medical conditions or substances that are judged to be the cause of the disorder. • Some clients could have symptoms of all three. When there is insufficient medical evidence to establish a specific etiology, the diagnoses should be: • Delirium Not Other Specified • Dementia Not Otherwise Specified • Amnestic Disorder Not Otherwise Specified.

Delirium, Dementia, and Amnestic and Other Cognitive Disorders