Transcript DDA PowerPoint

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
1.
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.)
2.
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.)
3.
Delirium Due to Multiple Etiologies. This diagnosis is
used when more than one cause for delirium is
identified in the same client, p. 147.
4.
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
1.
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
2.
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
3.
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
4.
5.
5.
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.
2.
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
1.
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:
2.



Dissociative Amnesia, p. 520
Dissociative Fugue, p. 523
Dissociative Identity Disorder, p. 526
Pseudodementia
3.



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
4.
Malingering.
Some clients intentionally exaggerate or falsify
cognitive symptoms to obtain funds (insurance,
worker’s compensation) or to avoid punishment
or military service.
5.
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 Diagnosis
of “Delirium”
Ask yourself these questions:
1.
Does the client have a disturbance of consciousness? If the answer is “yes,” then the
diagnosis is “delirium.”
2.
Is the client unconscious? Then the diagnosis is not “delirium.”
3.
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.
4.
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.