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Diagnostic Criteria Section_Index.

Refer to conditions of use

Deliriums

Delirium is a rapidly developing disorder of disturbed attention that fluctuates with time.  Although the clinical presentation of delirium differs considerably from patient to patient, there are several characteristic features that help make the diagnosis.

Delirium Due to a General Medical Condition

The patient has a reduced level of consciousness and difficulty focusing, shifting or 
     sustaining attention.

There has been a cognitive change (deficit of language, memory, orientation, perception)
      that a dementia cannot better explain.

These symptoms develop rapidly (hours to days) and tend to vary during the day.

History, physical examination or laboratory data suggest that a general medical condition
      has directly caused the condition.

Coding Notes

The name of the general medical condition is included as a part of the Axis I code for delirium; that is, the term "General Medical Condition" does not appear in the code.

If the patient has a preexisting Alzheimer's or vascular dementia, only one code is needed because "with delirium" can be coded as a specifier. For Example:

Axis I 290.11 Dementia of the Alzheimer's Type, With Early Onset, With Delirium.

If the dementia is caused by a general medical condition, it and the delirium must be coded separately. For example:

Axis I 294.1 Dementia Due to Parkinson's Disease

293.0 Delirium Due to Congestive Heart Failure

Axis III 332.0 Parkinson's Disease

428.9 Congestive Heart Failure

Note also that all causative agents are coded on Axis III.


Criteria for Substance Intoxication Delirium

The patient has a reduced level of consciousness and difficulty focusing, shifting or sustaining
     attention.

There has been a cognitive change (deficit of language, memory, orientation, perception) that
      a dementia cannot better explain.

These symptoms develop rapidly (hours to days) and tend to fluctuate during the day.

History, physical examination or laboratory data suggest that either:

* the symptoms developed during Substance Intoxication or
* they are caused by the use of a medication


Criteria for Substance Withdrawal Delirium

The patient has a reduced level of consciousness and difficulty focusing, shifting or sustaining
      attention.

There has been a cognitive change (deficit of language, memory, orientation, perception) that
      a dementia cannot better explain.

These symptoms develop rapidly (hours to days) and tend to fluctuate during the day.

History, physical examination or laboratory data suggest that the symptoms developed during
     or shortly after Substance Withdrawal.


Criteria for Delirium Due to Multiple Etiologies **

The patient has a reduced level of consciousness and difficulty focusing, shifting or sustaining
     attention.

There has been a cognitive change (deficit of language, memory, orientation, perception) that
      a dementia cannot better explain.

These symptoms develop rapidly (hours to days) and tend to fluctuate during the day.

These symptoms have more than one cause, as judged by history, physical examination
     or laboratory data.

Associated Features 

Learning Problem
Dysarthria or Involuntary Movement
Hypoactivity
Psychosis
Euphoric Mood
Depressed Mood
Somatic or Sexual Dysfunction
Hyperactivity
Addiction
Sexually Deviant Behavior

Differential Diagnosis 

Some disorders have similar or even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis.

Some disorders have similar or even overlapping symptoms. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which need to be ruled out to establish a precise diagnosis. The major problem in differential diagnosis is in distinguishing a delirium from an acute functional psychosis.  The delirious patient is usually more acute and confused, and the hallucinations are usually more disorganized and are more likely to be visual.  Patients with functional psychoses usually don’t have confusion, disorientation, and illusions, and they are more likely to have a formal thought disorder.  Always check the personal and family history for serious psychiatric illness.

Schizophrenia;
Schizophreniform Disorder and other psychotic disorders;
Dementia;
Factitious Disorder with Psychological Symptoms.

Cause:

This common condition may be caused by physical illness, several causes simultaneously, or by unknown organic conditions. 


Treatment:

The presence of a delirium usually means that the patient is seriously medically ill.  Delirium is a diagnosis that immediately demands a search for causes.  Most causes produce diffuse cerebral impairment and lie outside the CNS–usually due to some form of deranged metabolism (e.g., infection, fever, hypoxia, hypoglycemia, medication side effects, drug withdrawal states, hepatic encephalopathy, postoperative changes)–but also include CNS trauma and postictal states.  The goal of treatment is to control or reverse symptoms. Treatment varies with the specific condition causing delirium. The person should be in a pleasant, comfortable, nonthreatening, physically safe environment for diagnosis and initial treatment.

Medications that may be considered for use include:

* thiamine
* anti-psychotics
* beta-blockers if dementia is related to central nervous system lesions
* serotonin-affecting drugs (lithium, trazodone, buspirone, clonazepam)
* dopamine blockers (such as haloperidol)
* fluoxetine, imipramine may be used to stabilize mood
* stimulant drugs, may improve mood


Coding Notes

You would not diagnose both a Substance Intoxication (or Withdrawal) Delirium and a Substance Intoxication (Withdrawal) due to the same substance. Whenever the symptoms are severe enough to warrant, diagnose only the delirium.

Use the exact name of the substance, not the class name (such as Toluene Intoxication Delirium, not Inhalant Intoxication Delirium).

Code the Intoxication Delirium according to the specific substance, eg:

Axis I 291.0 Alcohol

292.81 All remaining, including Amphetamine [or Amphetamine-Like Substance]; Cannabis; Cocaine; Hallucinogen; Inhalant; Opioid; Phencyclidine [or Phencyclidine-Like Substance]; Sedative, Hypnotic or Anxiolytic; Other [or Unknown] Substance

Code the Withdrawal Delirium according to the specific substance:

Axis I 291.0 Alcohol

292.81 All remaining, including Sedative, Hypnotic or Anxiolytic; Other [or Unknown] Substance

For multiple substances, list each one separately.

Delirium induced by medications will almost always be due to toxicity. They are categorized as "other" substances and coded with the exact name of the medication. For example:

Axis I 292.81 Digitalis-Induced Delirium

292.81 Imipramine-Induced Delirium


Coding Note **

Multiple Axis I codes must be used to indicate specific causes of Delirium. Also indicate the relevant physical (or substance use) condition on Axis III. For example:

Axis I 293.0 Delirium due to cirrhosis

292.81 Cimetidine-induced Delirium

Axis III 571.2 Alcoholic cirrhosis

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