Delirium, Dementia, and 

Amnestic Disorders and 

Other Cognitive Disorders

Contents of this page:

Deliriums            Dementias          Amnestic Disorders

Mental Disorders Due to A General Medical Condition

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Deliriums

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.

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

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.

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

293.89 Delirium NOS

Dementias

Dementia of the Alzheimer's Type

• The patient has developed problems with thinking, as shown by:
  Impaired memory (can't learn new information or can't recall information previously learned) plus
• At least 1 of:
  -Aphasia (problems using language)
  -Apraxia (trouble carrying out motor activity, despite intact motor functioning)
  -Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)
  -Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Each of these symptoms materially impairs work or social functioning.

• The decline in mental functioning begins gradually and worsens steadily.

• These impairments aren't due to any other disorder that causes dementia, such as:
  -central nervous system disease (brain tumor, cerebrovascular disease, Huntington's disease, normal pressure hydrocephalus, Parkinson's disease, subdural hematoma)
  -systemic disease (hypothyroidism, vitamin deficiency, HIV infection, neurosyphilis)
  -substance-related disorders
• These impairments don't occur solely during a delirium.

• They aren't better explained by another Axis I disorder such as a depressive disorder or Schizophrenia.

Code according to age of onset and accompanying symptom:

Alzheimer's Dementia Type With late onset (over 65) With early onset (65 or less)

Uncomplicated 290.0 290.10

With delusions 290.20 290.12

With depressed mood* 290.21 290.13

With delirium 290.3 290.11

Specify if: With Behavioral Disturbance. This specifier is added to the end of the diagnosis whenever the patient wanders a great deal or is markedly combative.

Coding Notes

There are several ways to code Alzheimer's dementia, depending on the accompanying symptoms. If more than one of these symptoms is present, code according to the most prominent symptom. The exact diagnosis might even change during the course of a patient's illness.

*With depressed mood is only coded when depression meets the full symptomatic criteria for Major Depressive Episode (page 160). In such a case, you would not also code mood disorder.

On Axis III, also code 331.0 Alzheimer's Disease.

Vascular Dementia

• The patient has developed deficits of thinking as shown by both of:

• Impaired memory (can't learn new information or can't recall information previously learned) plus

• At least 1 of:
  -Aphasia (problems using language)
  -Apraxia (trouble carrying out motor activity, despite intact motor functioning)
  -Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)
  -Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Cerebral vascular disease has probably caused the above deficits, as judged by laboratory data or by focal neurologic signs and symptoms.*

• Each of these symptoms materially impairs work, social or personal functioning.

• These impairments don't occur solely during a delirium.

If more than one of the following symptoms is present, code according to the most prominent symptom:

290.40 Uncomplicated

290.41 With Delirium

290.42 With Delusions

290.43 With Depressed Mood**

Specify if: With Behavioral Disturbance. This specifier is added to the end of the diagnosis whenever the patient wanders a great deal or is markedly combative.

Coding Notes

*Radiographic evidence of multiple infarctions that involve cortex and white matter; neurologic signs include increased deep tendon reflexes, weakness in limbs, abnormal gait, extensor Babinski reflex.

**Only code With Depressed Mood when depression meets the full symptomatic criteria for Major Depressive Episode (page 160). In such a case, you would not also code mood disorder.

On Axis III, also code the specific cerebrovascular condition. For example:

Axis III 434.9 Cerebral artery occlusion

Dementia Due to Other General Medical Conditions

• The patient has developed deficits of thinking as shown by both of:

• Impaired memory (can't learn new information or can't recall information previously learned) plus

• At least one of:
  -Aphasia (problems using language)
  -Apraxia (trouble carrying out motor activity, despite intact motor functioning)
  -Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)
  -Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Each of these symptoms materially impairs work, social or personal functioning.

• These symptoms don't occur solely during a delirium.

• A general medical condition has probably directly caused the above deficits, as judged by history, laboratory data or physical examination.

Besides coding the dementia on Axis I, you should also code the underlying disease on Axis III. Some of the more common responsible general medical conditions are listed in the table below.

Type of Dementia Axis I Axis III

Dementia Due to HIV Disease 294.9 043.1

Dementia Due to Head Trauma 294.1 854.00

Dementia Due to Parkinson's Disease 294.1 332.0

Dementia Due to Huntington's Disease 294.1 333.4

Dementia Due to Pick's Disease 290.10 331.1

Dementia Due to Creutzfeldt-Jakob Disease 290.10 046.1

Dementia Due to Other General Medical Condition 294.1 *

Coding Notes

As distinct from Alzheimer's and vascular dementias, None of these dementias have a codable subtype.

*Specify these numbers on Axis III. They might include normal pressure hydrocephalus, hypothyroidism, brain tumor, B12 deficiency and many others. See table on page 45 for more.

If one of these disorders is superimposed onto Alzheimer's or vascular dementia, code both diagnoses on Axis I and the specific general medical conditions on Axis III.

Substance-Induced Persisting Dementia

• The patient has developed deficits of thinking as shown by both of:

• Impaired memory (can't learn new information or can't recall information previously learned) plus

• One or more of:
  -Aphasia (problems using language)
  -Apraxia (trouble carrying out motor activity, despite intact motor functioning)
  -Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)
  -Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Each of these symptoms materially impairs work, social or personal functioning.

• These symptoms don't occur solely during a delirium.

• They last longer than the typical effects of intoxication or withdrawal.

• Substance use is evident from history, physical examination or laboratory data, and the clinician believes that this abuse has directly caused the impaired memory.

The following code numbers can be utilized:

291.2 Alcohol

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

Also code Substance Dependence as appropriate on Axis I.

Dementia Due to Multiple Etiologies

• The patient has developed deficits of thinking as shown by both of:

• Impaired memory (can't learn new information or can't recall information previously learned) plus

• One or more of:
  -Aphasia (problems using language)
  -Apraxia (trouble carrying out motor activity, despite intact motor functioning)
  -Agnosia (despite intact sensory functioning, the patient fails to recognize or identify objects presented)
  Impaired executive functioning (problems abstracting, organizing, planning or sequencing information)

• Each of these symptoms materially impairs work, social or personal functioning.

• These symptoms don't occur solely during a delirium.

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

Coding Notes

Multiple codes are used to record the causes of multiple dementias. In addition, multiple Axis III codes may be required for the physical causes themselves. For example, a demented patient with Huntington's Disease also suffered a blow to the head might be recorded as follows:

Axis I 294.1 Dementia Due to Head Trauma

294.1 Dementia Due to Huntington's Disease

Axis III 905.0 Head Trauma

333.4 Huntington's Disease

Another example:

Axis I 290.10 Dementia of the Alzheimer's Type, Uncomplicated, With Behavioral Disturbance

292.82 Barbiturate-Induced Persisting Dementia

Axis III 331.0 Alzheimer's disease

294.8 Dementia Not Otherwise Specified

Amnestic Disorders

Amnestic Disorder Due to a General Medical Condition

• The patient develops impaired memory (can't learn new information or can't recall information previously learned).

• These symptoms materially impair work, social or personal functioning.

• These symptoms don't occur solely during a delirium or dementia.

• A general medical condition has probably directly caused this memory impairment, as judged by history, physical exam or laboratory data.

Specify whether:

Transient. Duration is one month or less, or

Chronic. Duration is longer than one month.

Coding Notes

In the wording for the name of the amnestic disorder, indicate the exact name of the cause, not the class name. That is, Amnestic Disorder Due to Herpes Simplex Encephalitis.

Code the general medical condition on Axis III.

Substance-Induced Persisting Amnestic Disorder

• The patient develops impaired memory (can't learn new information or can't recall information previously learned).

• These symptoms materially impair work, social or personal functioning.

• These symptoms don't occur solely during a delirium or dementia.

• Enduring effects of substance use have probably caused these deficits, as judged by history, physical exam or laboratory data.

The following code numbers can be utilized:

291.1 Alcohol

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

Coding Notes

Also code Substance Dependence as appropriate on Axis I.

Patients who abuse sedatives/hypnotics/anxiolytics can have intoxication and withdrawal syndromes identical to users of alcohol. On occasion, these can cause an amnestic disorder. When this is the case, the disorder should be coded as 292.83 with the exact substance specified, if known. Thus, 292.83 Phenobarbital-Induced Persisting Amnestic Disorder

Multiple diagnoses can be made when multiple substances are responsible.

If you can't identify the substance responsible, you would use this code:

292.83 Unknown Substance-Induced Persisting Amnestic Disorder

294.8 Amnestic Disorder NOS

294.9 Cognitive Disorder Not Otherwise Specified

Mental Disorders Due to a General Medical Condition

Catatonic Disorder Due to a General Medical Condition

• The patient has catatonic symptoms as shown by immobility, pronounced negativism, muteness, echolalia, echopraxia or peculiarities of voluntary movement (such as posturing or waxy flexibility).

• History, physical exam or laboratory findings suggest that these symptoms are caused directly by a general medical condition.

• The symptoms don't occur solely during a delirium.

• No other mental disorder better explains these symptoms.

Coding Note

Use the name of the general medical condition on Axis I.

On Axis III record the general medical condition diagnosis responsible for the catatonia.

Personality Change Due to a General Medical Condition

• There has been a lasting change from the patient's established personality.

• History, physical exam or laboratory findings suggest that a general medical condition has directly caused the personality change.

• No other mental disorder (including those caused by a general medical condition) better accounts for these symptoms.

• The symptoms don't occur solely during a delirium.

• This problem causes important clinical distress or impairs work, social or personal functioning.

Specify type (depending on the main feature):

Aggressive Type: aggressive behavior

Apathetic Type: indifference

Disinhibited Type: loss of impulse control as shown by such behavior as sexual indiscretions

Labile Type: unstable affect

Paranoid Type: paranoid ideas or suspiciousness

Other Type: DSM-IV gives the example of personality change that occurs with a seizure disorder

Combined Type: more than one feature of the clinical picture stands out

Unspecified

Coding Notes

Use the name of the general medical condition on Axis I.

On Axis III record the general medical condition diagnosis responsible for the personality change.

To make this diagnosis in children, there must be at least a year-long, pronounced deviation from normal development or a material change in the child's usual patterns of behavior.

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