Wednesday, September 15, 2010

Diagnostic criteria of Dementia of the Alzheimer's Type

This form of progressive dementia named for Alois Alzheimer begins gradually, and is usually diagnosed after other specific causes have been ruled out through appropriate diagnostic procedures.

DSM-IV-TR: Diagnostic criteria for Dementia of the Alzheimer's Type (cautionary statement)  

A. The development of multiple cognitive deficits manifested by both  (1) memory impairment (impaired ability to learn new information or to recall previously learned information)  (2) one (or more) of the following cognitive disturbances:
  (a) aphasia (language disturbance)
  (b) apraxia (impaired ability to carry out motor activities despite intact motor function)
  (c) agnosia (failure to recognize or identify objects despite intact sensory function)
  (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. 

C. The course is characterized by gradual onset and continuing cognitive decline. 

D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
(1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
(2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
(3) substance-induced conditions 

E. The deficits do not occur exclusively during the course of a delirium. 

F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Episode, Schizophrenia). 

Code based on presence or absence of a clinically significant behavioral disturbance:

294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.

294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance. (e.g., wandering, agitation)

Specify subtype:
With Early Onset: if onset is at age 65 years or below 
With Late Onset: if onset is after age 65 years 

Coding note: Also code 331.0 Alzheimer's disease on Axis III. Indicate other prominent clinical features related to the Alzheimer's disease on Axis I (e.g., 293.83 Mood Disorder Due to Alzheimer's Disease, With Depressive Features, and 310.1 Personality Change Due to Alzheimer's Disease, Aggressive Type).

What Is the DSM-IV TR?

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV TR) is used by clinicians and psychiatrists to diagnose psychiatric illnesses. The DSM-IV TR is published by the American Psychiatric Association and covers all categories of mental health disorders for both adults and children. The manual is non-theoretical and focused mostly on describing symptoms as well as statistics concerning which gender is most affected by the illness, the typical age of onset, the effects of treatment, and common treatment approaches.

The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. An updated version, called the DSM-IV TR, was published in 2000 and contains minor text revision in the descriptions of each disorder. Mental health providers use the manual to better understand a client's potential needs as well as a tool for assessment and diagnosis.

The DSM-IV TR is based on five different dimensions. This multiaxial approach allows clinicians and psychiatrists to make a more comprehensive evaluation of a client's level of functioning, because mental illnesses often impact many different life areas.

  • Axis I: Clinical Syndromes
    This axis describes clinical symptoms that cause significant impairment. Disorders are grouped into different categories, including adjustment disorders, anxiety disorders, and pervasive developmental disorders.
  • Axis II: Personality and Mental Retardation
    This axis describes long-term problems that are overlooked in the presence of Axis I disorders. Personality disorders cause significant problems in how a patient relates to the world and include antisocial personality disorder and histrionic personality disorder. Mental retardation is characterized by intellectual impairment and deficits in other areas such as self-care and interpersonal skills.
  • Axis III: Medical Conditions
    These include physical and medical conditions that may influence or worsen Axis 1 and Axis II disorders. Some examples may include HIV/AIDS and brain injuries.
  • Axis IV: Psychosocial and Environmental Problems
    Any social or environmental problems that may impact Axis I or Axis II disorders are accounted for in this assessment. These may include such things as unemployment, relocation, divorce, or the death of a loved one.
  • Axis V: Global Assessment of Functioning
    This axis allows the clinician to rate the client's overall level of functioning. Based on this assessment, clinicians can better understand how the other four axes are interacting and the effect on the individual's life.
While the DSM-IV TR is an important tool, it is important to note that only those who have received specialized training and possess sufficient experience are qualified to diagnose and treat mental illnesses. Clinicians also use the DMS-IV to classify patients for billing purposes, since the government and many insurance carriers require a specific diagnosis in order to approve payment for treatment.

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), published in 1994 was the last major revision of the DSM. It was the culmination of a six-year effort that involved over 1000 individuals and numerous professional organizations. Much of the effort involved conducting a comprehensive review of the literature to establish a firm empirical basis for making modifications. Numerous changes were made to the classification (i.e., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text based on a careful consideration of the available research about the various mental disorders.

In anticipation of the fact that the next major revision of the DSM (i.e., DSM-V) will not appear until 2010 or later (i.e., at least 16 years after DSM-IV), a text revision of the DSM-IV called DSM-IV-TR was published in July 2000. The primary goal of the DSM-IV-TR was to maintain the currency of the DSM-IV text, which reflected the empirical literature up to 1992. Thus, most of the major changes in DSM-IV-TR were confined to the descriptive text. Changes were made to a handful of criteria sets in order to correct errors identified in DSM-IV. In addition, some of the diagnostic codes were changed to reflect updates to the ICD-9-CM coding system adopted by the US Government.

Sources and Additional Information:

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