Imagine a client suddenly feels disoriented, struggles to focus, and shows significant changes in behavior and cognition. These signs can indicate a serious medical condition that requires immediate attention.

Delirium is a complex neuropsychiatric syndrome that can lead to severe consequences if untreated. Mental health therapists play an important role in identifying and addressing signs of delirium in their clients.

In this article, we'll cover the key information therapists need about delirium, including its diagnostic criteria, causes, and clinical implications. When therapists understand this condition, they can help ensure their clients receive timely and appropriate care.

Diagnostic Criteria (ICD-10 F05)

Under ICD‑10, F05 refers specifically to delirium due to a known physiological or medical condition (excluding alcohol or other substances). Delirium is a syndrome, not a disease, characterized by a disturbance in attention and/or awareness, with an abrupt onset, fluctuating course, and at least one new cognitive deficit not explained by dementia.

Key diagnostic components include:

• Disturbance in consciousness and attention: Difficulty focusing, sustaining, or shifting attention.
  
  
• Additional cognitive changes: Such as memory impairment, disorientation, language issues, visuospatial problems, or perceptual abnormalities (e.g., hallucinations or illusions).
  
  
• Psychomotor alterations: May present as hypoactivity, hyperactivity, or a mixture of both.
  
  
• Sleep–wake cycle disturbance: Fragmented sleep, reversed sleep patterns, or daytime drowsiness are common.
  
  
• Acute onset and fluctuating severity: Symptoms typically emerge over hours to days and often worsen in the evening (sundowning)
  
  
• Evidence of physiological cause: Clinical link to an acute medical issue (e.g., infection, metabolic imbalance, hypoxia), separate from substance use.
  
  

Additionally, for delirium to be diagnosed, it must represent a marked change from baseline and not be better explained by pre-existing neurocognitive disorders. Prompt identification and treatment are critical given delirium’s association with increased morbidity, mortality, and risk of lasting cognitive impairment.

Common Causes and Risk Factors

Delirium can result from various medical conditions that often interact to disrupt normal brain function. Some of the most common causes include:

• Infections: Urinary tract infections, pneumonia, influenza, and COVID-19 are frequent culprits, especially in older adults and children.
• Medication toxicity: Certain medications or drug combinations can induce delirium. Withdrawal from substances like alcohol or drugs is another potential trigger.
• Metabolic imbalances: Electrolyte disturbances, dehydration, poor nutrition, and abnormal blood sugar levels can contribute to delirium onset.
• Organ dysfunction: Acute or worsening chronic illnesses such as stroke, heart attack, lung disease, liver failure, or advanced dementia increase delirium risk.

Aside from these direct causes, several factors can make an individual more prone to developing delirium:

• Post-operative or ICU settings: Major surgeries under general anesthesia and critical illness requiring intensive care are well-known precipitants.
• Pre-existing cognitive or medical conditions: Individuals with dementia, a history of stroke, Parkinson’s disease, or chronic illness (e.g., renal or liver disease) are at significantly higher risk of developing delirium.
• Polypharmacy and substance use: The simultaneous use of multiple medications, as well as substance misuse and withdrawal, are significant risk factors in mental health populations.

Recognizing these common causes and risk factors helps therapists stay alert for signs of delirium in their clients. Early detection and prompt medical intervention are important for preventing the serious consequences of untreated delirium.

Clinical Recognition: Red Flags for Therapists

Detecting delirium can be tricky because its symptoms often mimic or overlap with other mental health conditions, such as dementia. However, several key signs can help therapists differentiate delirium from other disorders during sessions.

One of the most noticeable aspects of delirium is the sudden change in a client's cognitive function and behavior. These shifts may include:

• Confused mental state: Clients might seem disoriented, have difficulty following conversations, or give irrelevant or incoherent responses to questions.
• Fluctuating attention: Clients may find it hard to maintain focus, get easily distracted, or struggle to shift attention appropriately.
• Memory impairment: Clients may have trouble recalling recent events or information discussed earlier in the session.
• Perceptual disturbances: Hallucinations or delusions might occur during therapy, causing distress or confusion.

The severity of these symptoms can vary throughout the day, with clear moments alternating with confusion. This fluctuation can complicate assessments and requires therapists to be alert to changes in their clients' behavior.

To aid in early detection of delirium, therapists should:

• Obtain baseline information about a client's usual cognitive function and behavior through chart reviews, collateral contacts, and collaboration with other healthcare providers.
• Keep communication open with the interdisciplinary team to share observations and concerns about potential delirium symptoms.
• Record any sudden changes in mental status, attention, or behavior during client meetings, as this information is vital for accurate diagnosis and treatment planning.

Timely detection of delirium is important because it allows for quick medical intervention to address underlying causes and prevent serious complications. As frontline providers, therapists play a key role in spotting the warning signs of delirium and initiating appropriate referrals and collaborative care.

Documentation and Coding Guidance

Accurate documentation and coding play a key role when dealing with delirium in mental health settings. To ensure proper reimbursement and compliance with coding guidelines, therapists need to know when and how to use the ICD-10 code F05 for delirium due to a known physiological condition.

Here are some important points to consider:

• Use F05 when the cause is clear: Apply the F05 code when the delirium is clearly linked to an underlying medical cause, such as an infection ormetabolic disturbance.. Thorough documentation of the specific cause supports accurate coding.
• Document symptoms and severity: Charting should include details about the onset, duration, and severity of delirium symptoms. This might involve noting confusion, disorientation, hallucinations, or impaired cognition, along with any fluctuations in mental status.
• Link delirium to comorbid conditions: When delirium occurs alongside other mental health diagnoses like substance misuse or depression it's important to code both conditions.
• Avoid unspecified codes when possible: While codes like R41.82 (altered mental status, unspecified) or R41.9 (unspecified cognitive symptoms) may be tempting, they should be used sparingly. Always aim for the most specific code that matches the clinical picture and documented cause of delirium.

Therapists can use charting language that flags possible delirium by noting key phrases such as "sudden onset of confusion," "fluctuating level of awareness," or "disoriented to time and place." These descriptions paint a clearer picture for coders and support the use of the F05 code.

Capture the full clinical complexity of each client's unique presentation of delirium. Detailed documentation not only ensures coding accuracy but also facilitates better communication and collaboration among the entire treatment team.

Treatment and Referral Considerations

When a therapist suspects delirium, quick action is needed to ensure client safety and prevent further deterioration. This will most likely involve referring the client for a medical evaluation to identify and address any underlying causes, such as infections, medication side effects, or metabolic disturbances.

While the medical team addresses the underlying factors, therapists can play an important role in providing ongoing support and care coordination. Some key aspects of the therapist's role include:

• Safety planning: Working together with the client, family, and healthcare team to create a plan that reduces risks and ensures a safe environment during the acute delirium episode.
• Psychoeducation: Providing information and guidance to the client's family and caregivers about delirium, its symptoms, and the expected course of recovery. This can help ease anxiety and improve their ability to support the client effectively.

As the client recovers from the acute delirium episode, ongoing therapeutic support can help address any lingering emotional effects of the experience. Therapists can assist clients in processing their experiences and rebuilding coping skills.

In addition, family and caregiver involvement is key for successful delirium management. Therapists can offer psychoeducation and support to help loved ones understand the nature of delirium, its impact on the client, and how they can contribute to the recovery process. This may include teaching strategies for creating a calming environment, providing reorientation cues, and maintaining a consistent routine.  Just as importantly, therapists can offer caregivers a space to express and process their own emotions, including fear, confusion, guilt, or frustration, which often accompany the experience of witnessing a loved one in delirium.

Throughout the treatment process, close collaboration and communication among the interdisciplinary team are important. Therapists should maintain open lines of communication with medical providers, nurses, and other professionals involved in the client's care to ensure a coordinated and comprehensive approach to delirium management.

Ethical and Practice Implications

Delirium poses specific challenges for mental health therapists, especially regarding capacity, informed consent, and maintaining client autonomy. As the client's cognitive state changes, therapists must navigate complex ethical considerations to ensure treatment decisions reflect the client's best interests and values.

One important aspect is informed consent. During episodes of delirium, a client's ability to understand and decide on their care may be impaired. Therapists need to assess the client's capacity carefully and involve family members or legal representatives in decisions when necessary. This requires balancing respect for the client's autonomy with the need to provide necessary care and support.

Therapists should also focus on preserving the client's dignity and well-being during delirium episodes. This might include:

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• Creating a safe, calming environment: Use strategies to reduce confusion and agitation, like maintaining a consistent routine and minimizing sensory overload.
• Working with the interdisciplinary team: Collaborate closely with medical providers and other professionals to ensure a coordinated, holistic approach to care.

Another ethical challenge occurs when clients have co-existing mental health conditions alongside delirium. Therapists need the skill to differentiate between delirium symptoms and underlying psychiatric disorders, as this impacts treatment decisions and outcomes. Close collaboration with medical providers is crucial for accurate diagnosis and appropriate interventions.

Therapists play an important role in advocating for the client's best interests and ensuring care aligns with their specific needs and values. This involves ongoing communication, adaptability, and a strong commitment to ethical practice in the face of complex challenges posed by delirium.

Conclusion: Therapists as Early Detectors of Delirium

Therapists often act as early detectors of delirium, noticing subtle changes in a client's cognitive function, behavior, and communication before other healthcare providers do. With their keen observational skills and understanding of each client's usual behavior, therapists can spot the warning signs of delirium during routine care and therapy sessions.

Recognizing warnings signs of delirium early on is a valuable clinical skill that can directly impact client outcomes. Quick detection allows for timely medical intervention, which can prevent serious complications associated with untreated delirium,.

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As healthcare professionals on the front lines of client care, therapists play a valuable role in safeguarding the well-being of those at risk for delirium. Their skills in early recognition and intervention are vital to improving outcomes and reducing the challenges of this complex condition.