Alterations in thought process is a common nursing diagnosis in older clients, especially in institutional environments. The 1985 National Nursing Home Survey reported finding 63% of nursing home residents with disorientation or memory loss severe enough to impair performance in basic activities of daily living.1 Confusion, disorientation, and/or misinterpretation of the environment may develop in older clients in the acute care setting postoperatively or during acute exacerbations of chronic conditions.
Overwhelming stress due to relocation, sleep deprivation, interruption of normal routine, sensory deficits, physical stressors, and/or altered body image2·3 may alter behavior. Altered thought process may be the result of physiological changes which alter the character or metabolism to the cerebral cortex. These changes include cerebral trauma, tumors, diminished oxygenation, and progressive degeneration. In addition, altered thought process may be due to the presence of chronic or acute psychiatric illness or lifelong developmental disabilities.
Because of the baffling behavioral nature of the defining characteristics, the broad scope of behavioral symptoms, and the wide range of etiologies, alterations in thought process are often misdiagnosed by nurses.4,5 However, despite mislabeling, nurses must develop measures to provide for client safety while maximizing comfort and function. Nursing interventions are based on defining behavioral symptoms, determination of the etiology, and eliminating it whenever possible.
This article will highlight etiologies, assessment criteria, and interventions for the diagnosis of alteration in thought process. A conceptual model will then be used as the basis for explicating interventions and evaluation of the efficacy of interventions used in treating persons with this nursing diagnosis.
Because of the broad range of etiologies, it is impossible to develop a single care plan for alterations in thought process. Several key components should be present in every plan:
- providing for client safety;
- intervening to eliminate the etiology, whenever possible;
CLUSTERS OF BEHAVIORAL SYMPTOMS ALTERATIONS IN THOUGHT PROCESS DUE TO PROGRESSIVE DEGENERATION OF THE CEREBRAL CORTEX
- elimination of overwhelming environmental, intrapersonal, or interpersonal stressors;
- provision of structure and routine to provide pattern and meaning;
- development of interpersonal relationships which promote trust; and
- evaluation of interventions.
Perhaps the most difficult type of thought process alteration to manage is caused by progressive organic degeneration of the cerebral cortex (ATP:SDAT). Unable to alter the etiology, caregivers must continuously adapt to increasing behavioral alterations and functional decline, often without understanding the nature of the symptoms. Too often, interventions are planned using a trial and error method based on general knowledge of what should benefit the healthy individual, such as a highly stimulating routine with frequent changes of pace. Behavioral alterations may result, seeming to appear without cause or reason.
Assessing clients with Alterations in thought process: Senile dementia of the Alzheimer's Type (ATP:SDAT) is usually problematic. The client is generally unable to share reliable information about their psychosocial and health history. Often, the nurse must validate information received from the client with family members who are reluctant to discuss symptoms with the client. It is important to validate behaviors associated with ATP: SDAT in order to establish the diagnosis. Table 1 lists four groups of behavioral symptoms commonly observed. Several symptoms from all groups must be present.
NURSING DIAGNOSES OBSERVED IN CLIENTS WITH ATP-SDAT
Once the diagnosis of ATP: SDAT has been made, the nurse should evaluate the client's ability to manage environmental stimuli, level of function, and concomitant medical conditions. Planning care for the client involves utilizing coping mechanisms and past interest to provide meaning in activities and positive interactions with others.
The nurse should also take time to assess the family and caregivers of the client. Frequently, they have been living with a state of chronic grief and/or have significant health problems. The family unit continues to provide care through visiting, social activities, and identification of individualized tasks throughout the institutionalization. In short, they become part client and part of the caregiving team. Therefore, it is important to assess their understanding of the client's diagnosis, care, and their own health and social needs.6-8
Clients with ATP: SDAT rarely have one nursing diagnosis. Common secondary diagnoses deserving consideration in care planning might include those listed in Table 2. When planning care, care should be taken to identify and plan for all diagnoses present.
The role of the nurse in caring for these clients is generally limited. The majority of these clients are cared for at home by family members or significant others until the disease is well advanced.9 When institutionalized in long-term care facilities, care is provided primarily by nursing assistants who may have received little training in the care of the behaviorally difficult client. The nurse assumes supervisory, supportive, and evaluative roles in the long-term care setting. Therefore, it becomes important to have a conceptual framework as a theoretical base from which to work. Using a conceptual framework, the nurse can plan care, educate staff, counsel family, and evaluate outcomes based on predetermined criteria. The conceptual model used for this article is "progressively lowered stress threshold."10
The Conceptual Models
Conceptual models in gerontology provide a means of organizing and guiding research and practice in the field of nursing.11,12 The progressively lowered stress threshold model was developed using psychological theories of stress, coping, and adaptation, in addition to behavioral and physiological research of Alzheimer's Disease and related disorders.10
Symptoms of dementing illnesses were categorized into three groups by researchers: cognitive or intellectual losses; affective or personality losses, and cognitive or planning losses which result in functional decline. Symptoms falling within these groups are listed in Table 1. Researchers also identified other behaviors which occurred with increasing regularity as the disease progressed, including night awakening, agitation, late-day confusion, agitated wandering, sudden withdrawal from activities, and catastrophic episode.13-16
Noting that most of these behaviors occurred late in the day or following a stimulating event, and that clients exhibiting these behaviors appeared to be uncomfortable or distressed, a hypothesis was developed that they were stress related.10 Examination of literature on stress, coping, and adaptation provided the following criteria required for successful coping: 1) The ability to provide adequate purposeful effective movement for sufficient periods of time; 2) The ability to produce energy to fuel memory and sensory operation; 3) The ability to receive sensory input and evoke appropriate responses; and 4) The ability to learn and organize appropriate sensory and cerebral input.16
In the presence of cortical degeneration, the ability to perceive, move, produce energy, and integrate cerebrally is progressively impaired. This is demonstrated by observing clients with Alzheimer's Disease and related disorders, evaluating the results of neurobehavior testing, and evaluating the findings of metabolic studies of brains of affected individuals, such as with positron emission scans (PET).'7-'8 The hypothesis of the model is that the dysfunctional and catastrophic behaviors described above indicate a progressive lowering of the stress threshold. These behaviors cause excess disability, further limiting the client's ability to function and interact with the environment. ICU9 Relieving stressors which cause excess disability results in maximum client function and comfort.
The model outlines five basic groups of stressors which produce excess disability in the client with ATP: SDAT. The nursing care plan should minimize these stressors using anxious or agitated client behavior as an indication for further intervention. The stressor groups are fatigue; change of environment, routine or caregiver; overwhelming and/or competing stimuli; demands which exceed capacity to function; and physical stressors such as acute illness, discomfort, and/or medication reactions.10
Fatigue. Clients with ATP:SDAT fatigue rapidly. The fatigue resulting from performing basic daily functions may necessitate frequent daily rests or naps. Midway through the disease, many clients sleep several times during the day and become agitated if kept awake. This may minimize their ability to sleep at night. The provision of scheduled "time outs," or rest periods two or three times during the daily schedule helps to minimize fatigue without promoting night wakening.
If the client tends to sleep during the rest periods, it is strongly recommended the nap be taken in a recliner. The recliner or easy chair provides a cue that the rest is only a nap, instead of the client believing it is morning. The use of time-out periods for ATP:SDAT clients was first recorded by Lawton20 on the Alzheimer's Disease Unit at the Philadelphia Geriatric Center. He reported subjects who spent 20% of their time alone in their room had higher levels of socialization and social contact the remaining 80% of the time.
The use of night lights, which provide a consistent low level of light after bedtime will assist caregivers with seeing the resident to provide late night cares, such as toileting the client. When used in hallways, client rooms, and bathrooms, night lights eliminate the need for flashlights and/or turning on the lights. Turning on room lights indicates to many clients that it is morning and time to rise for the day. One facility reports success with photosensitive night lights which turn on and off automatically, but do not draw residents' attention being turned on and off.21
Fatigue can also be avoided by organizing shorter group activities. If the client is being taken to a family gathering or out to dinner, make sure he/she is rested in advance. Counsel the family to provide the resident with frequent rests during the day and to heed the client's requests to return to the facility, often referred to by clients as "home. " Clients who have disease progression to the stage where they are unable to dress themselves may only be able to tolerate group activities in the morning. They may benefit from quiet one to one or a music activity during the afternoon.
Change of Environment, Caregiver, or Routine. One of the most devastating losses associated with ATP:SDAT is the altered ability to plan, initiate, and carry through to a goal, voluntary activities. Simply stated, the more the client must think about a task, the less likely he/she will be able to complete it. Planning losses result in functional decline; however, most clients are aware of the problems as they occur. They will express frustration at trying to initiate or complete simple tasks, occasionally refusing to try an activity they feel they cannot complete. To compensate for this, many clients develop a consistent routine, sticking to it with little variation. When the caregiver varies the routine or there is even a small change in environment, such as the addition of holiday decorations, the client is forced to rethink all activities and increased disability is noted.
The nursing care plan should reflect an understanding of these losses by including a consistent daily plan carried out as the client wishes. Areas of holiday decorations should be limited so that the client's environment remains relatively stable. Family members need counseling when making travel plans to anticipate potential behavioral alterations, providing time for the client to rest before and after traveling, and traveling early in the day to minimize problems with fatigue. Whenever possible, a primary care approach and consistent staffing should be used.
Changes of pace should be planned for family members and staff. The nurse, however, should evaluate the client 's ability to tolerate the change before and after the scheduled activity. If the client requests to leave the activity, is upset afterward, is up confused that night, or refuses to attend the activity, alternative plans should be made for a less complex activity.
Misleading, Overwhelming, or Competing Stimuli. ATP:SDAT limits the client's ability to receive and interpret stimuli. This is particularly noted in places with high noise levels, multiple activities, and many people, such as a group dining area. Clients with advanced ATP:SDAT frequently misinterpret abstract visual stimuli, such as television or pictures of people or animals.
Mirror images may become frightening, especially if the image is a window reflection. Unexplained auditory input, such as a public address system, may be interpreted as people in the attic. These misinterpretations are labeled pseudohallucinations and may seem mysterious to staff.22 Once informed, staff will be able to determine causes of illusions and eliminate the cause.
Residents with ATP:SDAT tend to choose levels of stimuli that they are comfortable with. This may be one reason for reports of increased social behavior on special units for clients with Alzheimer's Disease. The smaller, self-contained units offer quiet areas, small group activities, and minimize competing stimuli20"23 (Cleary T, Clamon C, Price M, et al, unpublished data). One area of particular concern is mealtime. When meals are served at small dining tables, with groups of three to four clients per table per room, normal social behavior is approximated. Residents eat more food off their trays and weight loss tends to stabilize.22
All environments housing clients with ATPrSDAT should be evaluated for level of auditory and visual stimuli. Environmental cues should be assessed to see what the environment is saying to the resident. Do long hallways invite wandering or pacing? Do the rooms indicate that this is the resident's home? Are there cues to leave?
Care must be taken to design an environment which approximates the home environments of the cultural grouping the facility serves. This may include the use of softly colored and patterned wallpapers, drapes, and bedspreads. Care also must be taken not to "overdecorate," providing an environment which will look too formal for residents to use comfortably. One rural facility utilized period reproduction furniture with pale rose and gray upholstery, which, they felt, would promote calm. The resulting decor looked wonderful, but few of the retired farmers would sit in the living areas, preferring instead the older recliners in their rooms.
Demands to Achieve which Exceed Functional Capacity. Clients with ATP:SDAT live in a world filled with pop quizzes. Someone is always asking them questions they cannot answer and telling them they are wrong. Attempts to read and speak are hampered by language loss. Simply trying to dress or bathe may result in a tangle of thought and actions.
To worsen their frustration, many family and staff believe the failing brain should be tested and exercised in order to prevent further loss. This notion may stem from the myth that Alzheimer's Disease is caused by disuse. Some families even try to hire tutors to retrain the client in reading or other lost skills. Others may feel it is their duty to test the client daily to observe how much memory is lost.
It is helpful to visualize the client with cortical degeneration as a lower extremity amputee. Just as we would not require the amputee to ambulate without a device to assist or prosthesis, we should not expect the client with ATP:SDAT to function and remember without assistance. One area of conflict is the function of reality orientation therapy. While reality testing may promote agitation, should the client be reoriented to the present?
Reality therapy can be meaningful to clients if the goals are realistic. Discussion of a concrete item, holiday, or pastime, may promote comfort and some understanding of the environment. Pets, short intergenerational activities with children, and special holiday programs may also provide positive stimulation for clients, staff, and families. Care must be taken to determine the resident's feelings concerning these activities prior to participation in them. One essentially mute resident was presented with the facility dog to try to evoke a warm response. She looked at the dog and screamed, "Get that d ____ dog out of my house!"
Physical Stressors. Anything which causes pain, discomfort, acute illness, metabolic imbalances, or other physiological alterations will worsen mental status in the ATP:SDAT client. One of the most commonly used physical stressors is caffeine. Elimination of caffeine may reduce agitation significantly.
Other common causes are full bladder, impacted bowels, urinary tract infections, dyspepsia, influenza, pneumonia, medication reactions and interactions, pain - especially from arthritis or back, and oncoming viral infections, such as a cold.
Dysfunctional behavior resulting from physical stressors is also known as acute confusional syndrome or delirium. Symptoms tend to be severe and unremitting. Clients exhibiting stressrelated behavior should receive a physical assessment as acute confusion may be the only presenting symptom of a severe illness.3
Another area which must be addressed in planning care for ATP:SDAT clients is safety. Clients become progressively unable to consider their own safety needs and risks. This may be expressed in problems with wandering or elopement. Care must be taken to identify clients who have a history of, or the potential for, wandering. Wandering may be defined as leaving the nursing unit, facility, or designated area without sanction of the caregiver and posing risk to the client. Wandering may be purposeful on the part of the resident or it may occur accidentally. Once identified as having the potential to wander, plans must be made for a potential elopement.
The resident's room may be located near an area where additional supervision can be provided. Clothing can be labeled subtly, such as a small label on the lapel or a special colored sweater. The resident's picture should be kept on the Kardex to provide for those who might look for the lost resident. Staff needs to be informed of the procedure to follow in case of elopement. Many facilities provide special alarm systems to alert staff when elopement occurs. The family and facility need to decide and record their preference for a resident's protection from wandering prior to implementing soft tie restraints.
Falls are another safety problem. As clients lose the ability to ambulate, they are at high risk for falls. The potential for falls should be discussed realistically with the family and an agreement reached and recorded concerning the use of restraints and safety measures.
Additional interventions for safety might include testing water temperature prior to bathing, food and beverage temperatures prior to eating, and training staff in methods to relieve choking. Hazardous objects, such as razors, canes, and electrical devices should be stored away from clients and used with supervision. Potentially ingestive substances, such as plants, toiletries, or cleaning solutions should be carefully monitored. All staff, even noncaregiving staff, should be trained in the potential hazards to clients with ATP: SDAT and their role in client protection. This includes training staff and visitors not to leave the keys in their cars, a problem in rural areas.
ATP: SDAT is a diagnosis where there is more than one client. Families and friends are often in a continued state of grieving. Care must be taken to include them in the plan of care with counseling on the disease process, informing them of rationale for care, providing them with support opportunities and special family programming to enhance the visiting experience.
Caring for the client with ATP:SDAT can be extremely rewarding despite the progressive nature of the etiology. Using the conceptual model, care can be evaluated using the presence of behavioral indicators which would change with increased stress such as:
the amount of food ingested;
presence of stress-related behaviors
- night wakening
- combative episodes
- agitated wandering
- noisy behavior
- antisocial behaviors;
level of socialization;
use of tranquilizers, sedatives, or other mood-altering medications; and
family satisfaction with care.10,22
While new literature is published regarding care of ATP:SDAT clients, continued nursing research is needed to validate assessment instruments, techniques, and interventions. While this raises difficult ethical legal issues of client protection, evaluation of the progressively Jowered stress threshold model has been accomplished primarily through retrospective chart review.
The following case study demonstrates care of the ATP:SDAT client in the long-term care setting. The nursing staff attempted to control for fatigue, change, overwhelming sensory input, demands to achieve which exceed capabilities, and physical stressors. Utilizing interventions to control these stressors, excess disability was minimized and the client appeared to be comfortable without medications and restraints.
Phil is a 78-year-old retired accountant and politician. He resided with his wife of 55 years in a small rural community. He is the father of two grown sons who reside in the same town and who are also politically active. About six years ago, Phil's family began to notice memory problems. He began to forget the names of constituents, lose bills, and have problems driving. Because of fear of social stigma, no physician was contacted.
Two years ago, Phil's wife felt she could no longer manage him in their home and placed him in a local nursing home. At the time of admission, his medical diagnoses were mild congestive heart failure and confusion. On admission to the facility, the nurse noted that Phil exhibited loss of memory for recent events, altered time sense, inability to reason and make decisions, flat affect, inability to inhibit, social withdrawal, language and functional loss. Phil required assistance with bathing and dressing. He became agitated late in the day and appeared to be searching for something.
Four days after admission, Phil climbed into bed with an elderly whitehaired female resident. After being removed by the staff and restrained in bed, Phil removed his restraints. He then attempted to drag the female resident to his bed by her hair. He was discharged from the facility.
This was repeated in two other facilities and Phil was sent for psychiatric evaluation. The psychiatry staff evaluated him, finding Phil to have a primary degenerative dementia, probably due to Alzheimer's Disease (SDAT) and multiple infarctions to the cerebral cortex (MID), or a mixed type of dementia. The nursing staff diagnosed ATP:SDAT. Secondary diagnoses of potential for violence, altered nutrition, fear, altered coping, altered oxygenation, impaired verbal communication, and knowledge deficit were established.
Upon meeting Phil's wife, the nurses were impressed by her inability to cope with Phil's behavioral symptoms and her beautiful white hair. She expressed concern with Phil's care, but was relieved to learn that this behavior was not the result of mental illness. Because of his prominence in the community, her sons' political careers, and the reputation Phil was gaining from the incidents in the care facilities, his wife requested Phil be placed in a facility a distance from their home. Arrangements were made for Phil to be admitted to a nursing home about 100 miles from their community and for ongoing counseling for Phil's wife nearer to their home.
Prior to admission, the director of nursing visited Phil in the psychiatric unit. He noted that Phil continued to be able to dress himself, but required assistance with bathing. Phil would tolerate the dayroom when other patients were not around, but would retreat to his room when others relumed from activities. Phil slept about an hour each afternoon, being somewhat groggy and agitated on arising. By evening, Phil became somewhat agitated and was occasionally up at night. A plan was developed to admit Phil to a quiet room in the nursing home with another resident with ATP:SDAT.
Because the home tended to bustle with activity, a plan was developed to slowly introduce Phil to the milieu of the facility. On admission he was taken to his room, where his wife had provided his recliner, afghan, and family pictures. Two strips of yellow tape had been placed in front of the door to the room and a sign hung in the doorway at Phil's eye level stating, "Phil, please do not cross these lines." Phil was encouraged to become acclimated to his room for about 24 hours prior to attempting to navigate the rest of the facility.
Because of Phil's history of occasional combative episodes with staff, and his social history of being a politician, the staff decided to address him by his last name. Using his last name evoked a set of well-preserved social responses for Phil. This provided him with a sense of mastery over his interaction with staff and the feeling he was respected by those caring for him.
A consistent daily routine was developed for Phil that all staff followed. He would rise, have breakfast, receive assistance with bathing, and dress himself. This period of activity was followed by a quieter time in his room, usually spent in his recliner with a newspaper for 40 minutes. Following the break, Phil would participate in a small group activity, such as stretching, a group exercise, music, ceramics, or a reminiscence group.
Lunch and other meals were provided at a small table placed in an alcove. Four residents with ATP:SDAT sat together, socializing while they ate. Caffeine was eliminated from their diet. Following lunch, Phil was taken to his room to rest for an hour. He spent part of the hour sorting through a reminiscence box and part of the hour napping in the recliner.
After resting, Phil was given a high protein with complex carbohydrate snack, such as crackers and cheese. The snack was provided in the form of a social gathering for all residents with ATP:SDAT to facilitate positive resident interaction. Following snacks, quiet activities and visiting took place. Dinner was served and residents had quiet socialization until being assisted to bed at about nine. Phil slept at night.
After several weeks, Phil was beginning to put on weight. He appeared more alert and increased his communication with the staff. There were no combative episodes. However, one night the director noticed Phil head into a female resident's room. Following him into the room, the director observed Phil trying to climb into bed with the white-haired resident. Phil was quietly redirected to his room. Asked if he missed his wife, he nodded.
The next day, Phil found a confused temale resident wandering the halls. He took her gently by the hand and led her up and down the halls. From that moment, they were inseparable during the day. Phil continued to sleep at night and did not attempt to go to bed with other female residents. When Phil's wife visited, he devoted his time to her, but the staff grew concerned that his wife might discover the relationship by accident.
A staff meeting was held and a plan developed to inform Phil's family of the situation. The director of nursing and social worker described Phil's need for companionship to his wife. With their help, she understood and encouraged staff not to keep Phil and the resident apart. The female resident's family also agreed they should be allowed to walk and eat together. Phil continued to walk with the female for the next two years, until his wife transferred him to a facility closer to home. The staff was satisfied that the ongoing care and counseling provided to Phil's wife helped her to accept her husband's condition and overcome her sense of shame. The new facility had implemented the same plan of care and is having no difficulty managing his behavior.
This article has presented the conceptual and research base for the nursing diagnosis of Alteration in Thought Process. A case study illustrated the diagnosis, etiology, and behavioral symptoms for the diagnosis. The development of this diagnosis and application of tested interventions is paramount in view of prevalence of this diagnosis among the elderly with and without mental illness.24 Testing interventions to treat and prevent impaired thought processes is critical to maintaining a quality of life for the older person.
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CLUSTERS OF BEHAVIORAL SYMPTOMS ALTERATIONS IN THOUGHT PROCESS DUE TO PROGRESSIVE DEGENERATION OF THE CEREBRAL CORTEX
NURSING DIAGNOSES OBSERVED IN CLIENTS WITH ATP-SDAT