Continuing Education Activity

Sensory-perceptual alteration can be defined as when there is a change in the pattern of sensory stimuli, followed by an abnormal response to such stimuli. Such perceptions could be increased, decreased, or distorted with the patient's hearing, vision, touch sensation, smell, or kinesthetic responses to stimuli. This activity reviews the evaluation and management of sensory-perceptual alterations and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Identify the etiology of sensory-perceptual alterations.
• Outline the presentation of a patient with sensory-perceptual alterations.
• Describe the management considerations for patients with sensory-perceptual alterations.
• Summarize the importance of collaboration and communication amongst the interprofessional team to enhance the care of patients with sensory-perceptual alterations.

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Introduction

Sensory-perceptual alteration is a change in the pattern of sensory stimuli, followed by an abnormal response to them. Such perceptions could be increased, decreased, or distorted with the patient's hearing, vision, touch sensation, smell, or kinesthetic responses to stimuli. Such changes in the pattern of responses to stimuli lead to alterations in a patient’s behavior, sensory acuity, decision-making, and problem-solving abilities. This can lead to irritability, restlessness, poor concentration, fluctuating mental status, communication difficulties due to inattention, and lack of focus. Furthermore, sensory deprivation in isolated patients can lead to anxiety, depression, aggression, hallucinations, and psychotic reactions.[1] 

Any alteration in a patient's normal environment can cause stress, especially if it is involuntary. Sensory overload occurs when an individual experiences a stimulus that they are unable to manage and process. Usually, the second stimulus is filtered out by selective perception or coping behavior. However, in certain environmental conditions, such as the emergency department, or in the presence of specific underlying illnesses, such as dementia, sensory overload can occur due to inadequate filtering of stimuli.[2]

Sensory deprivation occurs when an individual receives a stimulus below the threshold of normal perception. Risk factors for such alterations can be broadly due to acute illnesses, patient factors related to chronic medical conditions, aging, or environmental or iatrogenic causes.[3] This typically occurs when the patient is placed in isolation, such as during hospital admission or admission to an isolated ward. In isolation, there can be a reduction in the quantity and quality of stimuli and a restriction of social interaction. Other risk factors that can lead to increased or decreased alterations in the processing of stimuli include hearing impairment, vision loss, loss of smell or taste, aging, trauma, electrolyte imbalance, seizure disorder, mental health problems, and genetic causes.

Etiology

The cause of sensory-perceptual alteration depends on the underlying condition and risk factors. Factors that may increase the risk of sensory perceptual alterations include:

Psychiatric Conditions

Autism spectrum disorder (ASD): Alterations in sensory-dedicated neural circuits, including neuro-molecular and anatomical changes in primary sensory regions of the brain, are responsible for autism-associated sensory symptoms. GABAergic (gamma-aminobutyric acid) signaling is often affected and responsible for these alterations.[4]

Attention deficit hyperactivity disorder (ADHD): The inability to inhibit irrelevant sensory extraneous stimuli leads to sensory overload in ADHD. This occurs due to impaired information processing and faulty perceptual capacity. Individuals with ADHD have a reduced ability to filter intrusive sensory, motor, and/or cognitive information.[5]

Schizophrenia: Altered sensory processing and perceptual inference are responsible for the positive symptoms of schizophrenia.[6][7] Aberrant neurotransmitter signaling in the sensory pathway and abnormal cortical plasticity mechanisms are implicated in the pathology of schizophrenia.[8] One of the core features of both schizophrenia and ASD is dysfunctional face emotion recognition and motion processing.[9]

Sensory processing disorder (SPD): A neurological condition in children in which the brain is unable to process incoming information accurately and in an organized manner, leading to inaccurate processing and judgment of sensory information. Children can experience difficulty with regulating emotions, problems with attention, and adapting responses.[10]

Sleep Disorders 

Altered sleep or sleep deprivation can cause delirium, leading to sensory and perceptual alterations. A decrease in rapid eye movement (REM) sleep has been identified as a possible factor in delirium.[11]

Delirium in Intensive Care 

Critically ill patients in the intensive care unit (ICU) are at increased risk of developing delirium. Sensory and altered perceptions can occur due to host factors, acute illness, and environmental factors. Environmental and iatrogenic factors include sleep deprivation, sensory deprivation, immobilization, and social isolation.[3] Lack of quality and adequate sleep are important risk factors for the development of delirium in patients admitted to the ICU. Such changes negatively affect the quality of care provided to the patients.[12]

Causes of disturbed sleep in the ICU may be due to:

• Mechanical ventilation and medication (benzodiazepines used to treat delirium can also adversely contribute to delirium, particularly in elderly patients) [3]
• Continuous exposure to light disrupts the circadian rhythm
• Noise exposure: sound from equipment, alarms, conversations amongst healthcare staff or patients 
• Patient care activities: vital signs, nursing procedures, imaging, lab draws [13][14]

Prolonged or frequent sleep deprivation can lead to:

• Delirium: due to impaired cognitive function [14]
• Prolonged neurocognitive dysfunction
• A decrease in quality of life
• Impaired immune function [13] 

In certain circumstances (ex, infection control), it may become necessary to isolate patients. Contact isolation can adversely affect a patient’s mood, heightening the likelihood of depression, anxiety, hostility, and fear. Due to the uncertainty of the situation, the patient may feel they are losing control during social isolation, which may influence their mood.[15] Elderly patients with neurocognitive disorders under physical isolation are more prone to develop delirium.[16] 

Neurological Disorders

Several of the neurological disorders and syndromes can present with changes in behavior and cognitive function due to altered brain function.[17] These can be due to acute changes related to trauma, metabolic and electrolyte imbalance, medication, infections, or vascular changes. Furthermore, such changes can happen slowly and insidiously due to inherited disorders, neurodegenerative diseases, malignancies, or structural disorders.[17]

Alzheimer disease: Due to cortical disturbances, sensory visual impairments are a common finding in Alzheimer disease. This occurs due to the accumulation of neurofibrillary tangles and neuritic plaques in the visual cortical areas, leading to cortical degeneration and atrophy. Higher visual abilities are commonly compromised. These include simultanagnosia, problems with visual attention, visual memory, perceiving structure from emotion, object and face perception, visual learning, and reading. Impairment of visual perception in these patients decreases their quality of life and complicates the evaluation of other cognitive deficits.[18][19][20]

Parkinson disease: The progressive loss of dopaminergic cells in the retina and other areas of the visual system leads to visuoperceptual deficits in patients with Parkinson disease. This dopamine deficiency in the retina leads to selective spatial-temporal abnormalities in the retinal ganglion cell function. Patients who develop visuoperceptual deficits are at a higher risk of developing dementia.[18][21]

Seizure disorder: Patients with epilepsy can have perceptual functions with all 5 senses affected. This results in impaired or occasionally supranormal sensibility. Ictal perceptual experiences are common, but interictal function may also be affected. Since epilepsy is a network disease, it can affect neural circuits distant from the seizure focus. This may account for the correlation between the sensory modality affected and the underlying epilepsy syndrome. People with temporal lobe epilepsy often experience olfactory impairments, including odor discrimination, identification, and recall. Such altered sensation is due to the close association of the olfactory system with the limbic system (which is often implicated in mesial temporal lobe epilepsy). Visual information processing may also be disturbed in occipital lobe epilepsy.[22] 

Visual Dysfunction

Common causes of visual dysfunction in the elderly are:

• Age-related changes in the optics of the eye
• Diabetic retinopathy
• Glaucoma
• Cataract
• Age-related maculopathy
• Visual hallucinations due to Bonnet syndrome 

These dysfunctions lead to impairment in visual acuity, contrast sensitivity, color discrimination, motion perception, peripheral visual field sensitivity, temporal sensitivity, and visual speed processing.[18]

Hearing Problems 

Hearing loss can cause auditory hallucinations, such as Anton's syndrome. 

Electrolyte Imbalance

This can cause an altered sensorium, especially hyponatremia and hypocalcemia, which can induce delirium in elderly patients.[23]

Alcohol or Illicit Drug Use

This can lead to neurocognitive impairments resulting in altered sensory and perceptual alterations.[24][25][26]

Chronic Medical Problems

Liver failure, renal failure, and acquired immunodeficiency syndrome can cause sensory-perception alterations. Other causes can include hospitalized elderly patients, ventilation-perfusion mismatch, polypharmacy, patients with a terminal illness, post-surgical status, or patients with a high fever.[27]

Epidemiology

The prevalence of delirium can range from 3% to 42% during hospital admission.[28] Delirium can be as high as 80% in critically ill patients.[29] Such variations depend upon the cause and the host factors. The prevalence of hallucination in the general population has been reported to be as high as 12% and has a significant impact on functional impairment.[30]

Pathophysiology

Sensory and perceptual alterations can occur due to a direct insult to the brain or to aberrant stress responses.[31] Biochemical derangement due to increased release of dopamine, cortisol, glutamate, and norepinephrine, along with decreased cholinergic function, may cause such changes. Also, changes in serotonin or gamma-aminobutyric acid activity may manifest as distinct clinical presentations. Age-related changes in neurotransmission and intracellular signaling may also occur, leading to alterations. Aberrant stress responses, such as acute changes in the environment, trauma, severe illness, and surgery, can cause abnormalities and alter neurotransmitter release, leading to sensory and perceptual alterations. Decreased cerebral oxidative metabolism can cause abnormal neurotransmitter release, leading to cerebral dysfunction. The cellular signaling hypothesis posits that intraneuronal signal transduction is altered, leading to changes in neurotransmitter production and release and altered sensation.

History and Physical

The history is relevant to the underlying risk factor responsible for sensory-perceptual alteration. Signs and symptoms can occur at a specific time and place when the patient is exposed to a certain environment or trigger, or they can happen instantaneously without any triggers. Furthermore, signs and symptoms of sensory-perceptual alterations can occur when the patient is exposed to certain stimuli or environmental factors. Such sensory and perceptual disorders would be magnified in an unfamiliar environment, especially when patients are hospitalized in unfamiliar hospital rooms.

Vital signs can be abnormal or normal, depending on the etiology of the sensory and visual alterations. Patients may not be oriented to time, place, or person. They can be confused, irritable, and unable to focus or concentrate, and to solve problems or communicate. They may also be suffering from hallucinations (visual, auditory, or tactile). Depending on the altered perception, cranial nerve and sensory examination may be abnormal. The remaining systems examinations are expected to be normal or variable, depending on the patient's condition.

Evaluation

Validated assessment tools such as the Confusion Assessment Method for the Intensive Care Unit or the Intensive Care Delirium Screening Checklist should be used to identify delirium in ICU patients.[29][32] An electrocardiogram, echocardiogram, lab investigations, cerebrospinal fluid studies, electroencephalogram, chest x-ray, or computed tomography scan of the head may be required to ascertain the diagnosis.[33]

Treatment / Management

The main priority is the patients' safety. Such alterations not only increase the stress on the patient but also put patients at risk of falls and injuries. They may be a danger to themselves or to others due to their violent behaviors. Management and interventions depend on the cause of sensory and perceptual disturbances. Hence, careful evaluation is needed to ascertain the cause, assist the patient, and prevent further distress or injury. 

The patient can be supported in being reoriented to time, place, and person. This can be done by engaging the patient in a conversation about the current news, weather, or asking them about their hobbies or experiences. They should be frequently monitored and settled in a comfortable environment free of excessive stimuli (bright lights, ICU noise).

Visually impaired patients can be provided with corrective lenses and large-print or braille reading material. Conversations should be carried out at the patient's eye level and within their field of vision. The surrounding environment should be organized, and they should be aware of where their items are placed. Patients with hearing deficits should be provided with their hearing devices. To ensure effective communication, the environment should be noise-free. Written communication or sign language may be used to facilitate communication. 

To treat or prevent ICU delirium, a multicomponent intervention should be adapted. This includes both pharmacological and non-pharmacological interventions.[3] However, the response to pharmacological intervention with antipsychotics is variable.[34] Another review states that the use of pharmacological interventions for the prevention and management of delirium is associated with poor outcomes. Henceforth, pharmacological intervention to manage delirium in the ICU is not recommended.[35] 

Non-pharmacological interventions to prevent and manage delirium in the ICU include: 

• The use of earplugs and eye masks 
• Noise control strategies and music therapy
• Bright light therapy
• Cognitively stimulating activities
• Medication review [3] 

Providing adequate sleep in terms of length and quality is necessary to prevent sleep deprivation and, thus, delirium in patients admitted to the ICU. Improving sleep hygiene has been associated with a decreased risk of delirium.[36] The use of earplugs and eye masks is recommended to reduce noise levels and block out bright light. These non-pharmacological interventions are known to improve the quality of sleep in patients admitted to the ICU.[12][13][36] 

Auditory hallucinations due to mental health problems such as schizophrenia, bipolar disorders, post-traumatic stress, and dementia can be assessed by clinical observation or by talking to the patients. The patient may report hearing voices, or the clinician may observe the patient talking to themselves. Apart from a full assessment to identify the specific cause, the patient can be managed with medications, cognitive-behavioral therapies, or with a psychotherapist. Visual hallucinations due to mental health problems, sleep disorders, or substance misuse should be handled according to the cause with appropriate medications to treat the cause, along with cognitive-behavioral therapies or with a psychotherapist. Similarly, other hallucinations can affect smell and taste and need appropriate supportive therapy.

Differential Diagnosis

The following differential diagnosis can be implicated in sensory-perceptual alterations:

• Cognitive impairment
• Stroke
• Polypharmacy
• Anticholinergic drugs
• Psychotropic drugs
• Dehydration or malnutrition
• Multiple comorbidities, including liver and renal failure
• Sepsis due to an infectious cause
• Terminal illness
• Metabolic acidosis
• Constipation
• Sleep deprivation
• Depression
• Loneliness with few social contacts
• Transient electrolyte imbalance
• Generalized tonic-clonic seizure
• Vision or hearing impairment [33]

Prognosis

Prognosis depends upon the cause of the sensory and perceptual alterations. The key components of management are early recognition and prevention of injuries or patient distress.

Complications

The main complication is stress and potential harm to the patient due to an unsafe environment. Alterations not only increase the stress on the patient but also put patients at risk of falls and injuries. They may be a danger to themselves or to others due to their violent behaviors. A careful evaluation is needed to ascertain the cause, assist the patient, and prevent further distress or injury.

Deterrence and Patient Education

To mitigate the psychosocial effects of isolation, patients must understand the importance of contact isolation. Educating and emotionally preparing the patient for such a need reduces anxiety and distress and helps them cope better.[15] One way to prevent delirium in ICU patients is to involve family members in their care. Open communication should be established between family members and healthcare professionals. Family members are encouraged to bring personal items (ie, pillows, frames, eyeglasses, hearing aids) belonging to patients. This would ease communication and orientation, therefore assisting in cognitive stimulation.[37] Family members should also be educated about the signs and symptoms of delirium to facilitate early recognition and management.[3]

Pearls and Other Issues

Management is based on early diagnosis and early intervention. All such care should be provided in an unbiased, non-threatening, and non-judgmental manner, as managing these patients can be a challenge. The care should be supportive, caring, and compassionate, addressing patients' needs rather than being biased or judgmental.

Enhancing Healthcare Team Outcomes

Research has shown that delirium in the ICU is underdiagnosed, despite its high occurrence. For early detection and treatment, it is imperative to understand delirium and its clinical subtypes. To prevent adverse outcomes, healthcare professionals can help identify predisposing risk factors and eliminate precipitating risk factors for delirium.[29][32][38] To improve patients' sleep in the ICU, sleep protocols should be implemented, and a change in ICU culture is required. ICU clinicians, nurses, and other staff should be educated about the importance of sleep in preventing delirium. Performance can be routinely measured, as can compliance with protocol.[14]

Training caregivers responsible for patients with dementia improves their care and management. Family caregivers' skills, knowledge, competencies, and communication significantly improved after the training intervention. However, for this intervention to be effective, it is necessary to apply this training and practice. Training intervention for professional caregivers also improved knowledge and communication.[39] In dementia communication, an educational intervention promoting face-to-face and diverse instructional delivery methods showed a positive effect on communication skills across all carer groups. Because of this communication, training should be included as a strategy in dementia training.[40] A standardized approach to care for patients suffering from dementia was found to have an adverse effect. To improve the quality of care for these patients, consistent patient-centered nursing care should be adapted.[41] 

Advanced psychiatric nurses who have received specialized training to provide mental healthcare to children with sensory processing disorder can assist families in carrying out recommended sensory interventions and home programs. They also play a key role in promoting communication among all healthcare professionals working with children diagnosed with sensory-perceptual disorder.[10]

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Disclosure: Isra Khan declares no relevant financial relationships with ineligible companies.

Disclosure: Moien AB Khan declares no relevant financial relationships with ineligible companies.