Wandering Science: Wandering Science: Theoretical and Empirical FoundationsTheoretical and Empirical Foundations

Donna Algase, PhD, RN, FAAN. FGSAJosephine M. Sana Professor of Nursing

University of Michigan School of Nursing

Focus of PresentationFocus of Presentation• What is wandering?

– Theoretical and operational approaches

• What are the outcomes of wandering?– Empirical findings

• What explains wandering? – Theoretical models and empirical evidence

Early Definitions

– Aimless or purposeless walking – Increased amount of walking

Snyder et al., 1978Monsour& Robb, 1982

NANDA Definition • meandering, aimless, or repetitive

locomotion that exposes a person to harm and frequently is incongruent with boundaries, limits, or obstacles.

NANDA, 1999

Locomotion as a RhythmLocomotion as a Rhythm

CYCLE

TIME

MO

TIO

N

Walking Phase

Not walking Phase

Wandering as Spatial or Geographic Patterns

Wandering as Spatial or Geographic Patterns

Wandering Patterns

direct

lapping

pacing

random

Dimensions of WanderingDimensions of Wandering• Frequency

• Pattern

• Boundary transgressions

• Navigational deficits

• Temporal aspects

Pattern

Frequency

Proposed Standardized Definitiona syndrome of dementia-related locomotion

behavior

having a frequent, repetitive, temporally-disordered, and/or spatially-disoriented nature

that is manifested in lapping, random, and/or pacing patterns, some of which are

associated with eloping, eloping attempts, or getting lost unless accompanied.

Algase, Moore, Vande Weerd & Gavin-Dreschnack, 2006

Wandering Outcomes• Falls, fractures and injuries

• Elopement

• Victimization

• Weight loss

• Early institutionalization

• Premature mortality

• Higher caregiver burden

Need-Driven, Dementia-compromised Behavior Need-Driven, Dementia-compromised Behavior (NDB) Model (NDB) Model (Algase, Beck, Kolanowski, et al., 1996)(Algase, Beck, Kolanowski, et al., 1996)

Background Factors

Proximal Factors

Wandering

Background Factors• Neurocognitive factors

– memory, attention, language, visual-spatial skills

– circadian rhythm– motor ability

• Health Status• Socio-Demographics

– gender, occupation– personality, behavioral response to stress

Proximal Factors• Physiological need states

– hunger, thirst, elimination, pain, fatigue

• Affective states– depression, apathy, anxiety, euphoria,

irritability

• Physical environment– light, noise, temperature, humidity,

complexity of design

• Social environment– staff mix and stability, ambiance, social

engagement, crowding

Tested Interventions

• Subjective barriers• Walking, exercise and other activities• Specialized environments• Behavioral techniques• Music• Alarms

Subjective Barriers• Includes camouflage, visual barriers, and

floor grids• Capitalizes on visual-spatial distortions,

agnosia• Quality of evidence varies• Effective in some cases, severely impaired,

AD only?• Tested in residential facilities only

Exercise, Walking & Activities

• Some benefits reported, but studies too flawed to draw valid inferences

• Insufficient description of targeted population

• Tested in residential facilities only

Specialized Environments• Types of environments varies; secured

wards and nature/homelike areas

• Outcomes differed by type of environment

• Studies lacked theoretical underpinning to explain success

• Examined in residential facilities only

Behavioral Interventions

• Compelling results for reducing unwanted wandering

• Ideal reinforcement schedules unknown

• Consistency of approach may be unfeasible to implement with low staff to patient ratios

• Worth further evaluation, esp. in community/home contexts for specific wandering behaviors

Alarms

• Used to deter exit attempts

• Effective for reducing attempts

• Verbal versus aversive alarms have greater appeal

• May have applicability in home settings, especially as technology advances

Complementary/Alternative Therapies

• Hand/foot massage have been tested; acupuncture testing in progress

• Massage effective in the short run for agitation; impact on wandering unknown

Pattern as a Basis for Intervention: Random Wandering

To interrupt/stop active random wandering:

To reduce or prevent active random wandering:

Distraction

Social engagement

Small group or 1:1 activity

Calm, but engaging milieu

Pattern as a Basis for Intervention:Lapping

To interrupt/stop active lapping:

To reduce or prevent lapping: -

Redirection

Frequent rest periodsOther, more

comfortable repetitious activity

Pattern as a Basis for Intervention:Pacing

To interrupt/stop pacing:

To reduce or prevent pacing:

Address underlying concern, not behavior

Stress reduction techniques

Reassurance, trust-building

Anticipate needs; reduce eliminate known concerns

Trial and Error• Individualized approach based on

behavior log

• Context analysis

• Eliminate cause/precipitant

General Goals for Treatment General Goals for Treatment and Interventionand Intervention

• Assuring safety• Using preserved skills• Supporting abilities• Enabling functional navigation• Maximizing comfort and ease• Minimizing restriction

Assuring SafetyAssuring Safety

– Enroll in “Safe Return”– Deter elopement– Enhance lighting– Remove hazards from the environment– Provide a balance/rhythm in the level and

timing of stimulation

Using Preserved SkillsUsing Preserved Skills

• Encourage the person to do what they are able to do

• Provide progressive support matched to ability: remind, guide, assist, do for

• Provide orientation through cuing, signage, landmarks

Supporting AbilitiesSupporting Abilities

– Ensure adequate hydration and nutrition– Prevent exhaustion– Support circadian rhythm – Preserve skin integrity– Monitor effects of prescribed medications

ComfortingComforting

– Establish a working way to communicate– Build trust – Engage the person in meaningful, structured, supervised

activity that provides sensory stimulation– Create regular opportunity for 1:1 communication at the

person’s level of comprehension– Preserve elements of previous meaningful life activities– Create environments that are engaging, but not over-

stimulating

NavigatingNavigating

– Provide redundant cueing

– Decorate with relevant personal items and photo identification

– Keep desired areas in view; obscure line of vision to undesirable locations

– Display orienting information in multiple prominent places

– Use rooms for a single clear purpose

Minimizing RestrictionsMinimizing Restrictions

– Provide for flexibility within a larger structure – Simplify challenges– Lower performance expectations– Reserve chemical and physical restraint as a

last, if ever, resort

Suggested Practice Standards• Establish a clear goal for intervening• Use empirically-based interventions with caution• Balance safety and autonomy• Aim interventions to modify wandering only when it is

problematic for the wanderer• Be systematic in targeting known or suspected causes

of an individual’s wandering • Individualize strategies using case-study methodology