Wandering Science: Theoretical and Empirical Foundations

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Wandering Science Theoretical and Empirical
Foundations

• Donna Algase, PhD, RN, FAAN. FGSA
• Josephine M. Sana Professor of Nursing
• University of Michigan School of Nursing

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Focus 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

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Early Definitions

• Aimless or purposeless walking
• Increased amount of walking
• Snyder et al., 1978
• Monsour Robb, 1982

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NANDA Definition

• meandering, aimless, or repetitive locomotion
  that exposes a person to harm and frequently is
  incongruent with boundaries, limits, or
  obstacles.
• NANDA, 1999

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Locomotion as a Rhythm

Not walking Phase
MOTION
TIME
Walking Phase
CYCLE
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Wandering as Spatial or Geographic Patterns
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Dimensions of Wandering

• Frequency
• Pattern
• Boundary transgressions
• Navigational deficits
• Temporal aspects

Pattern
Frequency
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Proposed Standardized Definition

• a syndrome of dementia-related locomotion
  behavior
• having a frequent, repetitive,
  temporally-disordered, and/or spatially-disoriente
  d 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

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Wandering Outcomes

• Falls, fractures and injuries
• Elopement
• Victimization
• Weight loss
• Early institutionalization
• Premature mortality
• Higher caregiver burden

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

Background Factors
Wandering
Proximal Factors
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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

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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

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Tested Interventions

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

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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

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Exercise, Walking Activities

• Some benefits reported, but studies too flawed to
  draw valid inferences
• Insufficient description of targeted population
• Tested in residential facilities only

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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

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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

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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

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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

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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 11 activity
• Calm, but engaging milieu

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Pattern as a Basis for InterventionLapping

• To interrupt/stop active lapping
• To reduce or prevent lapping
• -

• Redirection
• Frequent rest periods
• Other, more comfortable repetitious activity

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Pattern as a Basis for InterventionPacing

• 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

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Trial and Error

• Individualized approach based on behavior log
• Context analysis
• Eliminate cause/precipitant

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General Goals for Treatment and Intervention

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

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Assuring 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

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Using 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

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Supporting Abilities

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

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Comforting

• Establish a working way to communicate
• Build trust
• Engage the person in meaningful, structured,
  supervised activity that provides sensory
  stimulation
• Create regular opportunity for 11 communication
  at the persons level of comprehension
• Preserve elements of previous meaningful life
  activities
• Create environments that are engaging, but not
  over-stimulating

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Navigating

• 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

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Minimizing Restrictions

• Provide for flexibility within a larger structure
  
• Simplify challenges
• Lower performance expectations
• Reserve chemical and physical restraint as a
  last, if ever, resort

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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 individuals wandering
• Individualize strategies using case-study
  methodology