Wandering Science: Theoretical and Empirical Foundations

1. Wandering Science: Theoretical and Empirical Foundations Donna Algase, PhD, RN, FAAN. FGSA Josephine M. Sana Professor of Nursing University of Michigan School of Nursing

2. 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

3. Early Definitions Aimless or purposeless walking Increased amount of walking Snyder et al., 1978 Monsour& Robb, 1982

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

5. Locomotion as a Rhythm Not walking Phase • MOTION TIME Walking Phase CYCLE

6. Wandering as Spatial or Geographic Patterns

7. Dimensions of Wandering Frequency Pattern Boundary transgressions Navigational deficits Temporal aspects Pattern Frequency

8. Proposed Standardized Definition a 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

9. Wandering Outcomes Falls, fractures and injuries Elopement Victimization Weight loss Early institutionalization Premature mortality Higher caregiver burden

10. Need-Driven, Dementia-compromised Behavior (NDB) Model (Algase, Beck, Kolanowski, et al., 1996) Background Factors Wandering Proximal Factors

11. 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

12. 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

13. Tested Interventions Subjective barriers Walking, exercise and other activities Specialized environments Behavioral techniques Music Alarms

14. 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

15. Exercise, Walking & Activities Some benefits reported, but studies too flawed to draw valid inferences Insufficient description of targeted population Tested in residential facilities only

16. 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

17. 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

18. 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

19. 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

20. 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

21. Pattern as a Basis for Intervention:Lapping To interrupt/stop active lapping: To reduce or prevent lapping: - Redirection Frequent rest periods Other, more comfortable repetitious activity

22. 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

23. Trial and Error Individualized approach based on behavior log Context analysis Eliminate cause/precipitant

24. General Goals for Treatment and Intervention Assuring safety Using preserved skills Supporting abilities Enabling functional navigation Maximizing comfort and ease Minimizing restriction

25. 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

26. 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

27. Supporting Abilities Ensure adequate hydration and nutrition Prevent exhaustion Support circadian rhythm Preserve skin integrity Monitor effects of prescribed medications

28. 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 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

29. 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

30. 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

31. 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