Journal of Gerontological Nursing

Evidence-Based Guideline 

Wandering

May Futrell, PhD, RN, FAAN, FGSA; Karen Devereaux Melillo, PhD, GNP, ANP-BC, FAANP, FGSA; Ruth Remington, PhD, GNP, ANP-BC

Abstract

Dr. Futrell is Professor Emerita, Dr. Melillo is Professor and Chair, and Dr. Remington is Associate Professor, Department of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts. Dr. Schoenfelder is Associate Clinical Professor and Editor, John A. Hartford Center for Geriatric Excellence, The University Iowa College of Nursing, Iowa City, Iowa.

Guidelines in this series were produced with support provided by grant P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing), National Institute of Nursing Research, National Institutes of Health. Copyright © 2008 The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core.

Address correspondence to Deborah Perry Schoenfelder, PhD, RN, Associate Clinical Professor, The University of Iowa College of Nursing, 430 Nursing Building, 50 Newton Road, Iowa City, IA 52242; e-mail: deborah-schoenfelder@uiowa.edu.

Wandering can be problematic for caregivers, as well as for the person with dementia. Wandering behavior may disrupt the individual’s sleep, eating, safety, or the caregiver’s ability to provide care. To individualize interventions for wandering, it is important to assess premorbid factors, the disease process, behaviors typical of the disease, and medications and their side effects. Other factors, including the environment and the knowledge and skill of the caregiver, should be considered when planning care for older adults with dementia who are at risk for wandering behaviors (Remington & Futrell, 2005). This article summarizes the evidence-based practice guideline Wandering (Futrell & Melillo, 2002), which was developed by the Gerontological Nursing Intervention Research Center at The University of Iowa College of Nursing, and is available online at http://www.nursing.uiowa.edu/products_services/evidence_based.htm.

The purpose of this evidence-based guideline is to assist caregivers in dealing with wandering behavior in community-dwelling or institutionalized older adults with dementia.

Individuals at risk for wandering behavior include community-residing or institutionalized older adults with dementia (Holtzer et al., 2003; Schonfeld et al., 2007). Wandering behavior is similar in long-term care facilities and assisted living facilities despite differences in staffing and regulations (Beattie, Song, & LaGore, 2005).

NANDA (2009) has identified defining characteristics that describe wandering, as well as related factors that put individuals at risk for wandering (p. 162). Defining characteristics include:

Related factors are as follows:

The following assessment criteria indicate patients who are likely to benefit the most from use of this evidence-based practice guideline. Caregivers should assess:

Triggers for wandering can be environmental conditions such as ambient temperature and sensory stimulation, or internal conditions such as physiological needs (Nelson & Algase, 2007). Interventions may be applied when patients are not wandering, thus reducing their impetus to wander (Heard & Watson, 1999). Travel patterns of patients who wander should also be identified. These include (Algase, Beattie, Bogue, & Yao, 2001; Martino-Saltzman, Blasch, Morris, & McNeal, 1991):

Whereas direct travel is most efficient, the other methods are inefficient. Travel inefficiency is inversely related to cognitive status. That is, severely demented patients travel inefficiently throughout the day. Less cognitively impaired patients travel more inefficiently near end of day, perhaps due to fatigue effects.

Assessment should also incorporate notation of the types of wandering behaviors (Lai & Arthur, 2003). These may include restless pacing, exit seeking, self-stimulating, and modeling or shadowing.

Premorbid lifestyles that help identify those likely to wander include an active interest—physically and mentally—in music. Examples include singing, playing an instrument, and having a recognized love of music (Thomas, 1999). Those who demonstrate extroverted personality characteristics of warmth, gregariousness, activity, positive emotion, and altruism may also be more likely to wander. Examples include being more continually active in daily activities, demonstrating social-seeking behavior, and demonstrating a greater positive regard toward oneself and others (Thomas, 1997).

Additional premorbid lifestyles to assess include…

Dr. Futrell is Professor Emerita, Dr. Melillo is Professor and Chair, and Dr. Remington is Associate Professor, Department of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts. Dr. Schoenfelder is Associate Clinical Professor and Editor, John A. Hartford Center for Geriatric Excellence, The University Iowa College of Nursing, Iowa City, Iowa.

Guidelines in this series were produced with support provided by grant P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing), National Institute of Nursing Research, National Institutes of Health. Copyright © 2008 The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core.

Address correspondence to Deborah Perry Schoenfelder, PhD, RN, Associate Clinical Professor, The University of Iowa College of Nursing, 430 Nursing Building, 50 Newton Road, Iowa City, IA 52242; e-mail: deborah-schoenfelder@uiowa.edu.

Wandering can be problematic for caregivers, as well as for the person with dementia. Wandering behavior may disrupt the individual’s sleep, eating, safety, or the caregiver’s ability to provide care. To individualize interventions for wandering, it is important to assess premorbid factors, the disease process, behaviors typical of the disease, and medications and their side effects. Other factors, including the environment and the knowledge and skill of the caregiver, should be considered when planning care for older adults with dementia who are at risk for wandering behaviors (Remington & Futrell, 2005). This article summarizes the evidence-based practice guideline Wandering (Futrell & Melillo, 2002), which was developed by the Gerontological Nursing Intervention Research Center at The University of Iowa College of Nursing, and is available online at http://www.nursing.uiowa.edu/products_services/evidence_based.htm.

Purpose of the Guideline

The purpose of this evidence-based guideline is to assist caregivers in dealing with wandering behavior in community-dwelling or institutionalized older adults with dementia.

Definition of Key Terms

  • Dementia: The loss of intellectual functions such as thinking, remembering, and reasoning of sufficient severity to interfere with a person’s daily functioning. Dementia is not a disease itself but rather a group of symptoms that may accompany certain diseases or conditions. Symptoms may also include changes in personality, mood, and behavior. Dementia is irreversible when caused by disease or injury but may be reversible when caused by drugs, alcohol, hormone or vitamin imbalances, or depression. Alzheimer’s disease is the most common cause of dementia (Alzheimer’s Association, n.d.).
  • Alzheimer’s disease (AD): AD is an irreversible, progressive brain disorder that occurs gradually and results in memory loss and confusion. Later symptoms include behavior that is unusual for the individual, personality changes, a decline in thinking and language abilities, and a severe loss of mental function. These losses are related to the death of brain cells and the breakdown of the connections between them. The course of this disease varies from person to person, as does the rate of decline, and symptoms usually appear after age 65. Although the risk of developing AD increases with age, it is not part of normal aging (National Institute on Aging, 2007).
  • Wandering: Wandering is a behavioral problem of AD patients that involves cognitive impairment affecting abstract thinking, language, judgment, and spatial skills (Algase, 1992); disorientation and difficulty relating to the environment (Roberts & Algase, 1988); and low social interaction, pacing, or increased motor activity and “aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment, or intruding in inappropriate places” (Morishita, 1990, p. 157). Wandering is also defined as “meandering, aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles” (North American Nursing Diagnosis Association [NANDA], 2009, pp. 246–247).

Individuals at Risk for Wandering

Individuals at risk for wandering behavior include community-residing or institutionalized older adults with dementia (Holtzer et al., 2003; Schonfeld et al., 2007). Wandering behavior is similar in long-term care facilities and assisted living facilities despite differences in staffing and regulations (Beattie, Song, & LaGore, 2005).

NANDA (2009) has identified defining characteristics that describe wandering, as well as related factors that put individuals at risk for wandering (p. 162). Defining characteristics include:

  • Continuous movement from place to place.
  • Getting lost.
  • Frequent movement from place to place.
  • Fretful locomotion.
  • Haphazard locomotion.
  • Hyperactivity.
  • Inability to locate significant landmarks in a familiar setting.
  • Locomotion into unauthorized or private spaces.
  • Locomotion resulting in unintended leaving of a premise.
  • Locomotion that cannot be easily dissuaded.
  • Long periods of locomotion without an apparent destination.
  • Pacing.
  • Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping).
  • Persistent locomotion in search of something.
  • Shadowing a caregiver’s locomotion.
  • Scanning behaviors.
  • Searching behaviors.
  • Trespassing.

Related factors are as follows:

  • Cognitive impairment (e.g., memory and recall deficits, disorientation, poor visuoconstructive or visuospatial ability, language defects).
  • Cortical atrophy.
  • Emotional state (e.g., frustration, anxiety, boredom, depression, agitation).
  • Overstimulating environment.
  • Physiological state or need (e.g., hunger, thirst, pain, urination, constipation).
  • Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia).
  • Sedation.
  • Separation from familiar environment.
  • Time of day.

Assessment Criteria

The following assessment criteria indicate patients who are likely to benefit the most from use of this evidence-based practice guideline. Caregivers should assess:

  • Cognitive decline using the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).
  • The degree of wandering behavior using the Revised Algase Wandering Scale (RAWS) (Nelson & Algase, 2007). The RAWS was developed to quantify wandering in several domains as reported by caregivers. It contains three subscales: persistent walking, spatial disorientation, and eloping behavior.
  • Depressive symptomatology using the Short Geriatric Depression Scale (SGDS) (Sheikh & Yesavage, 1986).
  • Agitation. In assessing these symptoms, it is critical to conduct a careful evaluation for a general medical, psychiatric, or psychosocial problem that may underlie the disturbance (American Psychiatric Association [APA], 2007). The Cohen-Mansfield Agitation Inventory: Long Form with Expanded Descriptions of Behaviors (Cohen-Mansfield, 1999; Cohen-Mansfield, Marx, & Rosenthal, 1989) is useful in assessing agitation.
  • The frequency with which memory and behavior problems occur, including wandering, and to what degree the behavior upsets the caregiver. The Zarit and Zarit (1983) Memory and Behavior Problems Checklist—1990R (MBPC) is useful for this assessment.
  • For factors associated with wandering, such as lack of activity, cognitive impairment, socially inappropriate behavior, resistance to care, and greater impairment in activities of daily living (ADLs) (Logsdon et al., 1998; Schonfeld et al., 2007).
  • What environmental strategies are currently used by formal and/or informal caregivers in dealing with problem wandering (e.g., latches and alarms on doors, barring or disguising exits, visual cues such as stop signs, constant personal supervision, restriction of caregiver’s own activities due to concerns about care recipient’s wandering in other settings such as shopping malls or community outings) and evaluate their effectiveness.
  • Wandering patterns (discussed below), which may help determine treatment.
  • For premorbid lifestyle (discussed below) to help identify those likely to wander.

Assessing Wandering Patterns

Triggers for wandering can be environmental conditions such as ambient temperature and sensory stimulation, or internal conditions such as physiological needs (Nelson & Algase, 2007). Interventions may be applied when patients are not wandering, thus reducing their impetus to wander (Heard & Watson, 1999). Travel patterns of patients who wander should also be identified. These include (Algase, Beattie, Bogue, & Yao, 2001; Martino-Saltzman, Blasch, Morris, & McNeal, 1991):

  • Direct travel: travel from one location to another without diversion.
  • Random travel: roundabout or haphazard travel to many locations within an area without repetition; no obvious route to stopping point.
  • Pacing: repetitive back and forth movement within a limited area.
  • Lapping: repetitive travel characterized by circling large areas.

Whereas direct travel is most efficient, the other methods are inefficient. Travel inefficiency is inversely related to cognitive status. That is, severely demented patients travel inefficiently throughout the day. Less cognitively impaired patients travel more inefficiently near end of day, perhaps due to fatigue effects.

Assessment should also incorporate notation of the types of wandering behaviors (Lai & Arthur, 2003). These may include restless pacing, exit seeking, self-stimulating, and modeling or shadowing.

Assessing for Premorbid Lifestyle

Premorbid lifestyles that help identify those likely to wander include an active interest—physically and mentally—in music. Examples include singing, playing an instrument, and having a recognized love of music (Thomas, 1999). Those who demonstrate extroverted personality characteristics of warmth, gregariousness, activity, positive emotion, and altruism may also be more likely to wander. Examples include being more continually active in daily activities, demonstrating social-seeking behavior, and demonstrating a greater positive regard toward oneself and others (Thomas, 1997).

Additional premorbid lifestyles to assess include having been physically active in social and leisure activities; having experienced a number of stressful events throughout a lifetime, necessitating readjustments; responding to stress with psychomotor activity, rather than emotional reactions; and having demonstrated more motoric behavioral styles in earlier years (Lai & Arthur, 2003; Monsour & Robb, 1982; Song & Algase, 2008).

A descriptive typology of wandering in dementia (Hope & Fairburn, 1990) is also helpful in determining individuals who may benefit from this guideline. The full list is included in the guideline (Futrell & Melillo, 2002), including definitions and descriptions of behavior such as checking/trailing, pottering, aimless walking, walking directed toward inappropriate purpose, and walking directed toward an appropriate purpose with inappropriate frequency.

Assessment Tools and Forms

As discussed in the previous section, several tools are available to assess older adults who wander. The following assessment tools are available in the complete guideline:

Description of the Practice

Wandering by individuals with dementia places them at risk for weight loss, falls, sleep problems, getting lost, and other safety issues, although wandering in a safe environment can be beneficial. In a review of research, Peatfield, Futrell, and Cox (2002) found “there is no single cause for wandering and no single solution” (p. 49). Five years later, a systematic review of studies by Hermans, Htay, and Cooley (2007) suggested this is still true. Why people wander remains unclear (Algase, 1998, 1999b, 2006); therefore, planning intervention strategies remains difficult for caregivers. Algase (2005) suggested that finding the causes of wandering is more effective than looking for approaches to management. For the time being, some interventions are available for professional and lay caregivers to try.

The Need-Driven Dementia-Compromised Behavior (NDB) model (Algase et al., 1996) remains an excellent model to use for conceptualizing behaviors and identifying individuals at risk. Algase (1999a) suggested there is an interplay of background and proximal factors, which might explain reasons for wandering and offers the NDB model to design management strategies. With regard to maintenance of weight, some evidence suggests a positive outcome for those who wander, by intervening with caregiver help at feeding time (Beattie, Algase, & Song, 2004). In addition, environmental ambiance has also been shown to decrease wandering (Yao & Algase, 2006).

In the guideline, practices to manage wandering (Futrell & Melillo, 2002) are grouped into four areas: environmental modifications, technology and safety, physical and psychosocial interventions, and caregiving support and education. According to systemic reviews by Siders et al. (2004), Algase (2006), and Hermans et al. (2007), there is inconsistent evidence regarding effective interventions that address wandering behaviors. Intervention studies that take into consideration a multifactoral approach to wandering are sorely needed.

Environmental Modifications

The following steps should be taken to modify the environment to prevent wandering:

Technology and Safety

Regarding technology and safety to prevent wandering:

Physical and Psychosocial Interventions

The following physical and psychosocial interventions should be considered to prevent wandering:

Caregiving Support and Education

Support and education for caregivers should include:

Evaluation of Process and Outcomes

Process Indicators

Process indicators are the interpersonal and environmental factors that can facilitate the use of a guideline. One process indicator that can be assessed with a sample of caregivers is knowledge about wandering. The Wandering Knowledge Assessment Test is available in the complete guideline (Futrell & Melillo, 2002). This test should be administered before and following the education of caregivers regarding use of this guideline.

The same sample of caregivers for whom the Wandering Knowledge Assessment Test was administered should also take the Process Evaluation Monitor (Figures 1 and 2) approximately 1 month following use of the guideline. The purpose of this monitor is to determine understanding of the guideline and to assess the support for carrying out the guideline.

Instructions on Use of the Process Evaluation Monitor.

Figure 1. Instructions on Use of the Process Evaluation Monitor.

The Process Evaluation Monitor.

Figure 2. The Process Evaluation Monitor.

Other process indicators can be used to evaluate the support and use of the guideline. For example, one method is to use chart audits to evaluate the inclusion and use of recommended assessment or evaluation forms.

Outcome Indicators

Outcome indicators are those expected to change or improve from consistent use of the guideline. The major outcome indicators that should be monitored over time include:

The Wandering Outcomes Monitor (Figures 3 and 4) is to be used for monitoring and evaluating the usefulness of the wandering guideline in improving outcomes of individuals who wander. The outcome monitor may be adapted for the user’s organization or unit, and additional outcomes may be added as desired.

Instructions on Use of the Wandering Outcomes Monitor.

Figure 3. Instructions on Use of the Wandering Outcomes Monitor.

The Wandering Outcomes Monitor.The Wandering Outcomes Monitor.

Figure 4. The Wandering Outcomes Monitor.

Conclusion and Implications for Nursing Practice

Wandering behaviors of patients with dementia present major challenges to caregivers. Caregivers should be alert to stressors that may precipitate these behaviors. Nursing research is needed to identify antecedents and consequences of wandering for individuals with dementia and their caregivers.

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Low-Cost Patient Locator System for Geriatric Wandering

Considerations in Using the Patient Locator System

Address caregiver concerns regarding financing, return of the device when no longer needed, and mechanical integrity of the device.

Make available highly individualized versions of the device (e.g., watch, jewelry, belt buckle); avoid necklace for safety reasons.

Ensure the device is small, able to be sewn into clothing, and lightweight.

Determine conditions for which the device is most effective (e.g., daytime, evening).

Introduce the Device to the Caregiver and Client and Search and Rescue Personnel On the Basis of:

Professional nursing assessment of the client’s hearing, vision, mobility, and cognitive status (i.e., Mini-Mental State Examination [MMSE, Folstein, Folstein, & McHugh, 1975]), and the environment.

Professional nursing assessment of the caregiver’s knowledge about the device, how to place the device on the client, and how to care for the device.

Assessment of the caregiver’s knowledge of when and how to activate search involving search and rescue personnel.

Individualized training in device placement and use.

Care recipient acceptance.

Provision of training in how to handle a potential catastrophic reaction.

Protocol Guideline for Wearing of Device Based on Results of Evaluation of Mock Device

Individual has been diagnosed with progressive memory loss (i.e., clinical diagnosis established using criteria from the National Institute of Neurological and Communicative Disorders and the Alzheimer’s Disease and Related Disorders Association (McKhann et al., 1984); MMSE scores of 10 to 19 are considered middle-stage Alzheimer’s disease, and scores of 9 or less are considered late stage (Folstein, 1997).

Caregiver reports one or more wandering episodes in past 6 months.

Following assessment of client and caregiver by professional nurse regarding knowledge and acceptance of device, place device on the individual.

Evaluate the pros and cons encountered with wearing the device.

Evaluate the type and frequency, if any, of wandering after placing the device on the individual.

Authors

Dr. Futrell is Professor Emerita, Dr. Melillo is Professor and Chair, and Dr. Remington is Associate Professor, Department of Nursing, University of Massachusetts Lowell, Lowell, Massachusetts. Dr. Schoenfelder is Associate Clinical Professor and Editor, John A. Hartford Center for Geriatric Excellence, The University Iowa College of Nursing, Iowa City, Iowa.

Guidelines in this series were produced with support provided by grant P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing), National Institute of Nursing Research, National Institutes of Health. Copyright © 2008 The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core.

Address correspondence to Deborah Perry Schoenfelder, PhD, RN, Associate Clinical Professor, The University of Iowa College of Nursing, 430 Nursing Building, 50 Newton Road, Iowa City, IA 52242; e-mail: .deborah-schoenfelder@uiowa.edu

10.3928/00989134-20100108-02

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