Dr. Futrell is Professor Emerita, and Dr. Melillo is Professor and Interim Dean, School of Nursing, College of Health Sciences, University of Massachusetts Lowell, Lowell; and Dr. Remington is Associate Professor, Department of Nursing, Framingham State University, Framingham, Mas-sachusetts.
The authors have disclosed no potential conflicts of interest, financial or otherwise. Copyright © 2014 The University of Iowa John A. Hartford Foundation Center for Geriatric Nursing Excellence.
Address correspondence to May Futrell, PhD, RN, FAAN, FGSA, Professor Emerita, School of Nursing, College of Health Sciences, University of Massa-chusetts Lowell, 113 Wilder Street, Suite 200, Lowell, MA 01854-3058; e-mail:
Wandering can be problematic for both caregivers and individuals with dementia, particularly when wandering behavior disrupts an individual’s sleep, eating habits, socialization, or safety, or a caregiver’s ability to provide care. Assessment of premorbid factors, the disease process, behavioral symptoms typical of dementia, and medications and their side effects is important when individualizing interventions for wandering behavior. Other factors, such as 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 behavior (Remington & Futrell, 2011). The purpose of the current evidence-based guideline is to help caregivers identify and manage wandering behavior in community-dwelling or institutionalized older adults with dementia. The current article updates the 2002 guideline (Futrell & Melillo, 2002) and summarizes the revised guidelines (Futrell, Melillo, & Remington, 2008, in press), which were developed at the Gerontological Intervention Research Center at the University of Iowa College of Nursing. The guidelines are available online at http://www.nursing.uiowa.edu/sites/default/files/documents/hartford/EBP%20Guideline%20Catalog.pdf. They identify key terms and individuals at risk; assessment criteria, tools, and related interventions are also suggested.
Definition of Key Terms
Dementia is “characterized by progressive global deterioration of abilities in multiple domains including memory and at least one additional area—learning, orientation, language, comprehension, and judgment—severe enough to interfere with daily life” (National Institutes of Health, 2010, p. 3).
Alzheimer’s disease (AD) is the most common cause of dementia. It is an irreversible, progressive brain disorder that occurs gradually and results in memory loss and confusion. Later symptoms include unusual behavior, personality changes, and a decline in thinking and language abilities and finally 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, with symptoms usually appearing after age 65. Although the risk of developing AD increases with age, it is not part of normal aging (National Institute on Aging [NIA], 2007, 2012).
Wandering is “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, Vandeweerd, & Gavin-Dreschnack, 2007, p. 696). 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] International, 2011, p. 230).
Individuals and Patients at Risk for Wandering
Individuals at risk for wandering behavior include community-dwelling or institutionalized older adults with dementia. Wandering behavior is similar in long-term care and assisted living facilities despite differences in staffing and regulations (Beattie, Song, & LaGore, 2005). The Need Driven Dementia Compromised Behavior Model (Algase et al., 1996) remains an excellent model to use for conceptualizing wandering behaviors and identifying individuals at risk. Beattie, Algase, and Song (2004) have tested this model, and some evidence exists suggesting a positive outcome regarding the maintenance of weight by intervening with those who wander by providing caregiver help at feeding time. In a recent study, Algase, Beattie, Antonakos, Beel-Bates, and Yao (2010) concluded that “location, light, sound, proximity of others, and ambience are associated with wandering and may serve to inform environmental designs and care practices” (p. 340). A framework for managing wandering has been suggested for further research and refinement (Moore, Algase, Powell-Cope, Applegarth, & Beattie, 2009). NANDA International has identified characteristics and other related factors that put individuals at risk for wandering (Table 1).
NANDA-I Characteristics and Related Factors that Put Individuals at Risk for Wandering
The following discussion presents areas for assessment that can help identify individuals who are likely to benefit the most from use of the current evidence-based guideline. To assess wandering, 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] Work Group on Alzheimer’s Disease and Other Dementias et al., 2007). Unmet needs or pain may increase wandering. Assessment for physiological processes that may trigger agitation and/or wandering, such as acute illness, exacerbation of chronic illness, fatigue, medication effects, and constipation (Remington & Futrell, 2011), could indicate the cause of the behaviors and direct treatment. Similarly, assessment for pain using a self-report or an observer rating tool (Lu & Herr, 2012), such as the Pain Assessment in Advanced Dementia Scale (Warden, Hurley, & Volicer, 2003), may identify a trigger that the individual with dementia is unable to communicate to caregivers. 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. Depressive symptomatology can be assessed with the Geriatric Depression Scale Short Form (Sheikh & Yesavage, 1986). It is important to assess the environmental strategies that are currently used by formal and/or informal caregivers to manage problem wandering and evaluate those strategies’ effectiveness. Strategies, such as latches and alarms on doors, barring or disguising exits, global positioning system (GPS) technology devices, visual cues (e.g., stop signs), constant personal supervision, and/or restriction of caregiver’s own activities due to concerns about a care recipient’s wandering in other settings, should be evaluated frequently; strategies should be continued only if deemed to be effective in decreasing wandering. Developing technologies has the potential to aid in assessment, diagnosis, and monitoring of dementia and related behaviors, such as wandering (Mahoney & Mahoney, 2010; NIA, 2007).
Wandering frequency tends to increase as cognitive decline progresses. The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) or Mini-Cog (Borson, Scanlan, Brush, Vitallano, & Dokmak, 2000) can be used to assess for cognitive decline. Behavioral problems in individuals with dementia cause distress for both patients and their caregivers. The frequency with which memory and behavioral problems, including wandering, occur and to what degree the behavior upsets the caregiver can be assessed using the Memory and Behavior Problems Checklist—1990R (Zarit & Zarit, 1983).
The capacity for attention is essential for safe cognitive and physical performance. The WAIS Digit Span Test of the Wechsler Intelligence Scale (Wechsler, 1981) can be used to assess attention through tests, such as by asking the individual to repeat a sequence of familiar items (e.g., days of the week, months of the year) in reverse order or by serial 7s (Kolanowski et al., 2012).
Factors that have been associated with wandering include lack of activity, cognitive impairment, socially inappropriate behavior, resistance to care, and greater impairment in activities of daily living (Logsdon et al., 1998; Schonfeld et al., 2007). To assess the degree of wandering behavior, the Revised Algase Wandering Scale (RAWS) (Algase, Beattie, Bogue, & Yao, 2001) can be used. The RAWS was developed to quantify wandering in several domains as reported by caregivers. It contains three sub-scales: (a) persistent walking, (b) spatial disorientation, and (c) eloping behavior. The scale is available in a long-term care version or a community version (Nelson & Algase, 2007).
Knowledge of individuals’ premorbid lifestyles can help identify those who may wander (Osborne, Simpson, & Stokes, 2010). Individuals most likely to wander had been described as demonstrating extroverted personality characteristics of warmth, gregariousness, activity, and positive emotion (Thomas, 1997); however, recent research has demonstrated conflicting results (Osborne et al., 2010; Song & Algase, 2008). Additional important lifestyle factors shown to be associated with increased wandering include: (a) having been physically active in social and leisure activities; (b) having experienced a number of stressful events throughout a lifetime, with less verbal means of dealing with it; (c) responding to stress with psychomotor activity rather than emotional reactions; (d) having demonstrated more motoric behavioral styles in earlier years (Osborne et al., 2010; Song & Algase, 2008); and (e) an active interest (physically and mentally) in music, including singing, playing an instrument, and having a recognized love of music (Thomas, 1999).
Identifying the travel patterns of those who wander can help with planning interventions (Algase et al., 2001; Martino-Saltzman, Blasch, Morris, & McNeal, 1991). Wandering behavior has been described as:
- Direct travel (i.e., travel from one location to another without diversion).
- Random travel (i.e., roundabout or haphazard travel to many locations within an area without repetition, and no obvious route to stopping point).
- Pacing (i.e., repetitive back and forth movement within a limited area).
- Lapping (i.e., repetitive travel characterized by circling large areas).
Direct travel is the most efficient. Travel inefficiency is related to cognitive status. Those with severe impairment travel inefficiently throughout the day. Less cognitively impaired patients may travel more inefficiently near the end of day, possibly due to fatigue effects. Assessment should also incorporate notation of the types of wandering behaviors, such as overtly goal-directed searching, goal-directed industrious behavior, or nongoal-directed behaviors (Snyder, Rupprecht, Pyrek, Brekhus, & Moss, 1978).
A descriptive typology of wandering in dementia (Hope & Fairburn, 1990) is also helpful in determining individuals who may benefit from the current guideline (Table 2). Algase, Antonakos, Beattie, Beel-Bates, and Yao (2009a) developed the only data-based typology of wandering.
A Descriptive Typology of Wandering in Dementia
Wandering by individuals with dementia places them at risk for weight loss in excess of that caused by the disease process alone, getting lost, and other safety issues. Wandering in a safe place can be beneficial. In an early review of the literature, Peatfield, Futrell, and Cox (2002) found “there is no single cause for wandering and no single solution” (p. 49). In a review of the literature, Halek and Bartholomeyczik (2012) stated that “at the moment there is no conclusive definition of wandering, there are no obvious causes for it and therefore no clear intervention recommendations; however, research has contributed towards defining and understanding this phenomenon” (p. 404). For the time being, some interventions exist that professionals and lay caregivers can try.
In this updated evidence-based guideline, wandering interventions continue to be grouped into four areas: (a) environmental, (b) technology, (c) physical and psychosocial, and (d) caregiver support and education (Futrell, Melillo, & Remington, 2010). No priority/suggested/additional interventions exist for individuals who wander, but professional and lay caregivers have found that these suggested ideas may work for some individuals.
- Provide a secure place for clients to wander, such as a lounge, garden, and/or a large, safe, walking area (Afshan & Shah, 2009; Allen-Burge, Stevens, & Burgio, 1999; APA Work Group on Alzheimer’s Disease and Other Dementias et al., 2007).
- Enhance the environment by increasing visual appeal, such as tactile boards or three-dimensional wall art (Allen-Burge et al., 1999; Cohen-Mansfield & Werner, 1998; Dickinson & McLain-Kark, 1998; Richter, Roberto, & Bottenberg, 1995; Yao & Algase, 2006).
- Place or paint a wall mural over doorways to disguise exits (Kincaid & Peacock, 2003).
- Place gridlines in front of doors to decrease exit seeking (Forbes, 1998; Hussian & Brown, 1987; Siders et al., 2004).
- Make exits less accessible by covering panic bars with cloth and allow walking where doors are not in the path, using safety locks or complex and less-accessible door latches (APA Work Group on Alzheimer’s Disease and Other Dementias et al., 2007; Dickinson & McLain-Kark, 1998; Price, Hermans, & Grimley Evans, 2000).
- Maintain safety by removing clutter, disabling appliances, and using safety locks (Gitlin & Corcoran, 1996).
- Provide stimulation clues, such as pictures and signs (Allen-Burge et al., 1999; Gitlin & Corcoran, 1996).
- Use a combination of large-print signs and portrait-like photographs to help with way-finding (Namazi, Rosner, & Rechlin, 1991; Nolan, Mathews, & Harrison, 2001).
- Use a multifaceted approach to environmental modifications, as it is more effective than singular modifications (Algase et al., 2010; Bair, Toth, Johnson, Rosenberg, & Hurdle, 1999; Coltharp, Richie, & Kaas, 1996; Dickinson & McLain-Kark, 1998; Padilla, 2011; Price et al., 2000).
Technology and Safety
- Use a verbal alarm system, as it is more effective than an aversive alarm system (Connell & Sanford, 1994).
- Use mobile locator devices, such as GPS, for quickly locating wanderers (Altus, Mathews, Xaverius, Engelman, & Nolan, 2000; Landau & Werner, 2012; McShane et al., 1998; Melillo & Futrell, 1998, 1999; Miskelly, 2004, 2005; Shoval et al., 2011).
- Use of wearable technology offers marketplace opportunities for future innovations. Considerable debate has begun regarding ethical issues and patient rights (Mahoney & Mahoney, 2010; Wigg, 2010).
Physical and Psychosocial Interventions
- Assess for and treat depression, if appropriate (Lyketsos et al., 1997).
- Decrease wandering during structured activities by using social interaction of staff and/or visitors or music (Cohen-Mansfield & Werner, 1995; Cox, Nowak, & Buettner, 2011; Holmberg, 1997a; Matteson & Linton, 1996).
- Music sessions have been shown to be more effective than reading sessions in decreasing wandering behavior (Fitzgerald-Cloutier, 1993; Gerdner, 2007; Groene, 1993).
- Prevent risky situations with adequate supervision (APA Work Group on Alzheimer’s Disease and Other Dementias et al., 2007; Aspinall, 1994).
- Walking should not be unnecessarily limited (APA Work Group on Alzheimer’s Disease and Other Dementias et al., 2007; Brungardt, 1994).
- Promote safe walking (Cohen-Mansfield & Werner, 1998; Coltharp et al., 1996).
- Minimize stressors from the environment, such as cold at night, changes in daily routines, and extra individuals at holidays (Hall & Laloudakis, 1999).
- Provide regular exercise, such as walking after meals (Holmberg, 1997a,b; Landi, Russo, & Bernabei, 2004; Thuné-Boyle, Iliffe, Cerga-Pashoja, Lowery, & Warner, 2012).
- Use systematic behavioral conditioning at mealtime to improve food intake, increase time sat at the table, and stabilize weight (Algase et al., 2004).
- Use air mattress therapy or massage for treatment of agitated wandering (Holiday-Welsh, Gessert, & Renier, 2009; Shalek, Richeson, & Buettner, 2004).
Caregiving Support and Education
- Educate caregivers to help with caring for the individual who wanders (Cohen-Mansfield, Werner, Culpepper, & Barkley, 1997; Dodds, 1994; Gitlin et al., 2009).
- A facility-based risk management approach should include (a) identification of the wanderer, (b) a wandering prevention program, (c) an elopement response plan when patients are missing, and (d) staff mobilization around the problem (Healthcare Risk Management Group, 2010; Heard & Watson, 1999).
- Provide dementia care training for residential care staff using training modules (Alzheimer’s Association, n.d.).
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:
- Safety of the individual.
- Body weight maintenance.
Conclusion and Implications for Nursing Practice
Wandering behavior by individuals with dementia presents a major challenge to caregivers. Family or professional caregivers should be alert to stressors that may precipitate wandering. Nursing research is needed to identify antecedents and consequences of wandering for individuals and their caregivers, as well as to evaluate the outcomes of specific interventions that may decrease unsafe wandering.
If assessment and intervention for wandering is not performed early, the potential exists for critical wandering, which occurs when individuals leave their residences, unaware of their situations in place and time and exposing themselves to dangers, such as falls or traffic (Petonito et al., 2013). Until research provides answers/causes for wandering, continued use of the interventions described in the current evidence-based protocol are critical.
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NANDA-I Characteristics and Related Factors that Put Individuals at Risk for Wandering
|• Continuous movement from place to place|
|• Frequent movement from place to place|
|• Fretful locomotion|
|• Getting lost|
|• Haphazard locomotion|
|• Inability to locate significant landmarks in a familiar setting|
|• Locomotion into unauthorized private spaces|
|• Locomotion resulting in unintended leaving of premises|
|• Locomotion that cannot be easily dissuaded|
|• Long periods of locomotion without an apparent destination|
|• Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping)|
|• Persistent locomotion in search of something|
|• Scanning behaviors|
|• Searching behaviors|
|• Shadowing a caregiver’s locomotion|
|• 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)|
|• Separation from familiar environment|
|• Time of day|
A Descriptive Typology of Wandering in Dementia
|• Checking/trailing. In checking, the subject repeatedly seeks the whereabouts of the caregiver (or occasionally another person). Trailing appears to be an extreme form of checking, in which the subject tends to follow the caregiver (or another person) around excessively, walking closely behind as he or she walks around.|
|• Pottering. The subject walks around the house and/or garden apparently trying, but ineffectively, to carry out a task (e.g., washing or drying up, cleaning, weeding) of own accord.|
|• Aimless walking. The subject walks around (either within the house or out-side) without there being any evidence of a purpose. This category is not used if there appears to be a purpose, however bizarre, or if the walking meets the criteria for either checking or trailing.|
|• Walking directed toward inappropriate purpose. The subject’s walking appears to be directed toward a purpose, but that purpose is inappropriate (e.g., the subject is searching for a deceased relative). Some definitive evidence for the purpose must be available (e.g., from what the subject says or does). If the purpose is inappropriate only because of excessive repetition of an appropriate purpose (e.g., subject goes shopping many times a day), then it is rated in the next category below.|
|• Walking directed toward an appropriate purpose, inappropriate frequency. The subject’s walking is directed toward an appropriate purpose (e.g., shopping) but is repeated with inappropriate frequency (e.g., goes to the green-grocers 6 times a day).|
|• Excessive activity. The subject is on the move for an abnormally large proportion of the time while awake. In the extreme form, the subject does not sit for more than a few minutes at a time. Subjects who rate here will normally rate also under one of the preceding categories.|
|• Nighttime walking. The subject walks around inappropriately at night. This category is not used if the subject gets up only to go to the toilet.|
|• Needs to be brought back home. The subject has been brought back to his or her place of residence on at least one occasion. This may be because the subject has been unable to get home without help, but not necessarily so. Others may be concerned and have brought the subject home even though the subject would have been able to get home by him- or herself. Often, it is not possible to know whether or not the subject could have returned home unaided.|
|• Attempts to leave home. The subject makes attempts to leave his or her place of residence, but these attempts are prevented by the carers. The purpose of this category is to include those whose behavior might fall into one of the other categories, were it not that their movements were restricted. In most cases, the carers restrict the subject’s movements because of previous problems associated with one of the other types of wandering.|