Research in Gerontological Nursing

Empirical Research 

Wayfinding Strategies and Spatial Anxiety in Older Adults With and Without Alzheimer's Disease

Rebecca Davis, PhD, RN; Amy Veltkamp, DNP, A-GNP

Abstract

Persons with Alzheimer's disease (AD) often experience problems finding their way (i.e., wayfinding) even in familiar locations. One possible explanation for wayfinding impairments in persons with AD is that they use different wayfinding strategies than persons without AD; and these strategies may be ineffective. The current study examined differences in wayfinding strategies and spatial anxiety in older adults with and without early-stage AD, as well as the effect gender has on both variables. Older adults with normal cognition (n = 50) and adults with early stage AD (n = 38) completed a demographic survey, cognitive tests, the Wayfinding Strategies Scale, and the Spatial Anxiety Scale. Results indicated that adults with normal cognition used significantly more orientation strategies (t [85] = 2.54, p = 0.013) than adults with AD, and men (n = 37) used significantly more orientation strategies than women (n = 51; t [85] = 2.41, p = 0.018). Participants with AD rated their spatial anxiety significantly higher than adults with normal cognition (n = 51; t [84] = −3.89, p < 0.001). Orientation strategy use was inversely related to spatial anxiety (r = −0.434, p < 0.001). These findings suggest that persons with early-stage AD may use fewer wayfinding strategies and have higher wayfinding-related anxiety compared to adults without AD. [Research in Gerontological Nursing, 13(2), 91–101.]

Abstract

Persons with Alzheimer's disease (AD) often experience problems finding their way (i.e., wayfinding) even in familiar locations. One possible explanation for wayfinding impairments in persons with AD is that they use different wayfinding strategies than persons without AD; and these strategies may be ineffective. The current study examined differences in wayfinding strategies and spatial anxiety in older adults with and without early-stage AD, as well as the effect gender has on both variables. Older adults with normal cognition (n = 50) and adults with early stage AD (n = 38) completed a demographic survey, cognitive tests, the Wayfinding Strategies Scale, and the Spatial Anxiety Scale. Results indicated that adults with normal cognition used significantly more orientation strategies (t [85] = 2.54, p = 0.013) than adults with AD, and men (n = 37) used significantly more orientation strategies than women (n = 51; t [85] = 2.41, p = 0.018). Participants with AD rated their spatial anxiety significantly higher than adults with normal cognition (n = 51; t [84] = −3.89, p < 0.001). Orientation strategy use was inversely related to spatial anxiety (r = −0.434, p < 0.001). These findings suggest that persons with early-stage AD may use fewer wayfinding strategies and have higher wayfinding-related anxiety compared to adults without AD. [Research in Gerontological Nursing, 13(2), 91–101.]

Alzheimer's disease (AD) is a progressive, debilitating illness affecting an estimated 5.8 million Americans (Alzheimer's Association, 2019). One major debilitating factor for persons with AD is impaired wayfinding. Way-finding is the ability to find one's way in an environment, typically with the goal of reaching a particular destination in an expedient manner (Passini, Pigot, Rainville, & Tétreault, 2000). It is estimated that approximately 40% to 50% of persons with early-stage AD have wayfinding difficulties in familiar and unfamiliar environments, making wayfinding one of the most prevalent and problematic symptoms (Pai & Jacobs, 2004). With more than 500,000 new AD cases diagnosed each year (BrightFocus Foundation, 2019), the number of older adults experiencing impaired wayfinding will continue to grow. This is a significant issue because wayfinding ability is essential for autonomous functioning, including independence in toileting, eating, and socialization. Impaired wayfinding ability can cause psychological responses such as anxiety, insecurity, and agitation, as well as physical safety concerns, such as increased risk for falls and getting lost in unfamiliar environments (Caspi, 2014; Chiu et al., 2004). Persons with AD can experience spatial anxiety or a feeling of apprehension related to wayfinding tasks (e.g., fear and/ or worry about navigating unfamiliar surroundings; Hund & Minarik, 2006; Lawton, 1994). Persons with wayfinding difficulties can be severely harmed or die from getting lost in their community (Rowe & Bennett, 2003).

Background

Wayfinding Strategies

Wayfinding is a complex process involving multiple cognitive functions that decline with normal aging and more significantly with cognitive disease (Allison, Fagan, Morris, & Head, 2016; Benke, Karner, Petermichl, Prantner, & Kemmler, 2014; Harris & Wolbers, 2014; Head & Isom; 2010). While wayfinding in a new or unfamiliar environment, persons with AD often use a route strategy, in which they follow a series of steps to reach a goal destination (Allison et al., 2016; Lawton, 1994). Individuals who use route strategies must be able to follow marked signs, recognize landmarks, or adhere to written or verbal sets of directions. An example of route strategy would be to “turn left at the first stop sign and then take the second driveway on the left.” Route strategies are somewhat inflexible due to their rigidity and reliance on sequential directions (Lawton, 1994).

As people become more familiar with an environment, they may develop a cognitive map or enduring memory of the environment based on the spatial relationships among the environmental information present, such as landmarks and paths (Iaria, Palermo, Committeri, & Barton, 2009). Orientation strategies use cognitive maps, have more flexible navigation than route strategies, and allow for route adjustments, such as short-cuts when needed (Lawton, 1994). Often, a person will switch back and forth between orientation and route strategies to successfully complete a wayfinding task (Harris & Wolbers, 2014).

Impaired Wayfinding in Older Adults

Multiple studies in the real world and virtual environments have shown that older adults have impaired way-finding abilities compared to their younger counterparts (Benke et al., 2014; Harris & Wolbers, 2014). For example, older adults take more time to learn a route and use fewer shortcuts (Harris & Wolbers, 2014), as well as make more errors and stops during a wayfinding task (Taillade et al., 2013). Head and Isom (2010) found that older adults completing a wayfinding task in a virtual environment were less able to recall landmarks and point them out on a virtual map and were less likely to complete the route successfully as the number of navigational arrows decreased. Wayfinding deficits in aging may be due to a decline in the ability to use orientation strategies (Gazova et al., 2013; Moffat, Elkins, & Resnick, 2006; Rodgers, Sindone, & Moffat, 2012), caused by age-related hippocampal changes (Colombo et al., 2017). Several studies have shown that older adults use route-based strategies more often than orientation strategies (Moffat et al., 2006; Rodgers et al., 2012).

Wayfinding Strategies in Alzheimer's Disease

Despite the growing body of knowledge related to way-finding in older adults, less is known about the wayfinding abilities and strategies of persons with AD. Although evidence is limited, persons with AD have a reduced ability to use route and orientation strategies compared to older adults without AD (Allison et al., 2016). Although persons with AD can form cognitive maps, they often require more time in an environment to do so (Allison et al., 2016) and have more difficulty recalling landmarks, affecting route and orientation strategy use (Benke et al., 2014). In addition, persons with AD can have difficulty maintaining directed attention, making them less able to focus on environmental information (Chiu et al., 2004). The ability to switch back and forth between route and orientation strategies may be reduced in persons with early-stage AD as it may be in older adults without AD (Harris & Wolbers, 2014).

Gender-Related Wayfinding Abilities and Strategies in Aging and Alzheimer's Disease

Men have been shown to find their way faster and more effectively than women in many kinds of spatial navigation tests (Boone, Gong, & Hegarty, 2018; Davis & Therrien, 2012). The differences in wayfinding between men and women are related to several factors. One of the studied differences between men and women is variation in spatial strategy use. On a self-reported Wayfinding Strategies Scale (WSS), healthy young women scored higher on route strategies and lower on orientation strategies (Lawton, 1994; Lawton & Kallai, 2002). In a qualitative study where older adult men and women were asked to describe the strategies they used in a virtual reality maze task, women with normal cognition reported using fewer strategies after initial learning (Davis & Weisbeck, 2015).

Spatial Anxiety

Some researchers have related the female disadvantage in spatial-task performance to spatial anxiety, a feeling of uneasiness related to wayfinding tasks (Hund & Minarik, 2006; Lawton, 1994). High spatial anxiety levels have been correlated with wayfinding errors and increased time to reach a destination (Hund & Minarik, 2006). Spatial anxiety has been shown to be more common in women than in men and is more likely to occur in those who use route versus orientation strategies (Lawton, 1994; Lawton & Kallai, 2002). Spatial anxiety may be related to hippocampal activity (Engin & Treit, 2007), as persons with hippocampal atrophy (often found in persons with AD) have significantly increased spatial anxiety (Kremmyda et al., 2016). Lawton (1994) found that persons who used orientation strategies were less likely to experience spatial anxiety than those who used route strategies.

To date, there is no research examining spatial anxiety in older adults or adults with AD. One large study showed that approximately 20% of older adults reported mild, moderate, or severe levels of anxiety related to the highly spatial task of driving (Taylor, Alpass, Stephens, & Towers, 2011). However, it is unknown whether AD–related cognitive deficits make people more or less likely to experience spatial anxiety. Persons with AD may not experience spatial anxiety because they overestimate their cognitive abilities (i.e., known as anosognosia; Perrotin et al., 2015). On the contrary, individuals with mild cognitive impairment (MCI) may be aware of their abilities, causing anxiety about complex spatial tasks (Piras, Piras, Orfei, Caltagirone, & Spalletta, 2016). Beginning evidence shows that general anxiety is common in individuals with dementia; therefore, persons with AD may have anxiety about any complex task, including spatial tasks (Seignourel, Kunik, Snow, Wilson, & Stanley, 2008). Although anxiety is correlated with decreased quality of life in persons with dementia (Seignourel et al., 2008), further research is needed to determine the prevalence of wayfinding-related spatial anxiety in adults with early-stage AD.

Purpose

Despite the growing body of research on wayfinding abilities in humans, there is a paucity of research on wayfinding strategy use and spatial anxiety in older adults with AD, as well as the effect gender has on these variables. Therefore, the purpose of the current study was to determine (a) differences in wayfinding strategies and spatial anxiety between older adults with and without early-stage AD; (b) gender effects on the use of wayfinding strategies and anxiety in this population; and (c) relationships among cognitive measures and spatial strategies and anxiety. Based on the literature review, the hypotheses were older adults with AD would have decreased orientation strategies and higher spatial anxiety scores compared to controls; men in both groups would have higher orientation strategies than women; and women in both groups would report higher spatial anxiety. The authors wanted to explore relationships among cognitive variables, wayfinding strategy use, and spatial anxiety.

Method

Participants

The current study is part of a larger study in which wayfinding was assessed in older adults without cognitive impairment (CI) and those with early-stage AD (Davis, Ohman, & Weisbeck, 2017).

In the parent study, a control group of 50 community-dwelling older adults without CI were recruited using newsletters, announcements, and flyers. Participants with AD (n = 38) were recruited from memory clinics and AD support groups. To be in the study, participants had to be age ≥62 and without a history of neurological or cognitive disorders (other than AD for the group with AD). To ensure participants could see to navigate, they needed a visual acuity of 20/40 with correction and could not have color blindness. The control group had to demonstrate cognitive ability within the normal range (i.e., score ≥27) according to the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). Participants in the group with AD had to have a diagnosis of AD or MCI due to AD and had to score within early-stage AD (i.e., 0.5 = questionable or 1 = mild) on the Clinical Dementia Rating Scale (CDRS; Hughes, Berg, Danziger, Coben, & Martin, 1982).

A descriptive correlational design was used to determine differences in wayfinding strategies and spatial anxiety between the control group and participants with AD, as well as correlations among cognitive tests, wayfinding strategies, and spatial anxiety.

Procedures

The University and affiliated hospital's Institutional Review Boards approved the current study. Study personnel discussed the current study with potential participants and then met with them in their homes or at the university lab. For participants with AD, study personnel also contacted their legally authorized representatives (LARs) or decision makers (with participants' permission) and asked them to attend the first meeting.

At the first meeting, the study was explained to participants and LARs. Participants with AD then completed the Evaluation to Sign Consent measure to determine consent capacity (Resnick et al., 2007). For those who did not exhibit consent capacity, the decision maker gave consent, and participants gave assent to participate. Participants then were asked to complete the surveys described below.

Measures

Participants completed an investigator-designed demographics survey to document their age, existing medical conditions, living situation, marital status, and socioeconomic status.

Cognitive Measures. Cognition was assessed with the 30-item Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), which measures memory, visuo-spatial ability, attention, concentration, working memory, language, calculation, orientation, and verbal language. The MoCA has documented sensitivity in identifying MCI (83%) and mild dementia (94% to 100%; Nasreddine et al., 2005; Smith, Gildeh, & Holmes, 2007).

Digit Span tests were administered to assess working memory and attention (Weschler, 1987). In the Digit Span Forward (DSF) test, researchers asked participants to repeat a gradually increasing series of numbers until a series is missed twice, and for the Digit Span Backward (DSB) test, participants had to repeat the series in reverse order. Those with better working memory and attention can repeat longer series of numbers. Lezak (1995) reported that the normal score for DSF is >5 and for DSB is >4. These measures were included because they have been shown to influence spatial tasks in other studies.

Wayfinding Strategies. The WSS was used to measure route and orientation strategy use (Lawton, 1994; Lawton & Kallai, 2002). In this instrument, participants are asked to rate how likely they are to use certain strategies when walking, driving, or riding a bike through a somewhat familiar town and trying to find their way in a large building or complex they have not visited before. Likert-scale responses ranged from 1 (never) to 5 (almost always). The 11 orientation-strategy questions asked respondents to perform tasks such as visualizing an area's map or layout and keeping track of direction. The six route-strategy questions asked respondents to give directions (e.g., how many streets to pass before making a turn).

A WSS factor analysis revealed two factors: route and orientation strategies (Lawton & Kallai, 2002). The WSS's predictive validity has been documented by several studies relating orientation strategy subscale scores to a sense of direction and wayfinding ability (Hund & Minarik, 2006; Lawton & Kallai, 2002). Because this tool has been tested only on young adults—never in an older adult population—a confirmatory factor analysis was conducted in MPlus (Muthén & Muthén, 2017) using Lawton and Kallai's (2002) two-factor model. The initial model did not have a good fit. A subsequent exploratory factor analysis resulted in a two-factor solution with three questions removed due to poor loading on either factor or cross loading. The final model comprised two factors: nine items (alpha = 0.85) for the orientation strategy factor and five items (alpha = 0.82) for the route strategy factor. Table 1 shows the factor loadings for each subscale's items. The questions loading on one of the two factors were consistent with prior research on the tool (Lawton & Kallai, 2002).

Factor Loadings for the Wayfinding Strategy Scale

Table 1:

Factor Loadings for the Wayfinding Strategy Scale

For the current study, each subscale's item total (after the three questions were removed) determined the overall rating for orientation and route strategy use. The scores ranged from 9 to 45 for the orientation subscale and 5 to 25 for the route subscale, with higher scores indicating more use of that subscale's strategy.

Spatial Anxiety. Lawton's Spatial Anxiety Scale (SAS) (Lawton, 1994; Lawton & Kallai, 2002) was used to assess self-rated anxiety about wayfinding tasks in an unfamiliar town or city. The scale includes eight Likert-scale items, with responses ranging from not at all anxious to very anxious. For the current study, researchers conducted a principle analysis and identified an alpha coefficient of 0.87, with all items loading on one factor (alpha coefficient = 0.91; Table 2). The sum of the eight items reflects an overall wayfinding anxiety score ranging from 8 to 64 points, with higher scores indicating higher anxiety.

Factor Loadings for Spatial Anxiety Scale

Table 2:

Factor Loadings for Spatial Anxiety Scale

Results

Sample

The current study had 88 participants (50 in the control group and 38 in the group with AD), ranging from age 62 to 92 (mean age = 76.24 years). The sample was 42% male and 58% female, and most participants were Caucasian (96.5%). There were no significant differences between groups regarding age, race, gender, years of education, marital status, financial status, or number of medications. There also were no significant differences between groups in DSF or DSB performance. Control group participants were more likely to live alone than participants with AD (Table 3). As expected, group participants with AD scored significantly lower on the MMSE and MoCA than control group participants.

Comparison of Demographic and Cognitive Variables Between Study Groups

Table 3:

Comparison of Demographic and Cognitive Variables Between Study Groups

Wayfinding Strategy Use

WSS scores ranged from 12 to 42 (mean = 29.51, SD = 6.68) for orientation strategies and 9 to 25 (mean = 18.14, SD = 3.35) for route strategies. Overall, control group participants scored significantly higher (mean = 31.02, SD = 6.93) in orientation strategy use than participants with AD (mean = 27.46, SD = 5.81) as hypothesized (t [85] = 2.54, p = 0.013). Men also reported using significantly more orientation strategies (mean = 31.46, SD = 6.20) than women (mean = 28.06, SD = 6.71) as hypothesized (t [85] = 2.41, p = 0.018). There was a trend for women to score higher in route strategies (mean = 19.44, SD = 3.39) than men (mean = 18.03, SD = 3.15; t [85] = −1.98, p = 0.051). Men in the control group scored significantly higher in orientation strategies than men in the group with AD. In addition, women in the control group scored higher in orientation strategies than women in the group with AD. There were no significant differences in route strategy scores for men or women in the control group compared to the group with AD (Figure 1).

Gender differences in wayfinding strategies between groups.Note. WS = Wayfinding Strategies.*p < 0.05.

Figure 1.

Gender differences in wayfinding strategies between groups.

Note. WS = Wayfinding Strategies.

*p < 0.05.

Spatial Anxiety

SAS scores ranged from 8 to 34 (mean = 16.78, SD = 6.07) for the whole group. As hypothesized, participants with AD scored significantly higher on the SAS (mean = 19.56, SD = 6.06) than their control group counterparts (mean = 14.78, SD = 5.285), indicating greater spatial anxiety (t [84] = −3.89, p < 0.001). Men with AD had significantly higher SAS scores (mean = 18.05, SD = 5.97) than men in the control group (mean = 13.93, SD = 4.25; t [35] = −2.40, p = 0.022). Women with AD had significantly higher SAS scores (mean = 21.24, SD = 5.89) than women in the control group (mean = 15.25, SD = 5.79; t [47] = −3.421, p = 0.001). Thus, spatial anxiety was higher for men and women in the group with AD compared to the control group.

SAS scores did not differ significantly between men (mean = 16.05, SD = 5.54) and women (mean = 17.33, SD = 6.45) in the overall group (t [84] = −0.962, p = 0.339). These results did not support the authors' hypothesis that men overall would have less spatial anxiety than women. There also were no significant SAS score differences between men (mean = 13.94, SD = 4.25) and women (mean = 15.25, SD = 5.78; t [48] = −0.836, p = 0.407) in the control group, or men (mean = 18.05, SD = 5.97) and women (mean = 21.24, SD = 5.89; t [34] = −1.607, p = 0.117) in the group with AD.

Correlations Among Wayfinding Strategies, Spatial Anxiety, and Demographic Factors

Table 4 shows correlations among the wayfinding strategies, spatial anxiety, and demographic measures. Orientation strategy scores were positively correlated with years of education completed (r = 0.318, p = 0.003). Orientation (r = 0.280, p = 0.009) and route strategy (r = 0.295, p = 0.006) scores were positively correlated with the MoCA score. A moderate negative correlation was found between the use of orientation strategy and spatial anxiety score (r = −0.434, p < 0.001). No significant correlation was found between use of route strategy and spatial anxiety (r = 0.022, p = 0.842). Spatial anxiety scores were negatively correlated with years of education (r = −0.246, p = 0.023) and MoCA score (r = −0.348, p = 0.001).

Pearson Correlations Among Wayfinding Strategies, Spatial Anxiety, and Demographic Factors

Table 4:

Pearson Correlations Among Wayfinding Strategies, Spatial Anxiety, and Demographic Factors

Discussion

The most important findings from the current study were the differences in wayfinding strategies and spatial anxiety scores between older adults with and without AD. These results showed that participants with early-stage AD had significantly lower orientation strategy scores and a trend toward lower route strategy scores. Participants with AD also had significantly more spatial anxiety than participants without AD. These findings are consistent with previous research about wayfinding strategies and AD.

Beginning research has shown older individuals with AD use fewer orientation strategies than older adults without AD (Allison et al., 2016). This difference may be related to AD's early, destructive effects on the hippocampus (Allison et al., 2016; Iaria, Petrides, Pike, & Bohbot, 2009). Decreased orientation strategy use may be related to reduced ability to maintain attention and recall environmental landmarks, which may impair the ability to establish and use a cognitive map (Benke et al., 2014; Chiu et al., 2004; Head & Isom, 2010). Results showed participants with AD were less likely to use orientation strategies than their control counterparts.

There is some evidence that individuals with early-stage AD use fewer route strategies compared to older adults without AD (Allison et al., 2016). Although results did not show a significant difference in route strategy use, there was a trend toward less route strategy use among participants with AD. Similar to orientation strategy use, a reduction in route strategy use may be related to the reduced ability to maintain attention and recall environmental landmarks (Benke et al., 2014; Chiu et al., 2004; Head & Isom, 2010). Although the WSS only measured spatial strategy use, participants with AD may resort to other non-spatial strategies (i.e., guessing, trial and error) because they have difficulty using spatial strategies in complex environments.

Results showed significantly increased spatial anxiety among participants with early-stage AD compared to control group participants. The authors found no other studies that examined the incidence of spatial anxiety in persons with AD. One contributing factor may be the hippocampal changes that take place in AD, as anxiety has been strongly linked to hippocampal function (Engin & Treit, 2007; Kremmyda et al., 2016). Furthermore, previous research has shown spatial anxiety to be associated with decreased orientation strategy use as compared to route strategy use (Lawton, 1994; Lawton & Kallai, 2002). Findings supported this hypothesis, as a significant negative correlation was found between orientation use and spatial anxiety scores. It is possible that decreased use of orientation strategies results in reduced navigational flexibility, leading to increased spatial anxiety. The reduced ability to maintain and use a cognitive map of one's environment may lead to feelings of disorientation, further escalating anxiety in persons with early-stage AD (Lawton, 1994).

Among participants, the authors found that men were more likely to use orientation strategies than women in the overall and control groups. This finding is consistent with similar findings from other studies (Davis & Weisbeck, 2015; Lawton, 1994; Lawton & Kallai, 2002). The authors did not find any difference in spatial anxiety between men and women in either the control group or the group with AD. Evidence regarding gender differences in spatial anxiety is mixed (Hund & Minarik, 2006; Lawton, 1994; Lawton & Kallai, 2002). Although some studies have suggested women have more wayfinding-related anxiety than men, findings did not support this pattern (Lawton, 1994; Lawton & Kallai, 2002).

Among participants with AD, lack of gender differences in spatial anxiety was an interesting finding. Lack of gender differences in spatial anxiety may be related to the sample's mean age. Although previous spatial anxiety studies focused on much younger populations (Lawton, 1994; Lawton & Kallai, 2002), often college-age individuals, participants in the current study had a mean age of 76. It is possible that with increasing age, men without cognitive disease retain their advantage over women in orientation strategy use but have less confidence in their abilities and thus more anxiety. Alternatively, it is possible that men have less orientation strategy use over time—despite still having an advantage over older adult women—causing them to have spatial anxiety on par with women of that age group.

Limitations

Several study limitations exist. The relatively small sample affects the current study's generalizability. In addition, the wayfinding measures relied on self-report in a population with memory impairment. Although participants were in the very early stages of AD, it is possible that their ability to answer questions was impaired. Of note, the differences found between groups with and without AD are congruent with the disease course and known changes that occur in the brain, giving some evidence for the predictive validity of the tools used.

Implications

The current study's clinical implications are that persons with AD may struggle with wayfinding; and that they have a reduced ability to use spatial strategies effectively. Large, complex environments, such as older adult living communities and hospitals, may prove especially difficult due to a lack of distinctiveness. Because wayfinding impairments have profound implications (i.e., loss of independence), interventions to help older adults with AD in wayfinding are needed.

Nurses and other caregivers should be aware that persons with AD may be anxious when asked to find their way, and they may need additional assistance and support. Because persons with AD had more spatial anxiety than those without AD, regardless of gender, it is important that carers provide support for persons with AD while they are learning new environments. Spatial anxiety has been associated with reduced wayfinding ability in younger persons (Hund & Minarik, 2006); thus, it would be interesting to determine if measures to reduce anxiety (i.e., reassurance, practice, support) could improve wayfinding ability in this population. In addition, it is important to analyze the impact of spatial anxiety on persons with AD, such as how it affects independence, spatial/neighborhood mobility, driving, and engagement with community resources. Life space, which is the spatial extent of mobility in a person's environment, has been related to cognitive decline (Crowe et al., 2008). It makes sense that when persons with AD experience anxiety about wayfinding, they may choose to lessen their engagement with the world. It is possible that part of the reason for a decreased life space in persons with cognitive decline is spatial anxiety.

Results support that research is needed to test interventions to support persons with AD in wayfinding. Persons with AD may be more dependent on the legibility of environments as well as personal support to find their way. Studies that examine ways to make complicated environments easier to navigate, such as improved signage, use of cues, and technological devices to assist with wayfinding, are needed. For example, several studies have shown that large, bright, easily distinctive cues can help persons with AD find their way in complex environments (Cogné et al., 2018; Davis, Ohman, & Weisbeck, 2017), and that special signage using icons, words, and high contrast letters and backgrounds can assist with wayfinding (Brush, Camp, Bohach, & Gerstberg, 2015).

Conclusion

Findings that suggest participants with AD had lower orientation strategy scores than the demographically similar control group beg the question of whether a change in wayfinding strategy use could be an early disease indicator. Although the current authors included only persons with diagnosed AD or MCI due to AD, it would be beneficial to assess whether these changes occur prior to diagnosis. Scientists have shown that a decline in orientation strategies can be linked to hippocampal changes indicative of developing AD (Konishi et al., 2018). Thus, a decline in spatial strategy use may be an early biomarker for AD development, which could lead to early diagnosis. The current study adds to the literature regarding wayfinding strategy use and anxiety in individuals with and without AD. Findings also add to existing evidence that changes in wayfinding strategy use may be an early clinical indicator for AD (Bianchini et al., 2014). These results may help guide development of wayfinding interventions for individuals with AD.

References

  • Allison, S. L., Fagan, A. M., Morris, J. C. & Head, D. (2016). Spatial navigation in preclinical Alzheimer's disease. Journal of Alzheimer's Disease, 52(1), 77–90 https://doi.org/10.3233/JAD-150855 PMID: doi:10.3233/JAD-150855 [CrossRef]26967209
  • Alzheimer's Association. (2019).2019 Alzheimer's disease facts and figures. Retrieved from https://www.alz.org/alzheimers-dementia/facts-figures
  • Benke, T., Karner, E., Petermichl, S., Prantner, V. & Kemmler, G. (2014). Neuropsychological deficits associated with route learning in Alzheimer disease, MCI, and normal aging. Alzheimer Disease and Associated Disorders, 28(2), 162–167 https://doi.org/10.1097/WAD.0000000000000009 PMID: doi:10.1097/WAD.0000000000000009 [CrossRef]
  • Bianchini, F., Di Vita, A., Palermo, L., Piccardi, L., Blundo, C. & Guariglia, C. (2014). A selective egocentric topographical working memory deficit in the early stages of Alzheimer's disease: A preliminary study. American Journal of Alzheimer's Disease and Other Dementias, 29(8), 749–754 https://doi.org/10.1177/1533317514536597 PMID: doi:10.1177/1533317514536597 [CrossRef]24906969
  • Boone, A. P., Gong, X. & Hegarty, M. (2018). Sex differences in navigation strategy and efficiency. Memory & Cognition, 46(6), 909–922 https://doi.org/10.3758/s13421-018-0811-y PMID: doi:10.3758/s13421-018-0811-y [CrossRef]
  • BrightFocus Foundation. (2019). Alzheimer's disease: Facts and figures. Retrieved from https://www.brightfocus.org/alzheimers/article/alzheimers-disease-facts-figures
  • Brush, J. A., Camp, C., Bohach, S. & Gerstberg, N. (2015). Developing a signage system that supports wayfinding and independence for persons with dementia. Canadian Nursing Home, 26(1), 4–8.
  • Caspi, E. (2014). Wayfinding difficulties among elders with dementia in an assisted living residence. Dementia (London), 13(4), 429–450 https://doi.org/10.1177/1471301214535134 PMID: doi:10.1177/1471301214535134 [CrossRef]
  • Chiu, Y. C., Algase, D., Whall, A., Liang, J., Liu, H. C., Lin, K. N. & Wang, P. N. (2004). Getting lost: Directed attention and executive functions in early Alzheimer's disease patients. Dementia and Geriatric Cognitive Disorders, 17(3), 174–180 https://doi.org/10.1159/000076353 PMID: doi:10.1159/000076353 [CrossRef]14739541
  • Cogné, M., Auriacombe, S., Vasa, L., Tison, F., Klinger, E., Sauzéon, H. & N'Kaoua, B. (2018). Are visual cues helpful for virtual spatial navigation and spatial memory in patients with mild cognitive impairment or Alzheimer's disease?Neuropsychology, 32(4), 385–400 https://doi.org/10.1037/neu0000435 PMID: doi:10.1037/neu0000435 [CrossRef]29809030
  • Colombo, D., Serino, S., Tuena, C., Pedroli, E., Dakanalis, A., Cipresso, P. & Riva, G. (2017). Egocentric and allocentric spatial reference frames in aging: A systematic review. Neuroscience and Biobehavioral Reviews, 80, 605–621 https://doi.org/10.1016/j.neubiorev.2017.07.012 PMID: doi:10.1016/j.neubiorev.2017.07.012 [CrossRef]28760627
  • Crowe, M., Andel, R., Wadley, V. G., Okonkwo, O. C., Sawyer, P. & Allman, R. M. (2008). Life-space and cognitive decline in a community-based sample of African American and Caucasian older adults. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 63(11), 1241–1245 https://doi.org/10.1093/gerona/63.11.1241 PMID: doi:10.1093/gerona/63.11.1241 [CrossRef]19038840
  • Davis, R., Ohman, J. M. & Weisbeck, C. (2017). Salient cues and wayfinding in Alzheimer's disease within a virtual senior residence. Environment and Behavior, 49(9), 1038–1065 https://doi.org/10.1177/0013916516677341 PMID: doi:10.1177/0013916516677341 [CrossRef]29230067
  • Davis, R. L. & Therrien, B. A. (2012). Cue color and familiarity in place learning for older adults. Research in Gerontological Nursing, 5(2), 138–148 https://doi.org/10.3928/19404921-20111004-01 PMID: doi:10.3928/19404921-20111004-01 [CrossRef]
  • Davis, R. L. & Weisbeck, C. (2015). Search strategies used by older adults in a virtual reality place learning task. The Gerontologist, 55(Suppl. 1), S118–S127 https://doi.org/10.1093/geront/gnv020 PMID: doi:10.1093/geront/gnv020 [CrossRef]26055772
  • Engin, E. & Treit, D. (2007). The role of hippocampus in anxiety: Intracerebral infusion studies. Behavioural Pharmacology, 18(5–6), 365–374 https://doi.org/10.1097/FBP.0b013e3282de7929 PMID: doi:10.1097/FBP.0b013e3282de7929 [CrossRef]17762507
  • Folstein, M. F., Folstein, S. E. & McHugh, P. R. (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198 https://doi.org/10.1016/0022-3956(75)90026-6 PMID: doi:10.1016/0022-3956(75)90026-6 [CrossRef]1202204
  • Gazova, I., Laczó, J., Rubinova, E., Mokrisova, I., Hyncicova, E., Andel, R. & Hort, J. (2013). Spatial navigation in young versus older adults. Frontiers in Aging Neuroscience, 5, 94 https://doi.org/10.3389/fnagi.2013.00094 PMID: doi:10.3389/fnagi.2013.00094 [CrossRef]
  • Harris, M. A. & Wolbers, T. (2014). How age-related strategy switching deficits affect wayfinding in complex environments. Neuro-biology of Aging, 35(5), 1095–1102 https://doi.org/10.1016/j.neurobiolaging.2013.10.086 PMID: doi:10.1016/j.neurobiolaging.2013.10.086 [CrossRef]
  • Head, D. & Isom, M. (2010). Age effects on wayfinding and route learning skills. Behavioural Brain Research, 209(1), 49–58 https://doi.org/10.1016/j.bbr.2010.01.012 PMID: doi:10.1016/j.bbr.2010.01.012 [CrossRef]20085784
  • Hughes, C. P., Berg, L., Danziger, W. L., Coben, L. A. & Martin, R. L. (1982). A new clinical scale for the staging of dementia. The British Journal of Psychiatry, 140(6), 566–572 https://doi.org/10.1192/bjp.140.6.566 PMID: doi:10.1192/bjp.140.6.566 [CrossRef]7104545
  • Hund, A. & Minarik, J. (2006). Getting from here to there: Spatial anxiety, wayfinding strategies, direction type, and wayfinding efficiency. Spatial Cognition and Computation, 6(3), 179–201 https://doi.org/10.1207/s15427633scc0603_1 doi:10.1207/s15427633scc0603_1 [CrossRef]
  • Iaria, G., Palermo, L., Committeri, G. & Barton, J. J. (2009). Age differences in the formation and use of cognitive maps. Behavioural Brain Research, 196(2), 187–191 https://doi.org/10.1016/j.bbr.2008.08.040 PMID: doi:10.1016/j.bbr.2008.08.040 [CrossRef]
  • Iaria, G., Petrides, M., Dagher, A., Pike, B. & Bohbot, V. D. (2003). Cognitive strategies dependent on the hippocampus and caudate nucleus in human navigation: Variability and change with practice. The Journal of Neuroscience: The Official Journal of the Society for Neuroscience, 23(13), 5945–5952 https://doi.org/10.1523/JNEUROSCI.23-13-05945.2003 PMID: doi:10.1523/JNEUROSCI.23-13-05945.2003 [CrossRef]
  • Konishi, K., Joober, R., Poirier, J., MacDonald, K., Chakravarty, M., Patel, R. & Bohbot, V. D. (2018). Healthy versus entorhinal cortical atrophy identification in asymptomatic APOE4 carriers at risk for Alzheimer's disease. Journal of Alzheimer's Disease, 61(4), 1493–1507 https://doi.org/10.3233/JAD-170540 PMID: doi:10.3233/JAD-170540 [CrossRef]
  • Kremmyda, O., Hüfner, K., Flanagin, V. L., Hamilton, D. A., Linn, J., Strupp, M. & Brandt, T. (2016). Beyond dizziness: Virtual navigation, spatial anxiety and hippocampal volume in bilateral vestibulopathy. Frontiers in Human Neuroscience, 10, 139 https://doi.org/10.3389/fnhum.2016.00139 PMID: doi:10.3389/fnhum.2016.00139 [CrossRef]27065838
  • Lawton, C. (1994). Gender differences in way-finding strategies: Relationship to spatial ability and spatial anxiety. Sex Roles, 30(11–12), 765–779 https://doi.org/10.1007/BF01544230 doi:10.1007/BF01544230 [CrossRef]
  • Lawton, C. & Kallai, J. (2002). Gender differences in wayfinding strategies and anxiety about wayfinding: A cross-cultural comparison. Sex Roles, 47(9–10), 389–401 https://doi.org/10.1023/A:1021668724970 doi:10.1023/A:1021668724970 [CrossRef]
  • Lezak, M. (1995).Neuropsychological assessment (3rd ed.). New York, NY: Oxford University Press.
  • Moffat, S. D., Elkins, W. & Resnick, S. M. (2006). Age differences in the neural systems supporting human allocentric spatial navigation. Neurobiology of Aging, 27(7), 965–972 https://doi.org/10.1016/j.neurobiolaging.2005.05.011 PMID: doi:10.1016/j.neurobiolaging.2005.05.011 [CrossRef]
  • Muthén, L. & Muthén, B. (2017). Mplus user's guide (8th ed.). Los Angeles, CA: Author.
  • Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I. & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699 https://doi.org/10.1111/j.1532-5415.2005.53221.x PMID: doi:10.1111/j.1532-5415.2005.53221.x [CrossRef]15817019
  • Pai, M. C. & Jacobs, W. J. (2004). Topographical disorientation in community-residing patients with Alzheimer's disease. International Journal of Geriatric Psychiatry, 19(3), 250–255 https://doi.org/10.1002/gps.1081 PMID: doi:10.1002/gps.1081 [CrossRef]15027040
  • Passini, R., Pigot, H., Rainville, C. & Tétreault, M. H. (2000). Way-finding in a nursing home for advanced dementia of the Alzheimer's type. Environment and Behavior, 32(5), 684–710 https://doi.org/10.1177/00139160021972748 doi:10.1177/00139160021972748 [CrossRef]
  • Perrotin, A., Desgranges, B., Landeau, B., Mézenge, F., La Joie, R., Egret, S. & Chételat, G. (2015). Anosognosia in Alzheimer disease: Disconnection between memory and self-related brain networks. Annals of Neurology, 78(3), 477–486 https://doi.org/10.1002/ana.24462 PMID: doi:10.1002/ana.24462 [CrossRef]26085009
  • Piras, F., Piras, F., Orfei, M. D., Caltagirone, C. & Spalletta, G. (2016). Self-awareness in mild cognitive impairment: Quantitative evidence from systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 61, 90–107 https://doi.org/10.1016/j.neubiorev.2015.10.002 PMID: doi:10.1016/j.neubiorev.2015.10.002 [CrossRef]
  • Resnick, B., Gruber-Baldini, A. L., Pretzer-Aboff, I., Galik, E., Buie, V. C., Russ, K. & Zimmerman, S. (2007). Reliability and validity of the evaluation to sign consent measure. The Gerontologist, 47(1), 69–77 https://doi.org/10.1093/geront/47.1.69 PMID: doi:10.1093/geront/47.1.69 [CrossRef]17327542
  • Rodgers, M., Sindone, J. III. & Moffat, S. (2012). Effects of age on navigation strategy. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S019745801000343X?via%3Dihub
  • Rowe, M. A. & Bennett, V. (2003). A look at deaths occurring in persons with dementia lost in the community. American Journal of Alzheimer's Disease and Other Dementias, 18(6), 343–348 https://doi.org/10.1177/153331750301800612 PMID: doi:10.1177/153331750301800612 [CrossRef]14682082
  • Seignourel, P. J., Kunik, M. E., Snow, L., Wilson, N. & Stanley, M. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review, 28(7), 1071–1082 https://doi.org/10.1016/j.cpr.2008.02.008 PMID: doi:10.1016/j.cpr.2008.02.008 [CrossRef]18555569
  • Smith, T., Gildeh, N. & Holmes, C. (2007). The Montreal Cognitive Assessment: Validity and utility in a memory clinic setting. Canadian Journal of Psychiatry, 52(5), 329–332 https://doi.org/10.1177/070674370705200508 PMID: doi:10.1177/070674370705200508 [CrossRef]17542384
  • Taillade, M., Sauzéon, H., Dejos, M., Pala, P. A., Larrue, F., Wallet, G. & N'Kaoua, B. (2013). Executive and memory correlates of age-related differences in wayfinding performances using a virtual reality application. Neuropsychology, Development, and Cognition. Section B, Aging, Neuropsychology and Cognition, 20(3), 298–319 https://doi.org/10.1080/13825585.2012.706247 PMID: doi:10.1080/13825585.2012.706247 [CrossRef]
  • Taylor, J. E., Alpass, F., Stephens, C. & Towers, A. (2011). Driving anxiety and fear in young older adults in New Zealand. Age and Ageing, 40(1), 62–66 https://doi.org/10.1093/ageing/afq154 PMID: doi:10.1093/ageing/afq154 [CrossRef]
  • Weschler, D. (1987). Weschler Memory Scale—revised manual. New York, NY: The Psychological Corporation.

Factor Loadings for the Wayfinding Strategy Scale

ItemsFactor IFactor II
Orientation Strategies
I visualized a map or layout of the area in my mind as I went.0.620.16
I kept track of the direction (north, south, east, or west) in which I was going.0.75−0.01
I kept track of where I was in relation to the sun (or moon) in the sky as I went.0.680.001
As I went, I made a mental note of the distance I traveled on different roads.0.680.32
I kept track of where I was in relation to a reference point, such as the center of town, lake, river, or mountain.0.600.33
I could visualize what was outside of the building or complex in the direction I was heading inside the building.0.680.06
I always kept in mind the direction from which I had entered the building or complex (e.g., north, south, east,0.62−0.05
or west side of the building).
Whenever I made a turn, I knew which direction I was facing.0.67−0.13
I thought of my location in the building or complex in terms of north, south, east, and west.0.62−0.03
Route Strategies
I asked for directions telling me how many streets to pass before making each turn.−0.0010.73
I asked for directions telling me whether to turn right or left at particular streets or landmarks.−0.020.84
I appreciated the availability of someone (e.g., a receptionist) who could give me directions.−0.160.80
Clearly visible signs pointing the way to different sections of the building or complex were important to me.0.010.88
Clearly labeled room numbers and signs identifying parts of the building or complex were very helpful in finding my way.0.120.79

Factor Loadings for Spatial Anxiety Scale

Scale ItemFactor Loading
Deciding which direction to walk in an unfamiliar city or town after coming out of a train/bus/metro station or parking garage.0.86
Finding my way to an appointment in an unfamiliar area of a city or town.0.82
Leaving a store that I have been to for the first time and deciding which way to turn to get to a destination.0.88
Finding my way back to a familiar area after realizing I have made a wrong turn and become lost while traveling.0.83
Finding my way in an unfamiliar shopping mall, medical center, or large building complex.0.52
Finding my way out of a complex arrangement of offices that I have visited for the first time.0.87
Trying a new route that I think will be a shortcut, without a map.0.82
Pointing in the direction of a place outside that someone wants to get to and has asked for directions, when I am in a windowless room.0.90

Comparison of Demographic and Cognitive Variables Between Study Groups

VariableControl Group (n = 50)Group with AD (n = 38)t (df)Chi-square (df)p Value
Age (mean, SD) (range)75.46 (5.25) (62 to 86)77.26 (6.73) (63 to 92)−1.412 (86)0.162
Years of education (mean, SD) (range)16.05 (2.75) (20 to 22)15.47 (3.21) (12 to 24)0.905 (86)0.368
Female (n, %)32 (64)19 (50)1.737 (1)0.188
White (n, %)47 (94)38 (100)2.360 (1)0.124
Single (n, %)18 (36)7 (18.4)3.281 (1)0.070
Lives alone (n, %)17 (34)3 (7.9)11.488 (3)0.009
Has financial needs (n, %)2 (4)3 (7.9)0.697 (2)0.706
Number of medications (mean, SD) (range)6.82 (4.55) (0 to 20)6.13 (3.54) (0 to 16)0.771 (86)0.443
DSF (mean, SD) (range)6.12 (0.96) (5 to 8)5.97 (1.09) (4 to 8)0.665 (85)0.508
DSB (mean, SD) (range)4.50 (1.182) (2 to 7)4.14 (1.16) (2 to 7)1.435 (85)0.155
MMSE (mean, SD) (range)29.16 (0.1) (27 to 30)25.87 (3.01) (19 to 30)6.484 (43.22)< 0.001
Snellen Eye Test (mean, SD) (range)27.06 (7.96) (15 to 40)28.16 (8.25) (15 to 40)−0.631 (86)0.530
MoCA total score (mean, SD) (range)25.64 (2.1) (20 to 30)18.97 (3.58) (12 to 26)10.120 (54.06)< 0.001

Pearson Correlations Among Wayfinding Strategies, Spatial Anxiety, and Demographic Factors

ItemRoute TotalSpatial Anxiety Scale TotalAge (Years)Education (Highest Year Completed)MoCA TotalDSFDSB
Orientation total0.039−0.434***0.0340.318**0.280**−0.142−0.070
Route total0.022−0.1520.0410.295**0.0160.097
Spatial Anxiety Scale total−0.169−0.246*−0.348**0.066−0.194
Age (years)0.145−0.159−0.044−0.066
Education (highest year completed)0.239*−0.0130.193
MoCA total0.1190.308**
DSF0.352**
Authors

Dr. Davis is Professor, Associate Dean for Research and Scholarship, Kirkhof College of Nursing, Grand Valley State University, and Dr. Veltkamp is RN, Spectrum Health, Grand Rapids, Michigan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current research was supported by the National Institute on Aging of the National Institutes of Health (NIH) (R15AG037946). The content of the current research is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The Grand Valley State University Institutional Review Board and Mercy Health Institutional Review Board approved the current study.

Address correspondence to Rebecca Davis, PhD, RN, Professor, Associate Dean for Research and Scholarship, Kirkhof College of Nursing, Grand Valley State University, 301 Michigan Street, 422 Center for Health Sciences, Grand Rapids, MI 49503; e-mail: davirebe@gvsu.edu.

Received: June 02, 2019
Accepted: August 23, 2019
Posted Online: November 11, 2019

10.3928/19404921-20191022-03

Sign up to receive

Journal E-contents