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Wandering Science: Wandering Science: Theoretical and Empirical FoundationsTheoretical and Empirical Foundations
Donna Algase, PhD, RN, FAAN. FGSAJosephine M. Sana Professor of Nursing
University of Michigan School of Nursing
Focus of PresentationFocus of Presentation• What is wandering?
– Theoretical and operational approaches
• What are the outcomes of wandering?– Empirical findings
• What explains wandering? – Theoretical models and empirical evidence
Early Definitions
– Aimless or purposeless walking – Increased amount of walking
Snyder et al., 1978Monsour& Robb, 1982
NANDA Definition • meandering, aimless, or repetitive
locomotion that exposes a person to harm and frequently is incongruent with boundaries, limits, or obstacles.
NANDA, 1999
Wandering as Spatial or Geographic Patterns
Wandering as Spatial or Geographic Patterns
Wandering Patterns
direct
lapping
pacing
random
Dimensions of WanderingDimensions of Wandering• Frequency
• Pattern
• Boundary transgressions
• Navigational deficits
• Temporal aspects
Pattern
Frequency
Proposed Standardized Definitiona syndrome of dementia-related locomotion
behavior
having a frequent, repetitive, temporally-disordered, and/or spatially-disoriented nature
that is manifested in lapping, random, and/or pacing patterns, some of which are
associated with eloping, eloping attempts, or getting lost unless accompanied.
Algase, Moore, Vande Weerd & Gavin-Dreschnack, 2006
Wandering Outcomes• Falls, fractures and injuries
• Elopement
• Victimization
• Weight loss
• Early institutionalization
• Premature mortality
• Higher caregiver burden
Need-Driven, Dementia-compromised Behavior Need-Driven, Dementia-compromised Behavior (NDB) Model (NDB) Model (Algase, Beck, Kolanowski, et al., 1996)(Algase, Beck, Kolanowski, et al., 1996)
Background Factors
Proximal Factors
Wandering
Background Factors• Neurocognitive factors
– memory, attention, language, visual-spatial skills
– circadian rhythm– motor ability
• Health Status• Socio-Demographics
– gender, occupation– personality, behavioral response to stress
Proximal Factors• Physiological need states
– hunger, thirst, elimination, pain, fatigue
• Affective states– depression, apathy, anxiety, euphoria,
irritability
• Physical environment– light, noise, temperature, humidity,
complexity of design
• Social environment– staff mix and stability, ambiance, social
engagement, crowding
Tested Interventions
• Subjective barriers• Walking, exercise and other activities• Specialized environments• Behavioral techniques• Music• Alarms
Subjective Barriers• Includes camouflage, visual barriers, and
floor grids• Capitalizes on visual-spatial distortions,
agnosia• Quality of evidence varies• Effective in some cases, severely impaired,
AD only?• Tested in residential facilities only
Exercise, Walking & Activities
• Some benefits reported, but studies too flawed to draw valid inferences
• Insufficient description of targeted population
• Tested in residential facilities only
Specialized Environments• Types of environments varies; secured
wards and nature/homelike areas
• Outcomes differed by type of environment
• Studies lacked theoretical underpinning to explain success
• Examined in residential facilities only
Behavioral Interventions
• Compelling results for reducing unwanted wandering
• Ideal reinforcement schedules unknown
• Consistency of approach may be unfeasible to implement with low staff to patient ratios
• Worth further evaluation, esp. in community/home contexts for specific wandering behaviors
Alarms
• Used to deter exit attempts
• Effective for reducing attempts
• Verbal versus aversive alarms have greater appeal
• May have applicability in home settings, especially as technology advances
Complementary/Alternative Therapies
• Hand/foot massage have been tested; acupuncture testing in progress
• Massage effective in the short run for agitation; impact on wandering unknown
Pattern as a Basis for Intervention: Random Wandering
To interrupt/stop active random wandering:
To reduce or prevent active random wandering:
Distraction
Social engagement
Small group or 1:1 activity
Calm, but engaging milieu
Pattern as a Basis for Intervention:Lapping
To interrupt/stop active lapping:
To reduce or prevent lapping: -
Redirection
Frequent rest periodsOther, more
comfortable repetitious activity
Pattern as a Basis for Intervention:Pacing
To interrupt/stop pacing:
To reduce or prevent pacing:
Address underlying concern, not behavior
Stress reduction techniques
Reassurance, trust-building
Anticipate needs; reduce eliminate known concerns
Trial and Error• Individualized approach based on
behavior log
• Context analysis
• Eliminate cause/precipitant
General Goals for Treatment General Goals for Treatment and Interventionand Intervention
• Assuring safety• Using preserved skills• Supporting abilities• Enabling functional navigation• Maximizing comfort and ease• Minimizing restriction
Assuring SafetyAssuring Safety
– Enroll in “Safe Return”– Deter elopement– Enhance lighting– Remove hazards from the environment– Provide a balance/rhythm in the level and
timing of stimulation
Using Preserved SkillsUsing Preserved Skills
• Encourage the person to do what they are able to do
• Provide progressive support matched to ability: remind, guide, assist, do for
• Provide orientation through cuing, signage, landmarks
Supporting AbilitiesSupporting Abilities
– Ensure adequate hydration and nutrition– Prevent exhaustion– Support circadian rhythm – Preserve skin integrity– Monitor effects of prescribed medications
ComfortingComforting
– Establish a working way to communicate– Build trust – Engage the person in meaningful, structured, supervised
activity that provides sensory stimulation– Create regular opportunity for 1:1 communication at the
person’s level of comprehension– Preserve elements of previous meaningful life activities– Create environments that are engaging, but not over-
stimulating
NavigatingNavigating
– Provide redundant cueing
– Decorate with relevant personal items and photo identification
– Keep desired areas in view; obscure line of vision to undesirable locations
– Display orienting information in multiple prominent places
– Use rooms for a single clear purpose
Minimizing RestrictionsMinimizing Restrictions
– Provide for flexibility within a larger structure – Simplify challenges– Lower performance expectations– Reserve chemical and physical restraint as a
last, if ever, resort
Suggested Practice Standards• Establish a clear goal for intervening• Use empirically-based interventions with caution• Balance safety and autonomy• Aim interventions to modify wandering only when it is
problematic for the wanderer• Be systematic in targeting known or suspected causes
of an individual’s wandering • Individualize strategies using case-study methodology