The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.
Refer to the original guideline document for a definition of key terms (dementia, Alzheimer's disease, and wandering), a description of individuals/patients at risk for wandering (i.e., defining characteristics and related factors), and a list of assessment tools and instruments.
Assessment Criteria
The following assessment criteria indicate patients who are likely to benefit the most from use of this evidence-based guideline:
- Assess for cognitive decline using the Mini-Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975). (See Appendix A.1 in the original guideline document).
- Assess 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 (see Appendix A.2 in the original guideline document).
- Assess for depressive symptomatology with Short Geriatric Depression Scale (SGDS) (Sheikh & Yesavage, 1986) (See Appendix A.3 in the original guideline document).
- Assess for 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], 1997). 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 (See Appendix A.4 in the original guideline document).
- Assess the frequency with which memory and behavior problems occur including wandering and to what degree the behavior upsets the caregiver. The Zarit & Zarit (Zarit & Zarit, 1983) Memory and Behavior Problems Checklist—1990R (MBPC) is useful for this assessment (See Appendix A.5 in the original guideline document).
- Assess for factors associated with wandering as lack of activity, cognitive impairment, socially inappropriate behavior, resistance to care, and greater impairment in activities of daily living (ADL) (Logsdon, et al., 1998; Schonfeld et al., 2007) (Evidence Grade = B2).
- Assess 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, and/or 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.
- Assess wandering patterns, which may help to determine treatment.
- Identify the triggers for wandering, such as staff attention, access to items (e.g., sweet foods) and sensory stimulation. Interventions may be applied when patients are not wandering, thus reducing their impetus to wander (Heard & Watson, 1999) (Evidence Grade = C1).
- Identify the travel patterns of patients who wander, such as (Algase et al., 2001; Martino-Saltzman et al., 1991) (Evidence Grade = C1):
- 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
Direct travel is most efficient; other methods (2b-2d) are inefficient. Travel inefficiency is inversely related to cognitive status. 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 (Snyder et al., 1978) (Evidence Grade = C1). These may include:
- Overtly goal directed/searching behavior – searching for something often unattainable, often associated with calling out repeatedly or approaching others in pursuit of a goal.
- Overtly goal directed/industrious behavior – inexhaustible drive to do things or remain busy, often commenting on need to perform a stated task or gesturing as if performing work.
- Apparently non-goal directed behavior – aimlessly drawn to one stimulus after another.
- Assess pre-morbid lifestyle to help identify those likely to wander. These include:
- An active interest, physically and mentally, in music. Examples include singing, playing an instrument, and having a recognized love of music (Thomas, 1999) (Evidence Grade = C1).
- Demonstrating extroverted personality characteristics of warmth, gregariousness, activity, and positive emotion; demonstrating altruism. Examples may include being more continually active in daily activities, demonstrating social-seeking behavior, demonstrating a greater positive regard toward oneself and others (Thomas, 1997) (Evidence Grade = C1).
- Additional important pre-morbid 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.
- Having demonstrated more motoric behavioral styles in earlier years (Monsour & Robb, 1982) (Evidence Grade = C1).
- A descriptive typology of wandering in dementia (Hope & Fairburn, 1990) is also helpful in determining individuals who may benefit from this guideline. This typology is listed in Table 1 in the original guideline document.
- Developing technologies have the potential to aid in diagnosis and monitoring of dementia and related behaviors such as wandering (National Institute on Aging, 2007) (Evidence Grade = D).
Description of the Practice
The Need Driven Dementia-Compromised Behavior Model (NDB) (Algase et al., 1996) remains an excellent model to use for conceptualizing behaviors and identifying individuals at risk.
Practices to manage wandering in this guideline are grouped into four areas: environmental modifications, technology and safety, physical and psychosocial interventions, and caregiving support and education (Futrell & Melillo, 2002).
Environmental Modifications
- Provide a secure place for clients to wander such as a wanderer's lounge and/or a large, safe, walking area (Allen-Burge, Stevens, & Burgio, 1999; APA, 1997; McGrowder-Lin & Bhatt, 1988). (Evidence Grade = C1).
- Enhance the environment by increasing visual appeal, such as tactile boards or three dimensional wall art (Allen-Burge, Stevens, & Burgio, 1999; Cohen-Mansfield & Werner, 1998; Dickinson & McLain-Kark, 1998; Richter, Roberto, & Bottenberg, 1995; Yao & Algase, 2006) (Evidence Grade = C1).
- Place or paint a wall mural over doorway to disguise exits (Kincaid & Peacock, 2003) (Evidence Grade = C1)
- Place gridlines in front of doors to decrease exit seeking (Forbes, 1998; Hussian & Brown, 1987) (Evidence Grade = C1).
- Make exits less accessible by covering panic bar with cloth and allow walking where doors are not in the path, using safety locks or complex and less accessible door latches (APA, 1997; Dickinson & McLain-Kark, 1998) (Evidence Grade = C1).
- Maintain safety by removing clutter, disabling appliances, and utilizing safety locks (Gitlin & Corcoran, 1996) (Evidence Grade = D).
- Provide stimulation clues such as pictures and signs (Allen-Burge, Stevens, & Burgio, 1999; Gitlin & Corcoran, 1996) (Evidence Grade = D).
- Use a combination of large-print signs and portrait-like photographs to aid in way finding (Namazi, Rosner, & Rechlin, 1991; Nolan, Mathews, & Harrison, 2001) (Evidence Grade = C1).
- Use a multifaceted approach to environmental modifications, as it is more effective than singular modifications (Bair et al., 1999; Coltharp, Richie, & Kaas, 1996; Dickinson & McLain-Kark, 1998; Price, Hermans, & Grimley, 2007) (Evidence Grade = C1). (See the National Guideline Clearinghouse [NGC] summary of the University of Iowa Gerontological Nursing [UIGN] Interventions Research Center guideline: Non-pharmacologic management of agitated behaviors in persons with Alzheimer disease and other chronic dementing illnesses by McGonigal-Kenny & Schutte, 2004).
Technology & Safety
- Use technological devices to locate and monitor wandering (Algase et al., 1997; Cohen-Mansfield et al., Assessment of ambulatory behavior, 1997) (Evidence Grade = B2).
- Use a verbal alarm system as it is more effective than an aversive alarm system (Connell & Sanford, 1998) (Evidence Grade = C1).
- Use mobile locator devices for quickly locating wanderers (Altus et al., 2000; McShane, et al., 1998; Melillo & Futrell, 1998; Melillo & Futrell, 1999; Miskelly, 2004; Miskelly, 2005) (Evidence Grade = C1).
- See Appendix B in the original guideline document for specific information on the Low Cost Patient Locator System for Geriatric Wandering (Melillo & Futrell, 1999) (Evidence Grade = C1).
Physical & Psychosocial Interventions
- Assess for and treat depression (Lyketsos, et al., 1997) (Evidence Grade = B2).
- Decrease wandering during structured activities by using social interaction of staff and/or visitors or music (Cohen-Mansfield & Werner, 1995; Holmberg, "A walking program," 1997; Matteson & Linton, 1996) (Evidence Grade = B2).
- Music sessions are more effective than reading sessions in decreasing wandering behavior (Fitzgerald-Cloutier, 1993; Groene, 1993) (Evidence Grade = B2). (See the NGC summary of the UIGN guideline: Individualized music for elders with dementia by Gerdner, 2007).
- Prevent risky situations by adequate supervision (APA, 1997; Aspinall, 1994) (Evidence Grade = D).
- Walking should not be unnecessarily limited (APA, 1997; Brungardt, 1994) (Evidence Grade = D).
- Promote safe walking (Cohen-Mansfield & Werner, 1998; Coltharp, Richie, & Kaas, 1996) Evidence Grade = C1).
- Decrease wandering by eliminating stressors from the environment, such as cold at night, changes in daily routines, and extra people at holidays (Hall & Laloudakis, 1999) (Evidence Grade = D).
- Decrease wandering by providing regular exercise such as walking after meals (Holmberg, "A walking program," 1997; Holmberg, "Evaluation," 1997; Landi, Russo, & Bernabei, 2004) (Evidence Grade = B2).
- Systematic behavioral conditioning at mealtime to improve food intake, to sit at the table longer, and to stabilize weight (Beattie, Algase, & Song, 2004) (Evidence Grade = C1).
- Use air mattress therapy for treatment of agitated wandering (Shalek, Richeson, & Buettner, 2004) (Evidence Grade = A2).
Caregiving Support & Education
- Educate caregivers to assist in their ability to care for the wanderer (Cohen-Mansfield et al., "Evaluation of an inservice program," 1997; Dodds, 1994) (Evidence Grade = C1).
- A facility-based approach could include: identification of the problem, a wandering prevention program, interactions with staff, and staff mobilization around problem (Heard & Watson, 1999; Rader, 1987) (Evidence Grade = C1).
- Dementia Care Training for Residential Care Staff using training modules (Alzheimer's Association, 2007) (Evidence Grade = D).
Definitions:
Evidence Grading
A1: Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
A2: Evidence form one or more randomized controlled trials with consistent results
B1: Evidence from high quality evidence-based practice guidelines
B2: Evidence from one or more quasi experimental studies with consistent results
C1: Evidence from observational studies with consistent results (e.g., correlational, descriptive studies)
C2: Inconsistent evidence from observational studies or controlled trials
D: Evidence from expert opinion, multiple case reports, or national consensus reports
