A RROTOOOL FOR ASSESSMENT AND GENERAL »
TAANAOEMENT STRATEGIES FOR WANDERING BEHAVIOR
OF OLDER ADULTS WITH DEMENTIA IN LONG-TERM
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A PROTOCOL FOR ASSESSMENT AND GENERAL MANAGEMENT
STRATEGIES FOR WANDERING BEHAVIOR OF OLDER ADULTS WITH
DEMENTIA IN LONG-TERM CARE FACILITIES
By

Meseret H. Gebissa

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
College of Nursing

1997

ABSTRACT
A PROTOCOL FOR ASSESSMENT AND GENERAL MANAGEMENT
STRATEGIES FOR WANDERING BEHAVIOR OF OLDER ADULTS WITH
DEMENTIA 1N LONG-TERM CARE FACILITIES
By

Meseret H. Gebissa

In recent years, research has shown that there is a relationship between old age and
dementing diseases. It is now established that dementing diseases afi‘ect older adults’
quality of life, causing their physical and cognitive conditions to deteriorate and limiting
their ability to perform routine activities. As it progresses, the disease is accompanied by
such negative behaviors as aggression, irritability, anxiety, paranoia and wandering.
Among these, wandering is the least understood, but one that most fi'equently results in
the unnecessary use of physical or chemical restraints. The challenge for the caregiver of
older adults with wandering behavior is to allow wanderers to ambulate fi'eely while
protecting them from harmful situations.

This scholarly project is a protocol developed to assess and manage the wandering
behavior of older adults with dementia. Based on Lawton and Nahemow’s ecological
theory of adaptive behavior, i.e., the person-environment interaction model, the protocol
provides suggestions on how to assess the wandering person, the environment and the
manifested behavior and recommends appropriate environmental interventions for
management of wandering behavior. By way of conclusion, the protocol discusses the

importance of educational programs'and suggests an agenda for fiirther research.

ACKNOWLEDGMENTS

This scholarly project would not have been possible without the support,
cooperation, and fiiendship I have received from many individuals. My debt is owed to
Professor Sharon King, my advisor and chairperson of my scholarly project committee,
who had confidence in me, encouraged me to pursue my goals, and guided me during the
various stages of my graduate studies and this project. Professor King showed unflagging
patience with me and never wavered in her support.

The members of my scholarly project, Professors Laura Struble and Kate Lein
gave me valuable suggestions and comments which I gratefiilly acknowledge. Professors
King and Struble firmished important materials on which this project is partially based. I
appreciate their professionalism and express a sincere gratitude for their generousness. I
salute all three members of my committee for their enthusiasm, prompt responses and solid
intellectual guidance.

I would like to express my appreciation and gratitude to my husband, Ezekiel, for
his encouragement, support, confidence, persistence and patience. I would also like to
thank my children, Haara and Kenna, for making it possible for me to find joy in school,
work and family. To my family, and my almighty God, who guided me through thick and
thin and provided me encouragement when I needed it most, I owe much more than I can

ever say.

TABLE OF CONTENTS

LIST OF TABLES .

LIST OF FIGURES

CHAPTERS

One:

Two:

Introduction .

1. The Problem .

2. Purpose of the Study

3. Conceptual Framework
3.1 Competence
3.2 Environmental Press
3.3 Behavior .

Literature Review . .
1. Definitions and Descriptions
2. Causes . . .
3. Types and Classifications .
4. Theories and Models

Three: The Protocol

Four:

1. Assessment .
1.1 Assessing the Person
1.2 Assessing the Environment
1.3 Assessing the Behavior

2. Intervention

Implications
1. Research
2. Education .
3. Practice

APPENDIX

LIST OF REFERENCES

\IOUIA-D-I—n—

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LIST OF TABLES

Table 1. Assessment of person and intervention
Table 2. Assessment of environment and intervention.

Table 3. Assessment of behavior and intervention

41

43

44

LIST OF FIGURES

Figure 1. Adapted Lawton’s Press-Competence Model (1982)

CHAPTER I
INTRODUCTION
1. Wm

In the past few decades a substantial proportion of the United States' population
has grown older. Since 1990 the number of older Americans has increased by 5% and the
proportion of Americans over age 65 is projected to reach 13% by the year 2000
(American Association of Retired Persons [AARP], 1994). The increased survival rate
has been largely due to breakthroughs in medical science and technology. Still, the
number of Americans diagnosed with diseases involving dementia was a staggering four
million in the late 19803 (Davies, 1988). By the year 2000, the number of individuals
with severe dementia is expected to increase by 60%.

The prevalence of dementing diseases increases significantly with age. Dementing
diseases afiect older Americans' quality of life by depriving them of the opportunity to
function independently and by causing their families both grief and greater burden of home
care responsibility. The stress that emanates from such responsibility becomes increasingly
intense with the inevitable decline in the physical and mental conditions of patients with
dementing diseases. Families of older adults with dementia worry about their relatives and
suffer from guilt of having to restrict their loved ones through the use of physical and/or
chemical restraints (F opma-Loy, 1988).

As their physical and cognitive conditions deteriorate, persons with dementing
disease become increasingly "confused, disoriented, and unaware of their surrormdings and

behavior" (Teri, Larson & Reifler, 1988, p. 3). Over time, they grow unable to do the

2

activities that they normally accomplish without difficulty. Dementing illnesses are ofien
accompanied by such negative behaviors as physical or verbal aggression, pacing,
irritability, withdrawal, fear, anxiety, paranoia and wandering (Mace 1991; Sweater,
Drachrnan, O'Donnell, & Mitchell, 1988; Teri et a1, 1988). These behaviors are believed
to be related to the degree of cognitive impairment and the stage of the illness (Fopma-
Loy, 1988; Teri et a1, 1988). Negative behaviors also lead older adults with dementia to
endanger themselves and cause their caregivers to suffer from stress, fear, and/or
exhaustion (Mace, 1991).

Winger, Schirm, & Stewart (1987) reported that 84% of nursing home residents
exhibited behaviors that were serious enough to endanger themselves or others. The
incidence of cognitive impairment or neurop sychiatric condition among residents in long-
term care facilities is estimated to be between 63% and 94% (Feldt & Ryden, 1992). It is
generally recognized that elderly residents with dementia in a long-term facility exhibit
diflicult behaviors such as yelling, wandering, abusive language, and physical aggression,
thus making caring for them a formidable challenge to caregivers (nurses, nurse assistants,
social workers, dieticians, and physical, occupational and speech therapists) (Hagen &
Sayers, 1995). Among negative behaviors of elderly residents, however, wandering is one
of the least clearly understood, but one that most frequently results in the unnecessary
physical or chemical restraint of residents.

Wandering is a serious problem that worries nursing staff as they attempt to
provide quality care and protect patients from falls, fatigue, excessive caloric utilization or

physical pain (Coltharp, Richie, & Kaas, 1996; Fopma-Loy, 1988; Heim, 1986 ). Stafl‘

3

members have the responsrhility of ensuring the wanderer’s need to move about freely
without exposing the individual to potentially harmful situations. The dilemma, coupled
with the lack of knowledge about the etiology of and intervention for the behavior,
increases the level of the stress for the care provider (Hirst & Metcalfi 1989; Namazi,
Rosner, & Calkins, 1989). Some researchers, oblivious to the underlying causes of
wandering, think of wandering as an aimless movement that holds many potential hazards
for the wanderer (Heim, 1986). Others believe that cognitively impaired persons wander
in an effort to firlfill their felt social, emotional, and physical needs (Algase, 1992a; Rader,
Doan & Schwab, 1985). Still others consider wandering as a natural outcome of the
searching process for a place of safety and familiarity (Coltharp, et aL, 1996).

In long-term care facilities, wandering causes disruptions in interpersonal relations
of residents. When wanderers indiscriminately enter other residents’ room and explore
others’ personal possessions, fellow residents become up set and endanger the wanderers
or themselves (Hirst & Metcalfl 1989; Hoflinan & Platt, 1990).

The Advanced Practice Nurse (APN) must have a full understanding of the causes
and consequences cf wandering behavior in older adults with dementia in order to provide
older adults comprehensive care. In such primary care settings as clinics, private
practices, or long-term care facilities, the APN needs a clinical guideline to identify
wandering behavior and implement appropriate interventions. Within long-term care sites
in particular, the APN should educate and train the nursing staff who is directly involved
in daily patient care to enable them manage wandering behavior in restraint-free

environment. In all facilities, the APN must collaborate with the residents' physician and

4

other health care team to enhance provision of quality care.
2- 121mm

This project seeks to develop a protocol for assessment and general management
of wandering behavior in older adults with dementia in long-term care facilities. The
protocol could ultimately be utilized in primary care settings and by families caring for
older adults with dementing diseases.

The proposed protocol is based on the fi'amework of person-environment
interaction and draws on pertinent literature on the phenomenon of wandering. The
literature review consists of definitions of wandering behavior, its possible causes and its
effects on the individual elderly patient, on other residents and on the caregivers. The
protocol also provides suggestions on how to assess the person (wanderer), the
environment and the wandering behavior as well as how to manage wandering behavior by
using different environmental interventions.

3. Qanmmallitammcrk

An ecological theory of adaptive behavior and aging was described by Lawton &
Nahemow (197 3) in terms of the adaptation of person to his/her environment and his/her
alteration of the environment 'as part of the process of human adaptation. According to
Lawton (1982), much of the research on aging has been essentially descriptive.
Descriptive data is a necessary step toward theorizing, but its practical benefit is minimal.
In order to encompass the growing body of studies of older people's behavior in specific
environments and increase the utility of the research, Lawton and Nahemow developed a

predictive model for the behavior of older adults. The model incorporates both non-

5

physical, extra-individual stimuli and intra individual environmental representations. The
major predictive components of the model have been referred to as competence and
environmental press.

3.1 Competence

According to Lawton (1982), competence is viewed as "a characteristic of the
individual, for heuristic purposes conceived of as relatively independent of factors outside
the individ " (p. 35). The degree of individual competence is conceived as a diverse
collection of abilities residing in a person, which differ among themselves and vary over
time and individual-specific. The term competence has an evaluative connotation, ranging
from adaptive to non-adaptive variations. Competence is characterized by such aspects as
cognitive ability, psychological adjustment, physical health, or other qualities (Lawton &
Nahemow, 1973). The processes that seem to most clearly represent competence are
biological health, sensory-perceptual capacity, motor skills, cognitive capacity, and ego
strength (Lawton, 1982).

Biological health refers to "the absence of disease states" and is commonly listed as
laboratory results, signs, symptoms, and medical diagnoses. Sensory and perceptual
capacities include vision, audition, olfaction, gustation, tactile, depth and pain perceptions.
Motor skills are related to biological health and sensory-motor capacity involving
muscular strength and coordination. Cognitive capacity is presumed to be an individual’s
ability to comprehend, process, and cope with the external world. Ego strength indicates
the individual differences in psychological strength that are independent of external events.

These five classes enabled Lawton to define competence as, "the theoretical upper limit of

6

capacity of the individual to firnction in the areas of biological health, sensation-
perception, motoric behavior, and cognition" (Lawton, 1982, p. 38).
3.2 Enxircnmsntalnms

Environmental press, as described in 1938 by Murray, refer to environmental
forces or "stimuli possessing some motivating quality to activate a cognate individual
need" (Lawton, 1982, p. 35). These forces in the environment, together with an individual
need, elicit a response. Press may be characterized by normative stress-producing
properties, problematic qualities, demand character (subjective or objective) and support
character (Lawton & Nahemow, 197 3 ). Environmental press fluctuate fi'om time to time,
as the environment itself alters momentarily; similarly, the individual's need and
competence vary over time.

In an attempt to classify environmental aspects of the behavioral system, Lawton
(1982) categorized environment as: (a) the interpersonal environment, constituting the
world of significant others -family members, friends, work associates; (b) the
suprapersonal environment, which is determined by the modal characteristics of those in
physical proximity to the individual (for example, the predominant race or the mean age of
other residents in an institution); (c) the social environment including institutions
operating in the individual's subgroup or culture, values and social norms; and (d) the
physical environment described as the nonpersonal and nonsocial aspects of the

environment.

3.3 Bahama

The behavior of the individual is a dependent variable and viewed as the outcome
of competence and environmental press equation (Lawton, 1982). Behavior is a function
of the person (competence of the individual) and the environment (press of the situation),
B = f (P, E). Behavior, also known as adaptive behavior, is a result of the individual-
environment transaction, usually thought of as the outer manifestation of individual
competence (Lawton & Nahemow, 1973 ). Behavior may be either outwardly observable
motoric behavior or an inner afl’ective response. In the discussion of the ecological model,
behavior usually refers to both the overt and inner afl’ective response falling in the range of
adaptive through nonadaptive (Lawton, 1982; Lawton & Nahemow, 1973 ).

The press-competence model incorporates another concept, adaptation level (AL),
that represents a state of balance between the level of external stimulation and the
sensitivity of the individual's sensory, perceptual, and cognitive state (Lawton, 1982).
Adaptation level is established by the individual to external stimuli It represents a
theoretical mean for all individuals at a given level of competence, averaged over the
particular environmental press at issue (Lawton & Nahemow, 197 3 ). Moreover, Lawton
states, "[N]ot only is there a tendency for every individual experiencing a given
environmental press to establish an adaptation level, but the magnitude of that neutral
stimuhrs level is partly determined by the competence of the individ " (p. 46). As the
competence of the individual decreases, the proportion of behavior attributable to
environmental characteristics increases. That is, the less competent are more vulnerable in

terms of their behavior being controlled by environmental, rather than intrapersonal forces

(Lawton & Nahemow, 1973 ).

 

HIGH

 

 

 

 

Ill
0
E mm...
5 BWVIOR
0
LOW
STRONG
ENVIRONMENTAL PRESS
13min Adapted Lawton’s Press-competence Model (1982).

As presented in Figure 1, the strength of press is shown on x-axis (horizontal line)
and the degree of individual competence is shown on y-axis (vertical line). Any point on
the schema indicates an individual‘s given level of competence for coping with
environmental press of a given magnitude. This point also implies behavior that may be
characterized in terms of adaptiveness.

The diagonal line labeled AL represents adaptation level of an individual over a
particular environmental press. Individuals of a given level of competence would be
distributed normally to the right and left of the AL point for that level. This is true for the

region in which the environmental demands are both slightly lower and slightly higher than

adaptation level.

The low point of environmental demand might occur in sensory deprivation
situations or perceived inaccessibility to bathroom and food, while the high point might
occur in stressful or overloading situations such as crowded room or overstimulating
activities. The challenge of health professionals is to balance between the individual
competence and the press so that the person with dementia stays within the adaptive
range. Thus, an eqttihhrium between personal resources (competence) and environmental
demands (press) result in person's behavior. When the environmental demand level
increases, the subject's behavior may range out of the positive outcome. In order to
correct this, Lawton & Nahemow (1973) suggest two methods, either lowering the level
of environmental press or raising the subject's competence. Environmental change, with
the subject assuming a relatively passive role, alters the person's adaptive behavior. The
person's competence could be enhanced by involving him/her in social interaction.

As indicated in the upper areas of the two shaded segments of Figure 1,
individuals of high competence have a wide latitude to interact with the environment in
ways that maximize adaptive behavior. However, owing to their cognitive impairment,
older adults with dementia have a drastically reduced competence. Lawton's model
suggests that behavioral change could be effected either by increasing the subject's
competence or by reducing the environmental press. To date, neither science nor medical
technology has succeeded in reversing the situation of demented individuals. Increasing
the competence of individuals with dementia is unlikely to be an option available to

produce a satisfactory result in managing their behavior. This protocol therefore focuses

10
on environmental press reduction, rather than on competence enhancement of individuals
with dementia who exhibit wandering behavior. Specifically, it suggests steps caregivers
need to follow to reduce environmental press on the wanderer. In order to prepare such a
protocol, it is necessary to understand the current state of knowledge regarding

wandering behavior. To that end, the existing literature on the subject will be reviewed.

CHAPTER 1]
LITERATURE REVIEW

Until recently, the phenomenon of wandering generated very little scholarly
interest. In 1987 Dawson and Reid (citing Burnside, 1980) reported that only five articles
on wandering were written between 1941 and 197 8 and another batch of five articles
during the five years prior to the publication of their study. Although more work has been
done in the last decade on the subject, it cannot be said that adequate empirical data has
been compiled to increase Our understanding of the causes of wandering or to respond to
wandering behavior with a more appropriate intervention. In the literature, researchers
concentrated on issues pertaining to definition, etiology, and classification or typology.
These subjects remained dominant because the primary stimulus for research has been the
need to reduce the effects of wandering and better manage the behavior.

Managing wandering behavior could be a tremendous task for caregivers in
providing adequate protection and quality care. The problem wanderers present reaches
unmanageable levels when the potential for injury abound, the rights of other residents are
infiinged, and precious staff time is spent on tracking residents rather than therapeutic
actions (Hirst & Metcalf, 1989).

The Advanced Practice Nurse needs to assess the health status of the wanderer and
his/her environment by obtaining relevant health, medical, social and mental history fiom
family members and past medical records and perform a complete physical examination in

order to identify the causes of wandering and implement appropriate intervention.

11

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Effective management of wandering, therefore, highly depends on the care provider’s
understanding of the phenomenon. In view of the importance of a more comprehensive
understanding of wandering, it is imperative that this study provides a review of the
existing literature.
1. Deminrnnsanfllescnnm

In common parlance, wandering is used to denote aimless movements. Terms such
as rove, ramble, stroll, digress, deviate, stray, rave and so forth are used to describe
behaviors that some people exhibit in their daily lives. From the vantage point of health
care professionals and care givers, none of these vocabularies adequately describe the
phenomenon that they encounter every day in their dealings with individuals identified as
wanderers. The impact of wandering on health care providers and caregivers includes
fear, embarrassment, frustration, overwhelming fatigue and feelings of helplessness. A
considerable amount of time, energy and money is spent on protecting wanderers fiom
getting lost, accidents and fatal injuries (F opma-Loy, 1988), but its effects are not
confined to the patient. Although the effects of wandering extend beyond the wanderer to
the care provider, the terminologies listed above depict wandering simply as an
idiosyncratic behavior and fail to capture the essence of the phenomenon as experienced
by health care providers and caregivers.

A review of the literature on wandering reveals lack of clarity and the absence of a
consensus among researchers who have conducted in-depth studies on the subject of
wandering. Some researchers provide definitions that are indistinguishable from the one in

common usage. Monsour and Robb (1982), for instance, following a dictionary definition,

l3

identify wandering as “disoriented activities and aimless movements toward an undefinable
or unattainable goals” (p. 411). Snyder, Rupprecht, Pyrek, Brekhus, & Moss (1978)
define wandering as “a tendency to move about, either in a seemingly aimless or
disoriented fashion, or in pursuit of an indefinable or unobtainable goal” (p. 272).

Similarly, Davidhizar and Cosgray ( 1990) define wandering as an aimless behavior
triggered by memory impairment, disorientation and confirsion caused by either organic or
environmental factors. Although Davidhizar and Cosgray conceive wandering as an
aimless behavior, their definition differs fiom others’ in one important respect. Unlike the
researchers who define wandering based on the behavior of the wanderer, Davidhizar and
Cosgray provide a definition that takes into account the wanderer’s behavior as well as the
organic and environmental factors that trigger wandering.

In an unpublished paper presented at an annual meeting of the Gerontological
Society of America in 1985, Robb defines a wanderer “as a person who moved, under his
or her own volition, into unsafe and/or inappropriate situations while experiencing
impaired cognitive status” (p. 214). Although Robb’s definition had evolved during the
years that had elapsed since her publication of the article she authored with Monsour, it
seems that the wanderer had remained the focus of her definition. In her latter definition,
Robb appears to have taken into account the cognitive impairment of the wanderer as a
cause for wandering.

Wandering is also defined as a person’s inability to return to his/her point of origin.
Hussian (1981b) defined wandering as, “Any change in physical location which results in a

person’s inability to return to the point of origin, with or without prosthetic devices” (p.

14

139). Researchers who perceive wanderers as lost persons, in essence, refer to
disorientation, the individual’s propensity to lose direction while attempting to reach a
certain destination. In other words, they consider wanderers as disoriented individuals in
pursuit of a given goal, not as not aimless ambulators (Hiatt, 1980; Hussain, 1981a).

Some researchers do not accept the notion that wandering is prompted by external
factors. Coons ( 1988), for instance, suggests that “wandering refers to ambulation that is
self-initiated and occurs independently of environmental cues such as the ringing of a bell
for meal time, or an invitation by staff to take part in an activity” (p. 31). Obviously,
Coons rejects external causation as a factor, emphasizing instead the initiative of the
wanderer in triggering wandering. As such, Coons describes a wanderer as “an individual
with a supply of unused energy, who is physically fit, who responds to well established
patterns of action, and who sets out to achieve a goal...” (p. 32). Even though Coons’s
definition is wanderer-centered, just as are the definitions by Monsour and Robb as well
as Snyder et a1, uner the latter, she recognizes that the wanderer is not an aimless,
purposeless individual who moves about to achieve unattainable objectives.

Categorically rejecting the notion that wanderers are aimless ambulators, Thomas
(1995) contends that the terms “aimless” or “purposeless” must be expunged from any
definition of wandering. He argues that these terms imply that the wanderer has no intent
or goal for moving about, while, in practice, even the most seemingly purposeless
behavior could very well be purposeful if viewed from the wanderer’s perspective.

Accordingly, Thomas defines wandering as:

15

A purposeful behavior that attempts to fulfill a particular need (from the context of
the wanderer), is initiated by a cognitively impaired and disoriented individual and
is characterized by excessive ambulation that often leads to safety- and/or
nuisance-related problems. (p. 37)

It is noted in the literature that wandering has been considered “so imprecise” a
term as to defy definition. In this respect, Algase has. expressed concern that the absence
of a more precise definition might impede the development of a valid and reliable
measuring instrument and distort detection and assessment of wandering in clinical
practice. It is perhaps impossible to attain a precise definition unless the most common
behavioral characteristics of wanderers are identified and the extent of the impact of
wandering on caregivers is factored in. From the perspective of this protocol, an overall
understanding of the phenomenon is more critical than definitional exactitude. To
comprehend wandering, a more comprehensive definition that takes into account the
behavior of the wanderer and the impact of wandering on caregivers is extremely
necessary.

Some researchers have preferred to describe the characteristics exhibited by
wanderers rather than attempting to define it. Commonly, wanderers’ characteristics
include: spending more time in motion than the average non-wanderers, having unmet
basic needs, and increasing disorientation that is induced by memory loss. Thus, wandering
may be a coping mechanism- a search for food, fluids, shelter, or fulfillment of

psychosocial needs.

l6

Cohen-Mansfield, Marx & Rosenthal (1989), identify wandering as a physically
nonaggressive behavior. They also explain the behavior as an increase in gross motor
movement with a repetitive nature, but has no apparent negative effect on others. Rader
and associates (1985) described wandering as a form of communication by the confused
person to alleviate fear and feelings of loneliness and separation. Mace and Rabins (1981)
agree with Rader and suggest that wandering may be an attempt to communicate feelings
of being lost and to find things perceived as lost. Hiatt (1980) also indicated that
wandering may be a form of commtmication perhaps used by individuals who are less
sociable or verbal

Davidhizar and Cosgray (1990) Consider the wandering patient as "an all-too-
common and fi'equently serious problem in an extended care facility" (p. 280). Wandering
behavior is problematic because it ofien is accompanied by anxiety and fear, adding
further to the patient's distress. When wandering occurs at night, it also deprives the
patient of needed rest.

Dawson and Reid (1987) distinguished wanderers from non-wanderers using
behavior descriptors. Based on their study, they concluded that wanderers have notably
greater difliculties with speech, reading, incontinence, constant rather than transitory
disorientation, and the inability to know they are lost. However, wanderers are less
withdrawn, exhibit better social skills, and are quite mobile and active with better hearing.
In the contrary, other studies found wanderers to have a low level of social interaction
and more stressfirl life events (Combleth, 1977 ; Snyder et al., 1978). Among cognitively

impaired nursing home residents, wanderers show a behavior pattern characterized by a

17

high degree of locomotion and gross motor output (Hussain, 1982; Snyder 197 8), and
more disorientation (Dawson & Reid, 1987; Rader, et a1, 1985).

Wanderers have demonstrated memory, orientation, and language deficits and
higher cognitive impairment (Algase, 1992b; Coons, 1988; Combleth, 1977 ; Dawson &
Reid, 1987; Fopma-Loy, 1988; Monsour & Robb, 1982; Snyder 1978). Algase (1992b)
recently studied 163 subjects from eight randomly selected nursing homes to determine
dimensions of cognitive impairment that would best discriminate wanderers from
nonwanderers. Results showed that wanderers had more cognitive impairment and
showed poorer performance on all cognitive dimensions (abstract thinking, language,
judgement, and spatial skills) than nonwanderers.

Algase (1988) has suggested that, if a more useful and meaningful definition of
wandering behavior were to be attained, the phenomenon must be seen as a behavior
characterized by high levels of locomotion and gross motor output that is manifested by
some cognitively impaired persons, possibly need-driven, and often incongruent with
objective circumstances. Except for environmental cues, this particular definition
incorporates the most salient indicators of wandering: ambulation, cognitive impairment,
purposefulness and disorientation.

From this investigator’s perspective, the impact of wandering on caregivers is as
important an element as the behavior of the wanderer in understanding the phenomenon of
wandering. Only a definition that encompasses the reactions of the caregiver to
wandering behavior could provide a more comprehensive understanding of the

phenomenon which enables care providers to detect, assess, measure and prescribe a more

18

appropriate intervention. In order to develop a protocol for appropriate intervention in
long-term institutionalized settings, a fuller understanding of the reasons for wandering is
required. The following section deals with the causes of wandering.

2. Causes

Even though the literature on wandering devotes considerable attention to the
question why people wander, no single reason has so far been identified as the cause of
wandering. While the existing studies are inconclusive as to what initiates its occupance,
there seems to be a consensus about factors that contribute to phenomenon of wandering.

One important work that attempts to systematize our understanding of the causes
of wandering is written by Algase and Struble (1992). The authors maintain that, as a
behavior, wandering can be initiated by factors in the person, the environment, or both.
Factors in the person have physiological and psychological explanations.

Physiological explanations of wandering include: medication interactions,
sedatives, or tranquilizers; physical discomfort due to pain, hunger, thirst, constipation, or
need to urinate; and desire to exercise. Weller (1987) postulated a hypothesis that
describes the cause of wandering as a biochemical mechanism, ie., low levels of the
enzyme acetylcholine in brain neurones (cholineacetyltransferase) and an over activity of
the dopaminergic system causes the restlessness and wandering. Wanderers are also said
to show overall impairment in basic and higher order cognitive skills. Combleth (197 7)
indicates that wandering behavior might be highly correlated with the presence of cortical
atrophy secondary to chronic organic mental disorders. Other identified underlying

pathophysiology for wandering include: deteriorative diseases of the central nervous

19

system or cardiac decompensation, neurotic disorders, restlessness associated with
depression, and organic brain syndrome (Heim, 1986; Teri et al., 1988). All of these
physiological conditions are based on surveys and researchers concede that more empirical
testing is needed to buttress these preliminary findings.

Another aspect of personal factors that Algase and Struble (1992) identified was
psychological Following Rader et al, (1985), the researchers depict wandering as a form
of agenda behavior, aimed at meeting felt social, emotional, or physical needs. Arguing
that wandering was shown to stem from loneliness and separation, they name three
sources for agenda behavior: 1) fear engendered by separation from familiar people and
environment; 2) fi'ustration over interference in agenda behavior, and 3) the desire to be
important or relevant. In these situations, wandering is a means of alleviating loneliness
and separation, i.e., wandering addressed a psychological need: releasing tension or
stress (Hussain, 1982).

Environmental factors are also noted as initiators of wandering. Citing Hussain
(1981b), Algase and Struble (1992) argue that wanderers ofien respond to environmental
cues. Wanderers’ difficulty in making sense of their environment, be it overly stimulating
or nonstimulating restrictive surroundings, and new or unpredictable situations are also
thought to induce wandering behavior. In addition, a poor or impoverished social
environment is suspected to play a role in the occurance of wandering. To support this
hypothesis, Algase and Struble cite Combleth’s (1977 ) study which showed that
wanderer’s have less competence than nonwanderers in the psychosocial areas of

fiiendliness, communication skills, and self-control.

20

Other environmental factors that have been suggested as causes for wandering
behavior inchrde relocating and becoming lost or seeking to learn a new environment
(Hiatt, 1980; Mace & Rabins, 1981; Monsour & Robb, 1982, Robb, 1985), and weather
or seasonal changes (Fopma-Loy, 1988). Environment can produce wandering by adding
to the confusion of residents. (Rader, 1987; Rader et a1, 1985) stated that the primary
cause of wandering is fear engendered by separation fiom familiar persons or environment.
A patient may feel lost when away from his or her familiar environment and become
disoriented in a new environment. Especially at night as disorientation increases,
wandering behavior will be manifested more frequently (Aronson, 1988; Burnside, 1980;
Snyder et a1, 1978).

Coons’ (1988) finding suggests that wandering may be an attempt to escape fiom
crowds or noise or from what may seem like a strange and unfiiendly environment.
Wandering behaviors are, at times, evidence of disorientation as with the person who
paces back and forth in a hallway, attempting to locate the bathroom or her own room
Wandering may result from increasing cognitive impairment or may be an expression of
agitation (Algase, 1992a; Heim, 1986; Mace 1981; Rader et al, 1985). Other causes of
wandering, identified by Butler and Barnett (1991), consist of sleep disorder, anxiety,
unmet physiological needs, and low self-esteem.

Several research studies (e. g. Coons, 1988; Mace, 1991; Monsour & Robb, 1982;
Snyder et al., 1978; Thomas, 1997) have shown that wandering behavior could be a
continuation of previous lifestyles or, coping mechanisms. Based on a study of a sample of

matched pairs of wanderers and nonwanderers in a nursing home, Snyder and associates

21

identified three psychosocial factors that may influence wandering: life-long patterns of
coping with stress (stress as abrupt change to new environment and new routine),
previous work roles (e. g. taking care of their children at home), and a search for security
associated with a need to search for familiar persons or places.

In a similar kind of study, Monsour and Robb (1982) found that wanderers
engaged in a higher level of social and leisure activities, experienced more stressful life
events, showed such motoric reactions as pacing and walking tmder stress, and
demonstrated more motoric behavioral styles earlier in their lives than nonwanderers.
Their study confirmed the suggestion made by Snyder et a1. (1978) that the tendency of
the elderly to wander is consistent with their lifelong psychosocial patters. In a more
practical way, the notion advanced by Snyder et a1 and Monsour & Robb, could be used
to predict wandering behavior and provide ideas for managing such behavior if and when
it occurs (Hoflinan & Platt, 1990).

In her seminal work on wandering, Coons (1988) has also stated that wandering
could result from excess energy and lifelong habits. Her finding suggests that, for some
individuals, wandering may release stress-induced tensions, while for others, the activity
may be a continuation of previously held job. Walking may represent a way of
recapturing familiar routines. Wandering could also be a substitute for social interaction
by the patient (Algase, 1992a; Monsour & Robb, 1982; Rader et al., 1985).

Boredom is also identified as a cause of wandering behavior (Coons, 1988; Mace
& Rabins, 1981; Snyder et al, 197 8). Boredom-home wandering can occur when there

are few or no opporttmities for resident involvement, no sensory stimulation, nothing to

22

help residents have a sense of belonging and being needed, and no meaningful use of time.

Overall, the reasons of wandering could be summed up as physiological,
psychosocial and environmental. Physiological factors consist of physical discomfort due
to pain, hunger, thirst, constipation, or need to urinate, need for warmth, desire to
exercise, sleep disorder, unmet physiological needs, or medication interactions, sedatives,
or tranquilizers; and underlying pathophysiology such as deteriorative diseases of the
central nervous system or cardiac decomp ensation, neurotic disorders, restlessness
associated with depression, and organic brain syndrome or the brain damage itself

Psychosocial factors constitute boredom, disorientation, searching for someone or
for something to handle, or reactions to crowds or noise, tension, anxiety, low self-esteem,
a substitute for social interaction, an indicator of worsening cognitive impairment, an
expression of agitation, the patient’s premorbid coping style, releasing tension or stress, a
means of alleviating loneliness and separation or fear engendered by separation from
familiar persons or environment.

Environmental factors that are thought to induce wandering behavior include the
physical, interpersonal, and internal environments. For instance, physical environment
could be overly stimulating or nonstimulating environments, restrictive surroundings, and
new or unpredictable situations, relocating, and weather or seasonal changes; internal
environment could be becoming lost or seeking to learn a new environment; and

interpersonal environment could be poor or impoverished social environment.

23
3- WW

An increasing awareness of the diversity of wandering behavior has led to the
formulation of wandering typologies and classifications (F opma-Loy, 1988; Thomas,
1995). In a situation where wandering appears to defy definition, classifying the
phenomenon according to types might help care providers to determine an intervention
appropriate to the particular kind of wandering at hand.

Using behavior mapping to reveal wandering patterns and space use, Snyder et al
(1978) delineated three types of wandering behavior. The first category is referred to as
the overtly goal-directed/ searching behavior. The wanderer’s behavior is characterized by
constantly searching for something that is often unattainable (mother, home, abstract
objects). The second type of wanderer, categorized as overtly goal-directed! industrious
behavior, is characterized by a seemingly inexhaustible drive to do things and engage in
activities. The third, designated as apparently nongoal-directed behavior, is related to
increased disorientation and short attention span The wanderer is aimlessly drawn to
various stimuli, momentarily attentive then diverted again.

Hoflinan & Platt (1990) built their typology based on Snyder’s classification, but
differentiated wandering in terms of energy level and presence or absence of a goal Their
approach resulted in four types wandering behavior: 1) high energy level/goal directed
(wants to go home), 2) high energy/no defined goal (activity itselfis the goal and
movement is soothing), 3) low energy level/goal directed (unexpectedly leaves), and 4)

low energy level/ no defined goal (a pacer).

24

Hussain (1985) identified four types of wandering patterns focusing on the
wanderers’ behaviors: a) the exit seekers, b) the akathesiacs, c) the self-stimulators, and
d)the modelers. Exit seekers are highly motivated and attempt to leave their physical
environment for any reason. Their focus seems to be centered on going out a door.
Akathesiacs are those individuals who exhibit restless, aimless, and pacing behavior, often
unable to sit still as a result of prolonged psychotropic medications use. Self-stimulators
are those whose focus is the desire to turn the door knob, showing inadequate sensory
stimulation. They do not necessarily care about actually leaving, but instead want the
physical stimulation of opening the door. The last type of wanderers are the modelers.
Their goal is to follow those around them. Ifthe people they are with leave, they too want
to leave.

Butler and Barnett (1991) constructed their classification based on the wanderer’s
behavior. They classified wandering as purposefirl, aimless, escapist and critical.
Purposeful wandering is manifested by walking with an apparent intent which could be
looking for something, exercising, walking to relieve boredom, or just to pass time. An
aimless wandering is wandering without knowing location or without any purpose. The
aimless wanderer is confirsed and disoriented. An escapist wandering is a deh’berate
action and a concerted attempt to get somewhere. The wanderer knows where he is or
where he is not, but slips away from the care facility undetected. The critical wanderer
strays from the nursing unit but does not understand the implications of his wandering.
This type of wandering is the most dangerous form of all and has been linked to out-of-

facility deaths.

25

In classifying wanderers, Thomas (1995) takes a different approach from most
researchers. He uses the quantitative variable of “time-in-motion” and distinguishes the
following two categories. The first includes continuous wanderers who are on the move
constantly (i. e., over 50% of one’s wakeful time) until they are literally too tired to stand
' or walk. These wanderers are associated with a greater degree of cognitive impairment
and inefficient travel behavior. The second category consists of sporadic wanderers who
are not constant movers but have an occasional desire to move about in an effort to satisfy
a particular need (i. e., going home). These sporadic wanderers are considered less
cognitively impaired than continuous wanderers and show a greater ability to verbally
commtmicate their needs to the care provider.

4. Ihanu'esandhmdels

The lack of adequate empirical data on wandering behavior has not allowed for the
development of theories of wandering. Based on the literature reviewed, there seemed to
exist only three works that attempt to build a theoretical model for understanding the
phenomenon of wandering. Weller (1987), for instance, has proposed a biochemical
hypothesis of wandering in which she suggested that the wandering of demented patients
might be similar to the dopamine hypothesis of schizophrenia which postulates an over
activity of the dopaminergic system It has been observed that amphetamines and
dopamine agonists cause restlessness and irrelevant (non-goal directed) behavior in
animals and humans. Weller suggests that the same biochemical mechanism, which
explains the wandering tendency of schizophrenic patients, could be responsible for the

wandering exhibited by older adults with dementia.

26

Other researchers have suggested the application of other theories of nursing to
wandering for the purpose of increasing our understanding of the phenomenon. Algase
(1992a), for instance, conceptualizes wandering in the context of rhythm theory. She
views the phenomenon as a naturally recurring processes resulting from oscillating
measurable variables which include the peak (maximum value), trough (minimum value),
and cycle (shortest repeating part of a rhythm). As a rhythm, she sees wandering as a
movement that changes over time, occurring in a nonlinear ultradian rhythm, with
locomoting and nonlocomoting phases. The rhythms could originate within the person
(endogenous) or could be triggered by environmental cues (exogenous). In suggesting the
applicability of the rhythm theory, Algase contends that it affords a view of wandering that
combines personal and environmental bases.

Thomas (1997 ) has also suggested conceptualizing wandering within the context
of continuity theory of aging. The theory assumes that a person evolves throughout
his/her life based on prior history and experience and employs past concepts to conceive
and structure his/her future. This continuity of experiences is an adaptive mechanism by
which individuals do what they had done well in the past in order to achieve feelings of
satisfaction. Thomas cites Arendt’s (1977) notion of habitual response (a demented
person’s involvement in ingrained, familiar behaviors in pursuit of a feeling of competence
and mastery) and Lawton’s concept of the continuity of personality types (the security-
autonomy continuum i.e., introverted people seek motivation from within themselves
while extroverts seek stimulation from the external world) and shows the near universality

of continuity theory’s applicability to old age behavior.

27

Viewed within the context of the broad spectrum of continuity theory, the
wanderer continues a lifelong conditioned response of looking to the external world for
security and comfort. In other words, “familiar relationships that were developed
externally , ie., social interactions, leisure activities and work experiences, are redeployed
in an attempt to establish comfort within a confirsing and irrational world created by the
illness (Thomas, 1997).

This review of the literature on wandering has shown that scholarly interest in the
phenomenon has increased Cover the last decade. Attempts have been made to define the
behavior, determine the personal and environmental factors that cause it and, to some
extent, propose theories that can help conceptualize the phenomenon. Definitions have
not resulted in accurate characterizations and have often evolved to subjective
classifications. The result has been a plethora of definitions and typologies that’have not
lead to a more informed intervention or continued research.

In preparing the protocol for intervention, I have not relied on any single definition
to conceptualize the phenomenon of wandering. In fact, I contend, following Thomas,
that the terms “aimless” or “purposeless” should be excluded from any definition of
wandering. Rather, we should strive to achieve a more comprehensive conceptualization
of the phenomenon that takes into account the impact of wandering on caregivers. It is
the experience of caregivers, not the apparently erratic behavior of wanderers, that
revealed the fact that wanderer’s move about in pursuit of certain goals. If we are to
better comprehend the phenomenoniof wandering and intervene in a more appropriate

manner, it is important to recognize that, viewed from the contextual wandering of the

28

wanderer, wandering has some purpose, at least most of the time. This is the first premise

on which the protocol is based.

CHAPTER III
THE PROTOCOL

1. Assessmmt

An initial interview with the potential resident and significant others or family
caregivers allows for the collection of comprehensive history, a vital component of
planning for the care of the individual who exhibits wandering behavior (Fopma-Loy,
1988; Thomas 1995 ). After obtaining pertinent subjective and objective data, the
Advance Practice Nurse should perform a complete physical assessment that incorporates
pertinent diagnostic tests to obtain a baseline data and consider other underlying medical
conditions.
1.1 Assessinglhraflersun

A comprehensive assessment should consist of present health problems, past health
history, health habits, family history, personal and social history. Present health status
constitutes a clear narrative of the initial onset of the problem, duration, alleviating and
aggravating factors, symptoms, treatment and impact on demented older adult’s life. Past
health history includes assessment of past medical and surgical history, i.e. operations,
hospitalizations, accidents and injuries. Heim (1986) suggests investigating history of
falls, fractures, dizziness, and orthostatic hypotension when obtaining data related to
wandering behavior. Interviews about health habits include tobacco use, alcohol use,
caffeine and medication or other drug use in addition to exercise patterns, sleep patterns,
elimination habits, and awareness and use of safety measures. Knowledge of family history

including chronic medical problems, cause of death, and psychosocial history enables the

29

30

APN identify some causes of current resident situation.

Personal and social history consist of wanderer’s previous lifestyle, interests,
hobbies, meaningful activities and roles, educational background, cultural influences,
patterns of socializing, patterns of stress and coping strategies, responses to touching and
preferences of the individual in the premorbid years. Understanding these factors and
identifying the social context of the cause[s] of wandering behavior, provides caregivers
with sufficient information to plan the behavior management program (Monsour & Robb,
1982; Snyder et al, 1978; Thomas 1995).

Physical assessment of the wanderer should include the wanderer’s ability to
ambulate, gait, facial expressions, speech, vision, hearing, and incontinence. The person’s
use of glasses, hearing aide, walker or cane, and other prosthetic devices should also be
noted (Heim, 1986). Besides, additional assessment should incorporate assessing the
wanderer’s skin, feet and legs for blisters, calluses, and edema as well as strength,
flexibility, pain and range of motion of extremities on admission and weekly (Algase &
Struble, 1992).

Nutritional assessment of wanderers should consist of weekly weight, calorie and
protein intake, diet history including food likes and dislikes, nutritional risk factors,
hydration status, and the use of vitamin supplements.

Functional assessment measures the person’s ability to perform self-care. It
includes assessment of impairment in communication, mobility, cognitive status and
psychosocial adjustment (Barkauskas, Stoltenberg-Allen, Baumann, & Darling-Fisher,

1994). Algase (19913) recommends assessing abstract thinking, judgment, language and

31

spatial skills to determine a medical rationale for cognitive impairment and to alleviate
reversible causes. In addition, assessing vital signs, monitoring patterns of elimination,
exercise, and food and fluid intake and evaluating medication regimen are crucial aspects.
Investigation of falls, analyses of contributing factors, and monitoring the frequency and
pattern of attempted exits are essential components of implementing safety precautions
(Algase & Struble, 1992). Moreover, assessing whether or not wanderers have trouble
finding their way allows caregivers to provide directional guides. Other components of
functional assessment include physical function (i. e. Activities of Daily Living and
Instrumental Activities of Daily Living), emotional status, social support, economic, legal
and the assessment of environment (S. King, personal communication, August 30, 1996).
1.2 Assassingrheinvirnnment

Environmental assessment should focus on safety and security of the wanderer and
modifications for physical and! or cognitive impairment. Fire safety, heating system, stairs,
floors, toilets and lighting are some of the general environmental factors that caregivers of
demented older adults need to consider.

Heim (1986) suggests that when caregivers assess the environment, they should
ask the following questions. Does the environment provide for safety, protection and
allow freedom? Does it allow the ability to explore? Are rest areas provided? Is the
wanderer’s room clearly labeled? Is the area well lit? Are there suficient night lights?
Are there door buzzers on exit doors to alert staff of a wanderer leaving unattended?

Other environmental factors that need to be taken into consideration during

assessment are room temperature, loud noises, and overstimulation such as too many

32

people and cluttered furniture, or under- stimulation such as lack of events, and unfamiliar
environment (Davidhizar & Cosgray, 1990; Nelson, 1995). Also note the effect of
weather and season on the fi'equency and pattern of wandering cycles (Algase & Struble,
1992)

Some of the social environmental factors that caregivers need to address are the
presence of planned group activities (e. g. handcrafis, cooking and gardening), exercise
program, opportunity for peer and staff interaction, and access to television or music
program for older adults with dementia. Care providers should also monitor the
wanderers’ whereabouts to avoid unintentional harm to self or others.

1.3 Mathew

A detailed history of the wandering behavior should be obtained from the
caregivers (Coltharp et al, 1996). Ongoing observation and assessment of residents who
wander aids in increasing understanding of the behavior i.e. clarification of the behavior
itself- timing, frequency and patterns and possible causes of the behavior (Algase, 1992a;
Burnside, 1980; Coltharp et al, 1996; Fopma-Loy, 1988;1-Iiatt, 1980). Identification of
patterns of behavior and documentation of antecedents and consequences of wandering
behavior is crucial for the management of the behavior (Hirst & Metcalf, 1989; Hussain,
1981b; 1982; Nelson, 1995). Moreover, identifying and dealing with the confirsed
residents’ agenda behavior helps the caregivers meet the wanderers’ felt social, emotional,

or physical needs (Rader et al, 1985; Rader, 1987).

33
2. IntenLention

Therapeutic interventions in wandering ideally should begin prior to admission to
the institutional setting. As the patient becomes increasingly dependent, due to cognitive
impairment, his or her quality of life is affected by the care received. A comprehensive
approach for management of wandering patient should include maximizing whatever
function the patient has left (Aronson, 1988), providing opportunities for safe ambulation,
increasing the patient’s quality of life (Aller & Coeling, 1995) and emphasizing on
decreased use of physical and/or chemical restraints (Goldsmith, Hoefl’er, & Rader, 1995 ).
As Coltharp et al, (1996) stated, “Manipulation of the environment is one of the best
means of dealing with wandering” (p. 7).

One of the interventions of managing wandering is providing a safe, controlled
environment to allow free ambulation without injury because wandering stimulates
circulation and oxygenation, promotes exercise, maintain strength and muscle tone, and
prevents contracture (Aronson, 1988; Coltharp et al, 1996; Fopma-Loy, 1988; Heim,
1986). Environment can be made safer by providing visual cues and a variety of
diversional activities and by having adequate glare-flee lighting along with minimizing
environmental hazards (Aronson, 1988; Coltharp et al, 1996; Thomas,l995). Other
environmental modifications include adequate lighting, color coding, picture symbols clear
signs on doors or wall aid increasing orientation of residents and prevent falls and
accidents (Burnside, 1980;1-Iiatt, 1980; Hussian 1981a). Combleth (1977) compared
wanderers and nonwanderers in both protected and unprotected wards and found that the

physical firnctioning of wanderers improved in the protected ward/ environment. Aronson

34

(1988) suggests that when caring for wanderers, caregivers must make sure the patient
wears eyeglasses or a hearing aid, if necessary, to receive environmental cues, wears
nonslippery footwear and the patient’s clothing is not too long to avoid tripping.
Furthermore, the environment should be decluttered and familiar items should be
maintained. The wanderer’s access to stairs and outdoor exposure in bad weather should
be limited, since he or she is prone to fall.

In order to design a therapeutic milieu, efforts should be made to create a calm
and relaxed atmosphere by eliminating disturbing sounds such as the clanging of carts,
loud chatter, voices on the intercom, television and radio. Maintaining a quiet dinning
area also enhances food intake and prevents weight loss [serving one food item at a time,
using high-calorie finger foods] (Thomas, 1995). A rich, stimulating, structured,
repetitive, predictable and accepting environment is critical It allows wandering older
adults to firnction at their maximum potential and enables the caregiver to provide a
quality life style by decreasing problem behaviors (Coons, 1988; Rader, 1987).

A setting that offers a variety of opportunities can provide companionship,
enhance peer interaction and reduce loneliness. One way of reducing wandering is
heightening social opportunity (Algase, 1992a; Coltharp et al, 1996; Monsour & Robb,
1982; Snyder et al, 197 8). “Lighthearted, engaging and stimulating activities can divert
residents from the things that cause them to become anxious and apprehensive; and their
self-esteem can be improved by helping them to continue to perform everyday tasks to the

fullest extent possible” (Coons, 1988, p.33).

35

Some of the efl‘ective interventions for evening restlessness afier meal and
wandering related to agitation are fi'equent monitoring of patient for physiological needs,
exercising, ball tossing, singing, and sharing in the preparation of snacks help residents to
lighten up their moods and divert their attention from problem areas (Coltharp et al,
1996; Coons, 1988). Decreasing stressful environmental features such as excess noise and
nighttime shadows will assist in reducing wandering related to tension (Burnside, 1980;
Fopma-Loy, 1988; Hiatt, 1980).

Coons (1988) recommends a variety of activities for night wanderers to help them
relax. These activities include stafl‘ walking with resident and gently distracting him/her
from walking alone. Distracting the wanderer’s attention could be achieved by having
snack together, baking cookies or muffins, watching TV, or chatting briefly and rubbing
resident’s back to relax and go to bed. Robb (1985), who studied the effects of exercise
on 20 wanderers, found that exercise program has significant influence in reducing
nighttime wandering. Physical exercise may include stretching and simple range of motion
exercises, walking and relaxation with deep breathing, and massage. The use of ‘Vvhite
noise” to reduce nocturnal wandering and facilitate sleep was found to be partially
successful by Young, Muir-Nash, & Ninos (1988). White noise was defined by these
authors as any low intensity, continuous, rhythmic, monotonous sound such as the whirl of
a fan, or the hum of an air conditioner.

For boredom staff should look for activities or chores that interest residents and
invite them to help staff in such areas as setting the table, pushing food cart, and wagiing

dishes. on, and structured activities to enhance enjoyment and relax wandering residents.

36

Fopma-Loy (1988) suggests that, in order to minimize the stress of relocation, and
subsequent anxiety related to wandering behavior, a tour of the prospective resident’s
area, introduction to stafl; and one or two further visits followed by a day-long visit
should be arranged. Staying with the patient and reassuring him or her in a new
environment during the first few days also lessens the anxiety (Aronson, 1988). Structured
recreational activities that influence quality of life and that are adapted for older people’s
energy and endurance level include dances, music, and sports singing, rhythmic
movements, and hand crafts (Aller & Coeling, 1995; Snyder et al, 1978).

In order to reduce continuous wandering, Thomas (1995) suggests that designing
an interesting environment through tactile and sensory cues could redirect wanderer’s
motion and avoid fatigue and falls. Instead of traditional group activities, environmental
cues such as sensory tables, tactile boards and “ activity barrels” attract the continuous
wanderer’s attention (Gaflirey, 1986). Sporadic wanderers benefit from organized group
activities and verbal interactions with other residents and staff The activities may
incorporate exercise, relaxation, music and reminiscence.

A variety of interventions are being tested in long-term care facilities to provide
safety and protection for those who wander. Camouflaging exit doors and concealing
doorknobs behind a cloth panel have been found to be successful visual barriers to reduce
the exit behavior of wandering residents (Dickinson, McLain-Kark, & Marshall-Baker,
1995; Namazi, et. al, 1989). Hussian & Brown (1987) investigated cognitively impaired
patients’ ambulation toward exit doors and their perceptions of two types of barrier

patterns. They found that placement of masking tape in front of the doors with horizontal

37

striping to be more effective than vertical striping in preventing exiting behaviors. In
unlocked units, chimes on doors (Snyder et al, 1978) that operate by pressing coded
sequence buttons, a firll-length mirror on the door, painting doors the same color as
surrounding walls serve as camouflage to prevent persons fi'om wandering from the area.
' A special identification bracelet with a phone number to call when a wanderer is lost and
an electronically coded tag installed in bracelet or necklace to trigger an alarm when the
wanderer opens doors are other ways of protecting the wandering older adults (Coons,
1988; Heim, 1986; Rader, 1987).

In the therapeutic setting, stafl' should be trained to accept and to recognize some
of the behaviors of the person with dementia as normal responses to the environment. It
becomes the responsibility of the staff to examine the events and conditions that might be
causing the impaired person to become agitated or angry and make essential adjustments
to reduce the stress or irritations that may be triggering by the behavior. The staff in
treatment settings are faced with the dificult challenge of making available to residents
safe and interesting areas to walk, at the same time, providing an exciting, stimulating, and
satisfying milieu that will reduce the person’s need to wander (Coons, 1988). Therefore,
Snyder et al (1978) suggest that stafl’ (nursing, activities, housekeeping, security, social
services, volunteers) should be informed that wandering may be a natural, coping
behavior; and they should also be educated to facilitate awareness and identification of the
meaning of wandering behavior and to formulate appropriate interventions to meet the
needs expressed through wandering (Fopma-Loy, 1988). Approaching the patient in a

gentle and quiet manner, using the patient’s name frequently, approaching the patient from

38

the front instead of the side, and reassuring the patient that his/her anxiety is understood
are some communication skills caregivers should utilize when dealing with demented older
adults (Hirst & Metcalf, 1989). Interacting in skillful, slow, concise, and concrete
sentences reduce the confirsion and allow demented residents to function at their best.
Non-verbal communication is also crucial since residents are sensitive to staff moods and
attitudes ( Burnside, 1980; Rader, 1987). Goldsmith .et. al (1995) contend that providing
suificient stafl‘ time, for interacting with residents and developing activity programs that
address residents’ needs for activa and rest, redirects wanderers’ energy.

It is also important that institutional policies identify procedures for handling a
wanderer who could present a danger to himselfl'herself or others, and at what point
physical or chemical restraints be employed (Coltharp et al, 1996). Organizational
procedures must also clearly delineate the approach stafl‘ is to take in the event the
“mislocated” resident is discovered (F opma-Loy, 1988). All policies should be sensitive

to the patient’s reasons for wandering by the patient (Hirst & Metcalf, 1989).

CHAPTER IV
IMPLICATIONS

1. Research

Wandering behavior is identified by caregivers as one of the perplexing problems in
caring for the elderly people with dementia. Current research indicates that the prevalence
of dementia and associated behaviors will rise in the future. In order to reduce the stress
of caring for persons with dementia and determine appropriate intervention, it is necessary
to conduct firrther research into the causes and management of wandering. Replication of
studies related to specific intervention and evaluation of its effectiveness could clarify the
existing ambiguities regarding the causes of wandering and its management. In sum,
more studies could mean providing caregivers choices of strategies in their efl‘ort to
manage wandering behavior.
2. Education

Since the prevalence of wandering is projected to continue, the challenge of caring
is likely to get even more difficult. It is, therefore, essential to make information available
and extend educational programs to care providers and families regarding assessments and
interventions for wandering behavior. Increasing the knowledge about the causes and
characteristics of wandering behavior and taking appropriate measures could prevent falls
and eliminate injuries while allowing wanderers to ambulate fieely. A rigorous
orientation and a continuous provision of educational information to stafl’ could equip
them with the knowledge and skill necessary to interact with older adults with dementia.

Educating stafi’ is a highly effective instrument of improving the quality of life for older

39

40

adults with dementia.
3. mm

Undoubtedly, more research on wandering will increase our understanding of the
phenomenon. In turn, an all-rounded and comprehensive knowledge will enable
caregivers to implement appropriate and effective intervention. Even though, older adults
with dementia have a drastically reduced competence due to cognitive impairment,
adaptive behavior could be achieved by manipulating the environment. A person's
competence could be heightened by involving him/her in social interaction. In other
wards, the competence of individuals with dementia who exhibit wandering behavior could
be enhanced by reducing the environmental press on the wanderer. The fact that, by
changing the environment, a person’s adaptive behavior can be increased should provide

badly needed encouragement and solace for families of older adults and other caregivers.

APPENDIX

41

Table 1 :MSmmfmmmdmmenfion

Assessment of Person

Intervention

 

1. A comprehensive assessment:

, a) Present health problems, past medical,
surgical, family history

b) Health habits: exercise patterns, sleep
patterns, elimination habits

c) Personal and social history: wanderer’s
previous lifestyle, interests, hobbies,
meaningful activities and roles, patters of
socialization, patterns of stress and coping
strategies, responses to touching and
preferences of the individual in the premorbid
years, emotional status

2. Physical assessment:

a) Ability to ambulate, gait, facial expressions,
speech, vision, hearing, and incontinence.

b) Use of glasses, hearing aide, walker or cane
and other prosthetic devices.

c) Assessing the wanderer’s skin, feet and legs
for blisters, calluses, and edema as well as
strength, flexibility, pain and range of motion
of extremities.

 

 

1. Increase quality of life

a) Determine association of health history
with present condition

b) Provide regular exercise, maintain bed time
routine, establish bowel and bladder program

c) Reinforce adaptive behavior, enhance social
interaction, encourage continuation of coping
strategies, touch gently when appropriate,
allow expression of feelings, involve resident
in activities, be non-judgmental

2. Intervention

a) Monitor exhaustion, provide resting areas,
approach fi'om fiont, speak clearly and slowly,
make eye contact.

b) Make sure the resident wears eyeglasses or
hearing aide, nonslippery footwear and use
appropriate prosthetic devices.

c) Monitor physical condition, treat
appropriately and refer when needed.

 

 

42

 

 

Table 1(Cont’d)

 

 

3. Nutritional assessment

a) Assess weight, calorie and protein intake,
diet history including food likes and dislikes,
nutritional risk factors, hydration status, and
the use of vitamin supplements

4. Functional assessment

a) Assess impairment in communication,
mobility, and way-finding

b) Assess cognitive status including abstract
thinking, judgment, language and spatial skills

c) Assess vital signs

d) Investigate falls and contributing factors,
monitor the fiequency and pattern of
attempted exits

 

3. Intervention

a) Maintain a quiet dinning area, serve one
food item at a time, use high-calorie finger
foods, monitor weekly weight and provide
nutritional supplement

4. Intervention

a) Use appropriate verbal and nonverbal
commrmication skills and respond to any
nonverbal communication, provide directional

guides

~ b) Alleviate reversible causes of cognitive

impairment, maintain remaining ability, give
simple and precise instruction

c) Determine tmderlying medical condition
(1) Avoid contributing factors for fall, distract

from exiting or walk together, equip with ID
bracelets

 

 

 

 

Table 2: ‘
Assessment of Environment Intervention
1.Environmental assessment should focus 1. Provide safe and controlled
on safety and security of the wanderer environment

a) Fire safety, heating system, stairs, floors,
toilets and lighting, provide for safety,
protection

b) Does the environment allow freedom &
the ability to explore? Are rest areas
provided? Is the wanderer’s room clearly

labeled?

c) Check for sufficient night lights
room temperature, loud noises

d) Note the effect of weather and season
on the fiequency and pattern of wandering

e)Are there door buzzers on exit doors?

f) Overstimulation such as too many people
and cluttered fumiture, over-activity

g) Under-stimulation such as lack of
events, and unfamiliar environment

 

 

a) Provide visual cues and a variety of
diversional activities and have adequate
glare-flee lighting, comfortable

temperature

b) Minimize environmental hazards-clear
pathways of any obstacle, fence in yard
for safe wandering, post picture symbols,
clear signs on wanderer’s door/ wall

c) Install night lights, use “white noise”
for night wandering

d) Limit access to stairs and outdoor
exposure in bad weather

e)Install alarm system, camouflage exit
doors

f) Control sensory input by decreasing
sounds such as the clanging of carts, loud
chatter, voices on the intercom, television
and radio, declutter the environment

g) Maintain familiar items, provide a tour
of the area and a rich, stimulating,
structured, consistent, predictable and
accepting environment

 

 

 

Assessment of Behavior

Intervention

 

 

1. A detailed history of the wandering
behavior from family

a) Onset, duration, timing, frequency and
possible causes of the behavior

b) Identify of patterns of behavior, i.e.
antecedents and consequences of
wandering behavior

c) Identify and deal with the confirsed
residents’ agenda behavior: way of social
interaction, agitation, physiological need,
boredom, disorientation, to relieve stress,
need for exercise, nocturnal wandering

 

1. Involve family in planning the care for
wanderer

a) Avoid aggravating factors of wandering
and encourage alleviating factors

b) Document intervention utilized and
evaluate effectiveness

0) Provide planned group activities (e. g.
supervised daily walks, handcrafts,
cooking, reading, dancing and gardening),
exercise and music program, access to
television, companionship, relaxation,
reminiscence, encourage peer and staff
interaction, heighten social opportunity,
use distraction and positive reinforcement,
ensure availability of food, fluid, and
bathroom, limit day naps, maintain bed
time routine

 

 

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