Wandering and Its Concept in Health Care Wandering is a significant concern in healthcare, particularly among patients with dementia or cognitive impairments. This behavior can pose safety risks and create challenges for caregivers and healthcare providers. Understanding the dimensions, etiology, characteristics, prevention strategies, and the role of caregivers in managing wandering is crucial for improving patient care and outcomes.
What is Wandering?
Wandering is a complex and multifaceted behavior often observed in patients with cognitive impairments, especially those with dementia. The term “wandering” has been difficult to define precisely, and there was little research or literature on the topic before the 1980s. In 1980, Irene expressed concern about the lack of a suitable definition and limited nursing research on wandering, citing only five articles published between 1941 and 1978. Since then, interest in the topic has grown significantly. For example, a CINAHL search for “dementia wandering” articles in 2003 alone returned 14,629 citations, covering subtopics like risk management, staff development, and observational tools.
Definitions of wandering have varied over time. However, most early definitions in the 1970s and 1980s included elements of aimless locomotion and cognitive impairment. For instance, Snyder et al. (1978) defined wandering as “a tendency to move about, either in a seemingly aimless or disoriented fashion, or in pursuit of an indefinable or unobtainable goal.” This definition captures the unpredictable and often purposeless nature of the behavior, which makes it challenging to manage in healthcare settings.
Dimensions of Wandering
The increased study of wandering has helped to clarify its complexity. Algase (1999b), in a review of 108 studies on wandering, identified four dimensions that characterize wandering in dementia patients:
- Frequency: Wandering behaviors occur often and are repetitive.
- Aimlessness: The movement appears aimless, lapping, or random.
- Environmental Limits: Wandering may exceed environmental boundaries, potentially leading the individual into hazardous areas.
- Spatial Disorientation: There is evidence of spatial disorientation or navigational deficits.
Some studies distinguish between pacing and wandering, while others consider them overlapping phenomena. Regardless, the core characteristics involve repeated, disoriented movements that can compromise the safety and well-being of both the individual and those around them.
Etiology of Wandering
The etiology of wandering remains a subject of debate and research. Several explanations have been proposed, ranging from physical discomfort and unmet needs to neurological dysfunction. Wandering has been positively correlated with cognitive impairment, spatial disorientation, stress, unmet needs, reduced cognitive planning abilities, and disturbances in circadian rhythms.
Wandering may be seen as either a meaningless behavior or an attempt by the patient to fulfill unmet needs that they may be unable to communicate. Cohen-Mansfield and Werner (1998) suggested that wandering might be adaptive and appropriate for the cognitively impaired elder, potentially offering physical and psychosocial benefits. However, the negative consequences of wandering, such as injuries or getting lost, have received more attention in the literature.
Algase (1999a) proposed the “Need-Driven Behavior Model” to explain wandering. According to this model, wandering results from the interaction of background factors (such as general health and neurocognitive status) and proximal factors (dynamic individual or environmental variables like physiological needs). This model highlights the complex interplay between fixed characteristics and immediate environmental influences in causing wandering behaviors.
Characteristics of Wandering
Studies examining the personal characteristics of wanderers have produced varied results. Algase’s (1999b) review found no consistent relationships between wandering and factors such as gender, education, or race. However, certain factors have been positively correlated with wandering, including general health, appetite, fewer medications, fewer medical diagnoses, and other agitated behaviors. Conversely, factors like pain and eating impairments have been negatively associated with wandering.
Research on the effects of environmental conditions on wandering has shown that wandering may increase in environments with low noise levels, normal lighting, and comfortable temperatures (Cohen-Mansfield et al., 1991; Cohen-Mansfield & Werner, 1995). The impact of premorbid personality, activity level, and stress-coping strategies on wandering remains inconclusive, with studies yielding conflicting results.
How to Prevent Wandering
During the 1980s, research on wandering primarily focused on understanding the characteristics and behaviors of wanderers and identifying methods to prevent wandering. At that time, physical and chemical restraints were commonly used to control disruptive behaviors. However, the passage of the Omnibus Budget Reconciliation Act (OBRA) in 1987, which mandated the use of the least restrictive interventions for behavioral problems, shifted the focus from preventing wandering to making it safer.
Intervention strategies have since expanded to include environmental adaptations, caregiver approaches, and pharmacologic management. Some of the simplest environmental adaptations involve creating visual illusions. For example, placing strips of dark tape across the floor near exit points can create the illusion of a gap that patients may be reluctant to cross. Covering doors with shower curtains or disguising doorknobs with cloth can also prevent patients from recognizing and attempting to open exits. Limited research on visual illusions suggests they can be effective with some patients but not others, possibly due to differences in cognitive skills related to the stages of dementia (Price, Hermans, & Grimley, 2003).
Role of Caregivers and Wandering
Caregivers play a crucial role in managing wandering behaviors. Increased tolerance for wandering, environmental modifications, and caregiver education have reduced the need for restrictive interventions, making drug therapy a last resort in most cases. When wandering is accompanied by agitation, neuroleptics may be used. However, neuroleptics have adverse effects, such as orthostatic hypotension, which can pose additional risks. Atypical antipsychotics like risperidone and olanzapine are often preferred for older adults due to their lower side effect profiles (American Geriatric Society Clinical Practice Committee, 2003). A comparative study found slightly fewer side effects with risperidone than with olanzapine among a sample of 730 adults with dementia (Martin et al., 2003).
Cholinesterase inhibitors have been found to improve cognitive function, particularly in the early stages of dementia, and may also reduce behavioral disturbances (Daly, Falk, & Brown, 2001). However, medication should be considered only when non-pharmacological interventions are insufficient, and the benefits outweigh the risks.
Conclusion of Wandering
Research on wandering has made significant strides in identifying the variables and characteristics associated with this behavior. The emphasis has shifted from preventing wandering to maintaining safety without undue restrictions. Continued efforts are needed to understand and meet the underlying needs of individuals who wander. Future research might focus on:
- Assessment and Management in Various Settings: Including acute care, transitional settings, assisted living facilities, and private residences.
- Strategies for Locating Lost Wanderers: Developing and testing effective methods for quickly and safely finding individuals who wander away from safe environments.
Overall, the approach to managing wandering has evolved to emphasize dignity, safety, and respect for individuals with cognitive impairments. Caregivers and healthcare professionals are increasingly encouraged to use innovative, patient-centered strategies that accommodate the unique needs and behaviors of those in their care. By understanding the complexities of wandering, healthcare providers can develop better interventions to ensure safety while preserving the quality of life for individuals with cognitive impairments.