Concept of Wandering in Health Care
What is Wandering,Dimensions of Wandering ,Etiology of Wandering,Characteristics of Wandering,How to Prevent Wandering,Role of Care Givers and Wandering,Conclusion of Wandering
What is Wandering
In 1980, Irene expressed dismay at the lack of a suitable
definition of wandering as well as the lack of nursing articles or research on
the topic. She cited only five articles on wandering published between 1941 and
1978.
Clearly, many nurses have studied this behavior since that time. A CINAHL
search for articles published in English under “dementia wandering” located
14,629 citations for 2003 alone. Among the subtopics identified were risk
management, staff development, and observational tools.
As might be expected with such a multifaceted topic, definitions
are numerous. Aimless locomotion and cognitive impairment were two elements
common to most definitions in the 1970s and 1980s.
For example, an early
definition of wandering was “a tendency to move about, either in a seemingly
aimless or disoriented fashion, or in pursuit of an indefinable or unobtainable
goal” (Snyder, LH, Rupprecht , Pyrek , Brekhus , &Moss , 1978 , p.272).
Dimensions of Wandering
The increased study of wandering has illuminated its complexity.
Algase’s (1999b) review of 108 wandering studies revealed four dimensions that
characterize wandering in dementia patients. To be classified as wandering, the
ambulating had to:
(1) occur often
(2) seem to be aimless, lapping, or random
(3) exceed environmental limits, possibly into hazardous territory
(4)
reflect spatial disorientation or navigational deficits. Some studies
differentiate pacing from wandering whereas others treat them as the same or
overlapping phenomenon ( Algase ).
Etiology of Wandering
The etiology of wandering remains a topic of
debate. Proposed explanations range from physical discomfort and unmet needs to
right parietal lobe dysfunction.
Positive correlations have been found between
wandering and cognitive impairment, spatial disorientation, stress, unmet needs,
reduced higher order cognitive and planning abilities, and circadian rhythm
disturbances.
Wandering can be viewed as meaningless or as an effort to fulfill
felt needs that the patient may or may not be able to communicate.
Cohen Mansfield and Werner (1998) asserted that wandering could be both
adaptive and appropriate for the cognitively impaired elder.
Wandering probably
has physical and psychosocial benefits; however, positive outcomes have
received less attention than negative consequences.
Algase (1999a) used the
need driven behavior model to explain wandering as the result of the interplay
of background (relatively fixed variable such as general health status and
neurocognitive status) and proximal factors (dynamic individual or
environmental variables such as physiological needs).
Characteristics of Wandering
Studies of personal characteristics of wanderers have produced
variable results. Algase’s (1999b) review reported no consistent relationships
between wandering and gender, education, or race.
Factors that positively
correlated with wandering included general health, appetite, fewer medications
and medical diagnoses, and other “agitated” behaviors. Factors that correlated
negatively with wandering were pain and eating impairment.
Studies of the
impact of premorbid personality, activity level, and stress coping strategies
on wandering have yielded conflicting results.
A limited number of studies on
the effects of environmental conditions on wandering have found that wandering
increased in the presence of a low noise level, and with normal lighting and
temperature (Cohen Mansfield, Werner, Marx, & Freedman, 1991;
Cohen-Mansfield & Werner, 1995).
How to Prevent Wandering
During the 1980s wandering research primarily addressed the
characteristics and behaviors of wanderers and measures to prevent wandering. Physical
and chemical restraints commonly were used to control all types of disturbing
behaviors.
The passage of the Omnibus Budget Reconciliation Act (OBRA) in 1987
that mandated the use of least restrictive interventions for behavioral
problems shifted emphasis from preventing wandering to making it safer.
The
focus of intervention studies has broadened to include environmental
adaptations and caregiver approaches, as well as pharmacologic management.
The simplest suggested adaptations create visual illusions. For
example, strips of dark tape placed across the floor in front of exit points
may appear as gaps that patients are reluctant to cross. A shower curtain over
a door and cloths over doorknobs may disguise the exit.
Limited research on
visual illusions shows that they work with some, but not all, patients (Price,
Hermans, & Grimley, 2003), Differences in patient responses to specific
adaptations could be attributed to differences in cognitive skills that
characterize each stage: of dementia among study subjects.
Role of Care Givers and Wandering
Increased tolerance of wandering, measures to create safer
wandering environments, and caregiver education have made drug therapy a last
resort in most cases. When wandering is accompanied by agitation, neuroleptics
are sometimes used.
A major adverse effect with neuroleptics is orthostatic
hypotension. The atypical antipsychotics such as risperidone and olanzapine are
preferred for older adults because they have fewer side effects than most older
neuroleptics (American Geriatric Society Clinical Practice Committee, 2003).
One comparative study found slightly fewer side effects with risperidone than
with olanzapine in a sample of 730 adults with dementia (Martin, Slyk , Deymann
, & Cornacchione , 2003).
Cholinesterase inhibitors generally have been
found to improve function, especially in the early stage of dementia, and may
also reduce behavioral disturbances (Daly, Falk, & Brown, 2001).
Conclusion of Wandering
In summary, research on wandering continues to elucidate variables
and characteristics associated with wandering. However, emphasis on
interventions to maintain safety without undue restrictions is receiving
increased attention.
Continued efforts to identify and meet underlying needs
are warranted. Other suggested topics for future studies might focus on:
(a)
assessment and management in various settings including acute care,
transitional settings, assisted living, and private residences.
(b)
strategies for locating lost wanderers.