Wandering and Its Concept in Health Care

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.