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Risk assessment of wandering behavior in mild dementia
Abstract
This prospective longitudinal study aims to determine the risk factors of wandering-related adverse consequences in community-dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior.
We recruited 143 dyads of persons with mild dementia and their caregivers from a veteran's hospital and memory clinic in Florida. Wandering-related adverse consequences were measured using the Revised Algase Wandering Scale - Community Version. Variables such as personality (Big Five Inventory), behavioral response to stress, gait, and balance (Tinetti Gait and Balance), wayfinding ability (Wayfinding Effectiveness Scale), and neurocognitive abilities (attention, cognition, memory, language/verbal skills, and executive functioning) were also measured. Bivariate and logistic regression analyses were performed to assess the predictors of these wandering-related adverse consequences.
A total of 49% of the study participants had falls, fractures, and injuries due to wandering behavior, and 43.7% demonstrated eloping behaviors. Persistent walking (OR = 2.6) and poor gait (OR = 0.9) were significant predictors of negative outcomes of wandering, while persistent walking (OR = 13.2) and passivity (OR = 2.55) predicted eloping behavior. However, there were no correlations between wandering-related adverse consequences and participants' characteristics (age, gender, race, ethnicity, and education), health status (Charlson comorbidity index), or neurocognitive abilities.
Our results highlight the importance of identifying at-risk individuals so that effective interventions can be developed to reduce or prevent the adverse consequences of wandering. Copyright © 2015 John Wiley & Sons, Ltd.
Copyright © 2015 John Wiley & Sons, Ltd.
... Approximately 60% of dementia patients may become disoriented and go missing. Furthermore, research found that roughly half of autistic children attempted to defy parental control at least once before eventually going missing while walking and suffering similar consequences for themselves and their caretakers [1,2]. But even healthy people may get lost as well, in different scenarios. ...
... Wandering and getting lost can happen during the mild, moderate, or serious stages of AD and can be risky (leading to falls and injuries, institutionalization, and death) as well as stressful for families and caregivers [13,14]. Having dementia over a longer period of time, the severity of dementia (though wandering can occur at any stage), the prevalence of a sleep disorder, deterioration in day-to-day functioning, and behavioral disturbances such as anxiety and depression are all associated with wandering [2]. Having this said, we can conclude that is of paramount importance to monitor the people suffering from such diseases, in order to find them when they get lost, as it can be dangerous for them and very stressful for their caretakers. ...
... Drowning was shown to be one of the major causes of death among people with ASD, with roaming being the most common behavior that led in drowning deaths. A convenience study of 1218 children with ASD aged 4 to 17 years revealed that 24% had a history of elopement and were at risk of drowning [2]. ...
Nowadays, IoT has been introduced in different aspects of our lives giving solutions to several problems, one of which is the Search and Rescue (SAR) operations. People that suffer from dementia or people with disease in the autism spectrum tend to elope from their caretaker’s attention, a fact that can lead to serious problems. Thus, a system that takes into consideration of the multiple requirements is of paramount importance. In this paper, a LoRa based SAR system is proposed in order to help in the localization of people with high risk of going missing. In contrast to most of the related systems, in this research article a different approach has been followed. Instead of focusing on the technology, in our approach a human-centered design has been used, leveraging the knowledge of Human-Computer Interaction (HCI) domain. Thus, the technologies used, are an outcome of the initial study. Finally, the system is evaluated using heuristic evaluation and questionnaires.
... A previous study found that 15 to 60% of all PwD and up to 25% of community-dwelling PwD exhibited wandering behaviour [9]. Although wandering within a safe environment improves appetite and provides opportunities for exercise and social contact [13], PwD who wander away from home or facilities can experience adverse outcomes such as sleep disturbance, injuries from falls and traffic accidents, getting lost, and even death [8,14]. In addition, PwD may intrude into other people's personal space with ensuing altercations, loss of privacy, and risk of physical harm, all of which impact quality of life [11]. ...
... Whereas wandering within safe limits may have some benefits, such as providing physical exercise and social contact and improving appetite [9,13], the adverse consequences of wandering may outweigh its benefits, especially when PwD wander away from home or facilities. These adverse consequences include experiencing physical injuries from falls or traffic accidents, getting lost, and death [8,9,13,46,47]. ...
... Whereas wandering within safe limits may have some benefits, such as providing physical exercise and social contact and improving appetite [9,13], the adverse consequences of wandering may outweigh its benefits, especially when PwD wander away from home or facilities. These adverse consequences include experiencing physical injuries from falls or traffic accidents, getting lost, and death [8,9,13,46,47]. Effective interventions to keep PwD safe should be taken to prevent these adverse outcomes, but physical restraints are considered unacceptable interventions to prevent wandering due to ethical issues and negative outcomes [23,49]. As highly unpredictable events, adverse outcomes such as becoming lost can happen to all PwD, even if they have never wandered previously, and the most common situation is when PwD are unattended in their residences [26]. ...
Background:
Wandering among people with dementia (PwD) is associated with a high risk of injury and death. The stigma of dementia prevents Chinese dementia families from seeking information and support earlier, which increases the demand for long-term care facilities. Despite universal recognition of the importance of care facilities, healthcare providers in care facilities still lack the relevant nursing knowledge and skills, including non-pharmacological interventions (NPIs) that have been proven to be effective in preventing wandering. Systematic and culturally appropriate NPI programmes for healthcare providers to manage wandering among PwD in long-term care facilities are still lacking. We aimed to develop an evidence-based and culturally appropriate NPI programme for wandering in PwD to guide healthcare providers in nursing homes to prevent wandering and its adverse outcomes.
Methods:
The NPI programme was developed according to the framework of the Belgian Centre for Evidence-Based Medicine (CEBAM). We, (1) performed a systematic literature search to summarize the available evidence, (2) developed evidence-based recommendations for the NPI programme based on the existing evidence, and (3) carried out a validation process to revise the content of the recommendations and to determine the grades of recommendations, including group meetings with experts and a survey for end-users.
Results:
Based on 22 publications and validation from 7 experts and 76 end users, we developed 21 recommendations covering 4 domains: (1) caregiver education, (2) preventing excessive wandering, (3) promoting safe walking, and (4) preventing people with dementia from going missing. We created almost all recommendations of the four domains with accompanying levels of evidence and grades of recommendations.
Conclusions:
By combining the evidence with expert and end-user opinions, a comprehensive NPI programme was developed to support institutional healthcare providers to prevent wandering and its adverse outcomes. The benefits of this programme are currently being tested.
... However, Barnard-Brak et al. (2018) provide a more detailed definition of elopement stating that this is "the act of an individual wandering off when that individual should be supervised as a result of disability or declining function" and suggest that this is actually an outcome of wandering, rather than a definition of the act itself (Dewing 2005). Elopement is particularly associated with adverse outcomes (Ali et al. 2016), and therefore should be examined alongside wandering behaviour. ...
... Several possible explanations for wandering have been proposed including cognitive decline, agitation and unmet needs (Dewing 2005). However, an agreed explanation remains elusive (Ali et al. 2016). There appears to be a complex interplay of factors which result in people with dementia exiting their home and becoming lost. ...
... Additionally, a survey of occupational therapists found that elopement was their main safety concern related to clients with dementia (Collins 2018 (Ali et al. 2016;Robinson et al. 2006). ...
Introduction: There is an acknowledged gap between the potential and achieved benefit of assistive technology in the care of people with dementia. In order to make better use of this resource, this research aimed to investigate the heterogeneity of population characteristics of people with dementia living at home who have safety and wandering risks and how this is related to assistive technology recommended and installed to meet their needs. Methods: This research consisted of two studies; a systematic review and secondary data analysis. Initially, published quantitative data describing the needs of people with dementia living at home was subjected to meta-analysis in order to explore the prevalence of needs reported by people with dementia and their caregivers and associated heterogeneity. Following univariate analyses, ordinal models were developed using secondary data which described the needs of people with dementia, and their level of wandering and safety risk, to explore the relationship between needs and risks in this population. The possibility of grouping participants according to data describing multiple needs, predisposing characteristics and enabling resources was investigated using cluster analysis. Associations between these groups and recommended and installed Assistive Technology were investigated. Results: Prevalence estimates for twenty-four needs reported by people with dementia and their caregivers were provided for the first time. Heterogeneity was associated with the person reporting the needs and age of onset. Level of need was often not recorded in the dataset indicating limited assessment. Wandering risks were shown to be associated with posture and mobility, routine and cognition needs, whilst safety risks were associated with posture and mobility, and problem-solving needs. Partitioning Around Medoids cluster analysis demonstrated that robust clustering solutions could be created from data describing participants. Clustering solutions were then validated through exploring their association with recommended and installed Assistive Technology data and the published literature. Caregiver support and living situation impact Assistive Technology installed for people with dementia. Discussion: This research advances understanding of the impact that needs, safety and wandering risks, caregiver support and the living situation of the person with dementia have on variation in the assistive technology interventions recommended and installed for people with dementia. Results have implications for needs assessment and for the tailoring of Assistive Technology for this population. Keywords: dementia, assistive technology, community dwelling, meta-analysis, cluster analysis, ordinal regression, wandering, safety, risk, needs.
... For older adults with cognitive impairment living in longterm care facilities, the risk factors also include the type and severity of the dementia, behavioral symptoms such as wandering, psychological factors including agitation and depression, psychotropic medication use, restraints, and disease-specific changes that alter gait and balance. [11][12][13][14][15][16][17][18][19] With regard to the use of psychotropics among nursing home residents, a Canadian study found that higher dosages in some drugs present greater risk than others (eg, quetiapine and risperidone increasing the risk vs olanzapine which was not associated with falls). 20 The use of restraints increased the risk of falls if the restraints were placed across the individual's trunk; conversely, full bed rails were associated with fewer falls. ...
... For example, although the Steinberg 23 showed that wandering was protective for falls, a more recent study suggested that wandering increased the risk of falls. 13 Similar contradictions are noted with regard to the relationship between psychological factors such as anxiety and depression and falls. An earlier study by Brody et al 24 noted that there was no relationship between agitation and depression and falls, while a recent study by Whitney et al 15 noted a significant association. ...
... This does not support prior findings, suggesting that wandering is protective against falls. 23 It is possible, however, that the protective value of wandering among community-dwelling older adults with dementia may be reversed in situations in which gait is unsteady, the resident has poor attention and orientation, or the resident is anxious or agitated, 13,15 which is often more common among nursing home residents with moderate to severe cognitive impairment. ...
Introduction:
The purpose of this study was to test differences in psychotropic medication, function, physical activity, agitation, resistiveness to care, comorbidities, and depression among moderate to severely cognitively impaired nursing home residents who were fallers versus nonfallers.
Methods:
This was a secondary data analysis using baseline data from a randomized controlled trial testing the Function and Behavior Focused Care intervention across 12 nursing homes. The sample included 336 older adults, the majority of whom were female and white.
Results:
There was a significant difference in the total number of comorbidities, agitation, the total number of psychotropic medications, depressive symptoms, and physical activity between those who fell and those who did not fall (Pillai-Bartlett trace = 4.91; P < .001).
Discussion:
Findings support prior work except with regard to medication use, cognition, and function. Due to inconsistent findings, additional research is recommended particularly with regard to the use of specific drug groups and medications.
... The present study highlighted that persistent walking, elopement behavior, and repetitive walking were common among the PWD. [28,29] Persons with wandering behavior in this study sample have experienced agitation and aggression, aberrant motor behavior, irritability, sleep and nighttime behavior, change in appetite, and changes in eating habits. [11] Two studies have reported similar to current findings; wandering is high during moderate dementia. ...
... [33] This study found that wandering severity was a predictor of caregiver burden. [28] Limitations of the study ...
Introduction
In dementia, wandering is a challenging and distressing behavioral problem. The caregiver burden will differ between the group of persons with dementia with or without wandering behavior. Understanding the difference in caregiver burden between these two groups will help mental health professionals to have a specific care plan for those who have wandering behavior.
Methodology
This is descriptive research which attempts to understand the wandering behavior and its association with the caregiver burden. The total sample size was 151. Samples were selected from a tertiary care center. The Revised Algase Wandering Scale Community Version and the Zarit Burden Interview were used to measure wandering and caregiver burden.
Results
There was a significant correlation between wandering behavior and caregiver burden ( r = 0.582, P = 0.001). Similarly, there was a significant correlation between wandering behavior and the severity of dementia ( r = 0.390, P = 0.005). The unique finding of the study was that wandering behavior predicted 30% of caregiver burden.
Conclusion
Findings indicate the need to address the wandering behavior to control the caregiver burden.
... Third, due to some of the participants' request for themselves and the persons with dementia they were observing, to remain anonymized for the data collection of this study, baseline data such as personality, wandering characteristics, cognitive impairment using assessment tool such as MoCA, gait and balance [42] could not be collected. This information, in addition to those reported in Ali et al. [43] could have been used to help explain the observations reported in this study. ...
... Due to the limitations of this study, a follow-up study will involve the participation of additional dyads, the observation period will be extended to 6 months, and the quantitative tools suggested in Ali et al., [43] will be used to further validate the identified antecedent behaviors recorded by caregivers. The behaviors identified from this study was used to design education tools to further assist in the awareness of critical wandering behaviors and the implementation of proactive interventions. ...
points • The purpose of this study was to identify antecedent behaviors to critical wandering attempts among persons with dementia in or outside of a facility care. • Family and paid caregivers were asked to record the type and frequency of antecedent behaviors they observed in persons with dementia who were about to critically wander. • A total of 63 critical wandering attempts were observed across 30 dyads, with a range of 1-3 attempts to leave in those who received care from family caregivers, and a range of 1-6 attempts among those living in a care facility. • Six types of antecedent behaviors indicative of critical wandering were observed in persons living with dementia. • There were unique combinations of antecedent behaviors, and there were behaviors that were observed to only occur in facility versus community living. • Common wander management strategies used by family and paid caregivers were identified. • The highlighted antecedent behaviors from this study can be used in the education of wander management strategy adoption among family and paid caregivers of persons with dementia at risk of getting lost. • Information collected from this study was used to develop a series of guidelines to assist persons with dementia and their caregivers choose appropriate wander management strategies. Aim: To understand antecedent behaviors to critical wandering among persons living with dementia in or outside of a facility. Materials & methods: Caregivers were asked to write down the type and number of antecedent behaviors they observed in persons with dementia that were about to critically wander for 2-4 weeks. Observations were made through a developed questionnaire. Results: Six antecedent behaviors were observed: stating intent to leave, door lingering/tampering, preparing to go outside, packing up belongings, calling to be picked up and draw to outside stimuli. Conclusion: Information from this study can be used in the education of wander-management strategy adoption among caregivers of persons with dementia at risk of getting lost.
... Third, due to some of the participants' request for themselves and the persons with dementia they were observing, to remain anonymized for the data collection of this study, baseline data such as personality, wandering characteristics, cognitive impairment using assessment tool such as MoCA, gait and balance [42] could not be collected. This information, in addition to those reported in Ali et al. [43] could have been used to help explain the observations reported in this study. ...
... Due to the limitations of this study, a follow-up study will involve the participation of additional dyads, the observation period will be extended to 6 months, and the quantitative tools suggested in Ali et al., [43] will be used to further validate the identified antecedent behaviors recorded by caregivers. The behaviors identified from this study was used to design education tools to further assist in the awareness of critical wandering behaviors and the implementation of proactive interventions. ...
Aim: To understand antecedent behaviors to critical wandering among persons living with dementia in or outside of a facility. Materials & methods: Caregivers were asked to write down the type and number of antecedent behaviors they observed in persons with dementia that were about to critically wander for 2–4 weeks. Observations were made through a developed questionnaire. Results: Six antecedent behaviors were observed: stating intent to leave, door lingering/tampering, preparing to go outside, packing up belongings, calling to be picked up and draw to outside stimuli. Conclusion: Information from this study can be used in the education of wander-management strategy adoption among caregivers of persons with dementia at risk of getting lost.
... Wandering and getting lost can occur during the mild, moderate or severe stages of AD and is potentially dangerous (leading to falls and fractures, institutionalization and death) and may cause significant stress for families and caregivers [1,4] . Characteristics and behaviors associated with wandering include having dementia for a longer duration, severity of dementia (though wandering can occur at any stage), presence of a sleep disorder, impairment in day-to-day functioning, and behavioral disturbances such as anxiety and depression [5] . Recent research on the management of wandering behavior focuses on promoting safe walking which often includes electronic tagging of a person who wanders. ...
... Recent research on the management of wandering behavior focuses on promoting safe walking which often includes electronic tagging of a person who wanders. While GPS tracking of people with AD is often seen as unethical because it decreases a person's autonomy and the individual's right to privacy, there are no alternatives except of constant supervision [5,6] . ...
Significant number of people with dementia are at risk of wandering and getting lost. These individuals may get hurt, cause distress to families and caregivers, and require costly search parties. This study explores the possibility of using machine learning methods applied to data from GPS trackers to create individualized models that describe patterns of movement. These patterns can be used to predict typical locations of individuals with dementia, and to detect movements that do not follow these patterns and may correspond to wandering. Data from a sample of 337 GPS trackers were used. After pre-processing the data are used for iterative clustering, followed by classification learning. The number of clusters ranged between one (devices that always stayed “home”) and nine for devices with maximum mobility. The average number of clusters was 2.62. Models for predicting location achieved varying accuracy, depending on regularity of wearer's schedule. The achieved average Area under ROC (AUC) is 0.778, with accuracy 0.631, precision 0.662, and recall 0.604. Unusual locations that potentially correspond to wandering incidents were identified by applying a secondary classification learning after filtering out data corresponding to normal movement.
... Those efforts are appropriated in regard to frame dementia-related wandering as a challenging behavior. It is mostly deemed as problematic by professional and family caregivers, who argue that people living with dementia who wander have higher risks of accidents, falls, fractures, and injuries (Ali et al. 2015). Moreover, media (De Mallevo 2011;Lagain 2017) as well as scientific narratives provide spectacular and disturbing accounts of elderly people with dementia who wander got lost and die, despite that according to dementia-related missing persons' police reports, this is a rare event (Bantry White 2012; Bantry White and Montgomery 2014). ...
... Interventions such as walking exercises, and nonpharmacological interventions such as music or art therapy, might reduce the need for wandering and are introduced to replace wandering behavior. Although understanding of the effectiveness of these interventions needs to be improved (Ali et al. 2015), researchers have shown that these interventions are important to people with dementia and their family carers when selecting residential care (Innes, Kelly, and Dincarslan 2011). ...
The increase of dementia makes cognitive disorder a global challenge. Even if wandering is not a symptom of dementia in general, professionals and scientists dominate the definition of wandering as an aimless movement of people with cognitive impairment, mainly dementia. In consequence, professional types of wandering management were elaborated trying to avoid or replace it. However, this can cause negative effects. The article analyses an apparently common informal type of wandering management. It consists of slipping an address paper in the wallet of the ill person. The analysis reveals that this practice is normatively structured by a gift of trust.
... Findings from the current analysis support and expand upon a previous study published with data from this study cohort. 27 Ali and colleagues 27 examined predictors associated with any caregiver endorsement of items contained within the negative outcomes and eloping behavior subscales of the RAWS-CV at baseline, utilizing separate logistic regression models. Their analyses indicated associations between the RAWS-CV persistent walking subscale and both dichotomous outcomes as well as associations between the Passivity subscales of the BRSS and any elopement behavior, and the Total Gait and Balance subscale of the Tinetti Gait and Balance scale and any negative outcomes at baseline. ...
... Their analyses indicated associations between the RAWS-CV persistent walking subscale and both dichotomous outcomes as well as associations between the Passivity subscales of the BRSS and any elopement behavior, and the Total Gait and Balance subscale of the Tinetti Gait and Balance scale and any negative outcomes at baseline. Our study builds upon the previous results of Ali et al, 27 with a longitudinal assessment of wandering behavior; our results also indicate statistically significant association with wandering and BRSS measures. ...
Objective:
To investigate baseline factors associated with caregiver-reported wandering among community-dwelling veterans with mild dementia.
Methods:
Veterans with mild dementia (N = 143) and their caregivers participated in a 2-year prospective longitudinal study. Measures assessed wandering, daily function, behavior, cognition, and personality features. Wandering was dichotomized as present or absent across study periods, and associations with baseline characteristics were examined.
Results:
One-quarter of participants demonstrated caregiver-reported wandering at 1 or more study visits, with 14% to 15% wandering at any 1 visit. Wandering was associated with significantly lower baseline scores in performance of daily function, behavioral response to stress, gait, and balance, and conscientiousness.
Conclusions:
This novel study evaluated wandering in a community-dwelling sample of veterans with mild dementia. Wandering was associated with a specific personality trait, poorer behavioral response to stress as well as greater functional and gait/balance impairment. These findings may assist in developing community-based interventions for caregivers.
... One of the most common indices used is Charlson Comorbidity Index (Charlson, Pompei, Ales, & MacKenzie, 1987;Deyo, Cherkin, & Ciol, 1992) comorbidity. Despite having been developed for non-dementia participants, these indices have been applied in many studies in dementia for the purpose of adjusting for comorbidity and severity (Ali et al., 2016;Farré et al., 2016). The Charlson Comorbidity Index was originally developed as a prognostic index to predict 1-year mortality in hospital patients in longitudinal studies and is now the most extensively used comorbidity index (Charlson et al., 1987). ...
... There are several implications of the study that warrant attention. The newly developed KDCI can be used as a potentially viable indicator of comorbidity for assessing the early risk of dementia, as the Charlson comorbidity index has already been widely used in dementia-related research in Korea (Ali et al., 2016;Farré et al., 2016). In addition, our findings and methodologies would be applicable in the ICD-10-based setting, especially for researchers concerned with measuring comorbidities. ...
This study develop and validate a simple and accessible measure of comorbidity, named the Korean Dementia Comorbidity index (KDCI), to assist in predicting the onset of dementia. This study used the National Health Insurance Service–Cohort Sample Database from 2002 to 2013 (n = 23,856). Cox proportional hazard model was used to estimate incident dementia (International Classification of Disease, 10th edition (ICD-10) codes: F00-F03, G30, G311), with a hazard ratio higher than 1.05 for each comorbid condition being assigned a score. Scores ranging from 1 to 4 were assigned based on the magnitude of the hazard ratio (HR): 1 (1.050 ≤ HR ≤ 1.099), 2 (1.100 ≤ HR ≤ 1.149), 3 (1.150 ≤ HR ≤ 1.199), and 4 (HR ≥ 1.200) Summated scores of comorbidities for each individual constituted the Korean Dementia Comorbidity Index (KDCI). Five patterns were extracted: (1) disease of the eye and adnexa; (2) endocrine and metabolic disease, and disease of circulatory system; (3) disease of the musculoskeletal system and connective tissue; (4) disease of the respiratory system; and (5) disease of the nervous system, and mental and behavioral disorders through factor analysis. Fitting performance by Akaike information criterion (AIC) of CCI by Charlson, CCI by Quan and KDCI adjusting for age and sex was 29,486, 29,488 and 29,444, respectively. Our analysis results on discriminatory abilities provided evidence that KDCI is superior to other comorbidity indices on incident dementia in terms of comorbidity adjustment. Therefore, KDCI can be a useful tool to identify incident dementia. This has implications for clinical management of patients with multimorbidity as well as risk adjustment for database studies.
... mates are highly relevant for families, health professionals, and first responders. The point estimate of 3% highlights the need for immediate actions to protect safety of clients and support family caregivers.The 5-year estimate of 42% identifies the need for preventive initiatives to reduce the probability of a critical wandering event occurring in the future.15 Our results also demonstrate the complexity of the health needs of persons with wandering behaviors. ...
INTRODUCTION
We used clinical assessment records to provide pan‐Canadian estimates of the prevalence and risks associated with recent (within the last 3 days) critical wandering among home care clients, with and without dementia.
METHODS
The data source is interRAI Home Care (interRAI HC) assessments. The population was all long‐stay home care clients assessed between 2004 and 2021 in seven Canadian provinces and territories (N = 1,598,191). We tested associations between wandering and cognition and dementia diagnoses using chi‐square tests and logistic regression.
RESULTS
Approximately 84% of the sample was over the age of 65. The overall rate of recent wandering was 3.0%. Dementia diagnosis was strongly associated with two to four times higher rates in the prevalence of recent critical wandering.
DISCUSSION
InterRAI HC offers insights into the wandering risk of home care clients. This information should be used to manage risks in the community and could be shared with first responders.
Highlights
In all the study regions combined, the rate of recent wandering is 3.0%.
Dementia was associated with 18 times greater prevalence of recent critical wandering.
Home care clients at risk of wandering have complex clinical profiles that pose important risks for their health and well‐being.
Collaboration and information sharing between search and rescue and health professions is essential for managing risks related to critical wandering.
... 4,6 For persons living with cognitive impairment, wandering increases the risks of being lost and injured. 4,7 People who wander may experience falls or sustain fractures or injuries, 8 whereas others may experience serious illness or death. 6 For example, persons who wander outside can easily become lost and could be at risk of sustaining a physical injury that can lead to fatal consequences. ...
Objectives
This study aimed to examine the effects of location-tracking devices on persons living with cognitive impairment, investigate facilitators of and barriers to using the devices, and provide future directions for the use of the devices.
Methods
An integrative review was conducted using 5 databases: PubMed, Embase, Web of Science, CINAHL, and Scopus. From the 1429 initially identified studies, 10 were included in the review.
Results
Location-tracking devices benefited persons living with cognitive impairment and their informal caregivers. The devices brought more independence to persons living with cognitive impairment, allowing them to go outside and feel safer there. Furthermore, the devices reduced the caregivers’ worries about their loved ones being lost.
Conclusions
Location-tracking devices have the potential to increase independence in persons living with cognitive impairment and to decrease psychological stress in informal caregivers. In the future, ways to minimize the barriers to using location-tracking devices need to be determined.
... Effective communication ensures that information, preferences, and concerns are shared and enables informed decision-making (Fetherstonhaugh et al., 2013(Fetherstonhaugh et al., , 2016. However, lack of consensus and standardization in defining and measuring risk behaviors, such as wandering, distorts how risk factors are reported and risk reduction measures are dependent on accurate assessment (Ali et al., 2016). While structured risk assessments are useful for systematically identifying safety hazards, high scores may be insufficient for predicting likelihood of an accident, but additional indicators can be assessed through dialog with carers (Bourgeois and Couturier, 2009). ...
Objective:Effective risk identification and assessment is important to help inform personalised care decisions, positive risk management, policy making and clinical practice in dementia. This mixed-method systematic review identified key components of risk assessment for people with dementia living within the community and care homes, examined attitudes towards risk identification and risk assessment, and appraised existing risk assessment tools.
Methods:Systematic searches of eight databases on two platforms (EBSCO, OVID) and grey literature databases (Open Grey, Base) were conducted. Studies were systematically screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesised using thematic synthesis.
Results:Twenty studies consisting of qualitative and mixed-method designs were included in the review. Five overarching themes emerged from the synthesis: Conceptualisation of risk - individual perceptions of risk, including how different individuals define, construct, and identify risk situations. Components of risk –key elements included in risk and safety assessments. Contributors to risk –factors that impact the risk level and how risk assessments are conducted. Perspectives on risk assessment –how individuals assess risk and approaches to risk management. Risk reduction –strategies to mitigate risk following an assessment.
Our review found differences in how risk is conceptualised between people with dementia, their family carers, and healthcare professionals, with views being shaped by media perceptions, personal experiences, sociocultural influences, dementia knowledge and severity. We found that mobilisation both inside and outside of the home is the most frequently identified risk factor. Our findings show people with dementia and carers are generally risk- tolerant, while healthcare professionals adopt risk-averse approaches that reflect organisational requirements and ensure safety. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute towards adverse risk events. Few studies considered people with dementia’s insight into the risk being assessed.
Conclusion:Accurate risk assessment and effective communication strategies are needed to enable risk- tolerant practices and ensure these approaches can be evaluated effectively. We did not find any instrument which to date had been shown to be widely acceptable and useful in practice.
... Despite the vast literature on missing persons (Greene & Alys, 2016; C. Taylor et al., 2019), few studies were identified in our review that explored the risk factors associated with missing incidents due to critical wandering among persons living with dementia (Ali et al., 2016;Bantry White & Montgomery, 2015b;Barnard-Brak et al., 2018). Of those that were included, three risk factor domains emerged: (a) demographics and personal characteristics, (b) health conditions and symptoms, and (c) environmental and contextual antecedents. ...
Worldwide, over 55-million people have dementia, and the number will triple by 2050. Persons living with dementia are exposed to risks secondary to cognitive challenges including getting lost. The adverse outcomes of going missing include injuries, death, and premature institutionalization. In this scoping review, we investigate risk factors associated with going missing among persons living with dementia. We searched and screened studies from four electronic databases (Medline, CINAHL, Embase, and Scopus), and extracted relevant data. We identified 3,376 articles, of which 73 met the inclusion criteria. Most studies used quantitative research methods. We identified 27 variables grouped into three risk factor domains: (a) demographics and personal characteristics, (b) health conditions and symptoms, and (c) environmental and contextual antecedents. Identification of risk factors associated with getting lost helps to anticipate missing incidents. Risk factors can be paired with proactive strategies to prevent incidents and inform policies to create safer communities.
... It is described as "leaving one's dwelling unescorted" (Chung & Lai, 2011). The persistent wandering and elopement are linked to the high morbidity and mortality rates among people with dementia (Ali et al., 2016). The common cause of death in people who wander or elope because of some type of dementia, is fatal accidental hypothermia, orthopedic injuries, soft tissue injuries, malnutrition, weight loss, and accidents (Woolford et al., 2017). ...
Alzheimer is a neurodegenerative type of dementia, that has progressive impairment of cognitive and behavioral functions, most commonly presented above 65 years old and it is divided in three stages. Wandering is the most frightening symptom for familiars and caregivers in the mild stage (second stage of the disease) because it can cause from a minor damage to death. Detecting and monitoring wandering is a complex task and has become a strong research line for several research projects. This paper focuses in proposing, developing and testing a support system for monitoring trajectories to identify direction changes alterations and positioning. The proposed system is called Motion acquisition system + Global positioning system(SAM + GPS). The system integrates an accelerometer, magnetometer, gyroscope and a GPS module. To address this challenge, after the development of the device, a pilot test was conducted with 9 young adult healthy subjects instrumented with the SAM + GPS. Each subject needed to route 2 specific trajectories to prove that the integrated device was able to measure different direction changes and map an accurate trajectory for future wandering detection. It was found that the SAM + GPS had an acceptable error of 12.29% measuring the direction changes in the first trajectory and a 27.44% critical error in the second trajectory. In addition, the device was able to map most of the trajectories with high similarities to an ideal pattern traced with the expected horizontal accuracy of 2.5m of the GPS Neo 6m module. It is worth mentioning that the device had a better performance in outdoor environments than in indoor environments, so in future work, more tests are considered with a larger population sample with the integration of an indoor positioning system and Humanitude methodologyprinciples.
... Tests of the relationship between missing events during the one-year follow-up period and personal attributes, such as sex, age, years of education, living alone, or financial difficulty at baseline did not reveal any significant findings consistent with the findings of previous studies [4,20]. ...
... The present study focused on wandering, and future studies should examine how wandering is linked to elopement. Studies using FD with individuals with dementia (a population with increased risk for an elopement) suggest that the degree of wandering is a precursor to elopement (e.g., Ali et al., 2016); however, we have yet to understand if this is true for children. Elopement is associated with higher mortality rates in children (Mouridsen, 2013;Solomon & Lawlor, 2013) and can lead to increased institutionalization (Kodak et al., 2004) as well as serious traffic and drowning accidents (Anderson et al., 2012). ...
Wandering, or random movement, affects cognitive and social skills. However, we lack methods to objectively measure wandering behavior. The purpose of this pilot study was to explore the use of the Ubisense real-time location system (RTLS) in an early childhood setting to explore wandering in typically developing (TD) children ( n = 2) and children with or at risk for developmental disabilities (WA-DD; n = 3). We used the Ubisense RTLS, a tool for capturing locations of individuals in indoor environments, and Fractal Dimension (FD) to measure the degree of wandering or the straightness of a path. Results of this descriptive, observational study indicated the Ubisense RTLS collected 46,229 1-s location estimates across the five children, and TD children had lower FD ( M = 1.36) than children WA-DD ( M = 1.42). Children WA-DD have more nonlinear paths than TD children. Implications for measuring wandering are discussed.
... 24 The study by Ali demonstrated that eloping behaviors are common even in mild dementia and account for 43.7%. 25 The persistent wandering and elopement are linked to the high morbidity and mortality rates among PwD. 26 The common cause of death in PwD who wander or elope from the facility is fatal accidental hypothermia, orthopedic injuries, soft tissue injuries, malnutrition, weight loss, and accidents. ...
Wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. Ethical and legal issues especially in the light of the new Indian Mental Healthcare Act of 2017, related to confinement by family members in their homes by family caregivers, seclusion, physical or chemical restraints, other pharmacological and behavioral treatment, highlighting their effectiveness as well as adverse consequences are discussed. This article attempts to address an approach in managing wandering behavior in PwD in light of MHCA, 2017
... Tests of the relationship between missing events during the one-year follow-up period and personal attributes, such as sex, age, years of education, living alone, or nancial di culty at baseline did not reveal any signi cant ndings consistent with the ndings of previous studies [4,20]. ...
Background
The burden of missing incidents is not only on the person with dementia, but also on their family, neighbors, and community. The extent to which dementia-related wandering and missing incidents occur in the community has not been evaluated thoroughly in the published literature. Therefore, we evaluated the incidence of and risk factors for missing events due to wandering.
Methods
We conducted a non-randomized prospective one-year follow-up cohort study based on symptom registration with missing events due to wandering as the endpoint. In the first consultation, 374 patients with dementia or mild cognitive impairment (MCI) and their caregivers who visited the National Center for Geriatrics and Gerontology in Japan were included. The incidence and recurrence rate of missing events were calculated. Participants were divided into (those with) dementia and (those with) MCI. Patients' basic and medical information was documented at baseline and after one year of follow-up. Furthermore, analysis of variance and logistic regression analysis were performed to clarify the risk factors associated with the missing event.
Results
Among the 236 patients with dementia enrolled, 65 (27·5%) had a previous missing event at baseline, and 28 had a missing event during the one-year follow-up period (recurrence rate of 43·1%). Of the 171 who did not have a previous missing event at baseline, 23 had a missing event during the one-year follow-up period (incidence rate of 13·5%). The scores of Mini-Mental State Examination (MMSE), Dementia Behavior Disturbance Scale (DBD), and Alzheimer's Disease Assessment Scale (ADAS) were statistically significant as the risk factors for the incidence of wandering leading to a missing event (p<0·05).
Conclusions
Prevention of missing event due to wandering requires focused attention on changes in the MMSE, DBD, ADAS scores, and the development of a social environment to support family caregivers.
... Wandering can also include random movements and increased duration of walking with frequent episodes of getting lost (2,6,7). Wandering has been associated with a myriad of negative outcomes including falls and subsequent injuries, increased caregiver burden, and early institutionalization (8)(9)(10). However, currently, there is no standardized approach to objectively describe and measure this behavior. ...
Patients with Alzheimer's disease (AD) and AD related dementias (ADRD) often experience spatial disorientation that can lead to wandering behavior, characterized by aimless or purposeless movement. Wandering behavior has been associated with falls, caregiver burden, and nursing home placement. Despite the substantial clinical consequences of wandering, there is currently no standardized approach to objectively quantify wandering behavior. In this pilot feasibility study, we used a lightweight inertial sensor to examine mobility characteristics of a small group of 12 older adults with ADRD and mild cognitive impairment in their homes. Specifically, we evaluated their compliance with wearing a sensor for a minimum of 4 days. We also examined the ability of the sensor to measure turning frequency and direction changes, given that frequent turns and direction changes during walking have been observed in patients who wander. We found that all patients were able to wear the sensor yielding quantitative turn data including number of turns over time, mean turn duration, mean peak turn speed, and mean turn angle. We found that wanderers make more frequent, quicker turns compared to non-wanderers, which is consistent with pacing or lapping behavior. This study provides preliminary evidence that continuous monitoring in patients with dementia is feasible using a wearable sensor. More studies are needed to explore if objective measures of turning behaviors collected using inertial sensors can be used to identify wandering behavior.
... In our study, family members expressed concerns about dire consequences of their relatives' elopement including their getting lost and becoming dehydrated and confused. Elopement is a major risk of wandering behavior with serious consequences to residents' morbidity and mortality (Ali et al., 2016;Aud, 2004). ...
While the use of walking interviews is not new in health care research, this method has not been used to study the wandering behavior of older adults living with dementia in long-term care (LTC) homes. The aim of this article is to describe ethical insights and consequential methodological outcomes when walking interviews were used as a means of exploring the perspectives of older adults living with mild to moderate dementia. We suggest that our use of walking interviews with older adults who presented with wandering behavior respected participants’ agency and, at times, placed the first author in the situation of “ethical vulnerability” in the roles of researcher and clinician. The first author, an experienced nurse clinician, walked with eight participants while interviewing them about why they walk and their intended destinations. Walking interviews provided the opportunity not only to interview participants but also to observe their walking behavior and interaction with others in the LTC home. Walking interviews with older adults living with dementia who are highly mobile in the LTC home acknowledge the primacy of the research participant and the researcher as learner.
... Nevertheless, aberrant motor behavior has been associated with frontal lobe dysfunction (Nagata et al., 2010) and decline in IADLs (Tekin et al., 2001). Wandering, a form of aberrant motor behavior, has also been suggested to be involved in ADL impairment (Ali et al., 2015;Scarmeas et al., 2007). Apathy, aberrant motor behavior and appetite disturbances have formed a distinct factor in some studies, but this has not been a frequent observation (Canevelli et al., 2013). ...
Background:
Neuropsychiatric symptoms (NPSs) in Alzheimer’s disease (AD) are related to activities of daily living (ADLs), but longitudinal studies are sparse.
Objectives:
We investigated which NPSs were related to decline in instrumental ADLs (IADLs) and basic ADLs (BADLs) in a 5-year follow-up of individuals with AD.
Methods:
ALSOVA 5-year follow-up study data of 236 individuals with very mild or mild AD at baseline and their caregiver were analyzed. IADLs and BADLs were assessed with Alzheimer’s Disease Cooperative Study ADL inventory, and NPSs with Neuropsychiatric Inventory at annual follow-up visits. Generalized estimating equations (GEEs) were used for longitudinal data analysis, and NPS–ADL networks were estimated to demonstrate symptom interactions.
Results:
Apathy [rate ratio (RR) 1.23, 95% CI 1.06–1.44, p = 0.007], aberrant motor behavior (RR 1.24, 95% CI 1.07–1.44, p = 0.005), and appetite disturbances (RR 1.22, 95% CI 1.06–1.41, p = 0.005) were related to impairment in BADLs, and the same symptoms (RR 1.13, 95% CI 1.07–1.21, p < 0.001; RR 1.13, 95% CI 1.07–1.20, p < 0.001; RR 1.14; 95% CI 1.08–1.21, p < 0.001, for apathy, aberrant motor behavior, and appetite disturbances, respectively), in addition to delusions (RR 1.09, 95% CI 1.03–1.15, p = 0.004), were related to IADL impairment. Symptom networks varied at different time points.
Conclusion:
As AD progresses, common (apathy) and uncommon NPSs (aberrant motor behavior, appetite disturbances, delusions) seem to be related to ADLs through various symptom interactions. Previous literature suggests that frontal pathology could underlie these relationships.
... When people with dementia go missing they are exposed to particular risks, such as dehydration, injuries such as bruising and abrasions, orthopaedic and soft tissue injuries, hypothermia, hyperthermia, and death. The risks of harm while missing are associated with the age of the missing person, weather conditions, the terrain, time of day, length of time missing and the mode of transport used during the missing episode (Ali et al., 2016;Aud, 2004;Rowe et al., 2004). Rowe and Bennett (2003) emphasize the importance of an intensive search as people with dementia may succumb to death by exposure and drowning relatively quickly. ...
Walking and exercising are an important part of living well with dementia. People with dementia may have an inability to recognize familiar places, find a familiar location, or become disoriented and are more likely to become missing. The aim of this article is to identify what factors influence family caregivers of people with dementia reporting them missing to the police. We used a qualitative approach based on semi-structured interviews of 12 family caregivers of people with dementia in UK. We identify four factors that inhibit family caregivers from reporting a missing person incident to the police and three factors that prompt family caregivers to call the police. We discuss implications for improved policy and practices by law enforcement agencies, social services, health services, and non-government organizations.
... There is a wide spectrum of symptoms, some of which may manifest in a propensity to walk independently at inappropriate times [4]. Literature indicates that this can lead to premature mortality [4][5][6]. Actions to mitigate this risk can lead to increased dependence, to curtailment of social activities, and reduction in quality of life [7]. Elopement episodes are a major reason for nursing home admission [8]. ...
A significant proportion of the population has become used to sharing private information on the internet with their friends. This information can leak throughout their social network and the extent that personal information propagates can depend on the privacy policy of large corporations. In an era of artificial intelligence, data mining, and cloud computing, is it necessary to share personal information with unidentified people? Our research shows that deep learning is possible using relatively low capacity computing. When applied, this demonstrates promising results in spatio-temporal positioning of subjects, in prediction of movement, and assessment of contextual risk. A private surveillance system is particularly suitable in the care of those who may be considered vulnerable.
... An estimated 27.5% of community-dwelling people living with dementia get lost at least once (Kwok, Yuen, Ho, & Chan, 2010). Getting lost is associated with problems of spatial disorientation, reduced topographical memory, reduced visual-perceptual ability, and executive dysfunction (Algase, 2007;Chiu, Algase, Liang, & Lin, 2005;Nagata et al., 2010;Swanberg, Tractenberg, Mohs, Thal, & Cummings, 2004). Psycho-social factors include personality responses to environmental stressors such as walking as a coping strategy or as a response to a suboptimal care environ- ment (Dewing, 2006;Lai & Arthur, 2003;Song & Algase, 2008). ...
Walking outdoors supports health and well-being but some people living with dementia are at increased risk of getting lost and of harm while missing. Electronic monitoring can potentially play an important preventative role by enabling the person’s location to be continuously monitored by caregivers. However, there are considerable ethical concerns arising from electronic monitoring. This paper explores these thematically, drawing attention to its implications for autonomy and liberty; privacy; dignity; the rights and needs of caregivers and families; beneficence and non-maleficence. Following from this, key questions for consideration in social work assessment are identified. The ethical issues necessitate assessment of the person’s unique circumstances and preferences and that of their caregivers, and careful ethical deliberation in decision-making. Social work can play an important role in facilitating inclusive assessment and decision-making, leading to consensus on intervening with electronic monitoring. The need for ongoing review following implementation is discussed to track whether decisions need modification in the light of experience of usage. In conclusion, while legislative instruments and professional codes of ethics frame social work practice responses, there is need for a nuanced debate about ethical use of electronic monitoring and specific guidance to inform assessment, decision-making and review.
... Recommendations were made for future studies. 20 Azermai et al. 1 Bidewell and Chang 2 Cankurtaran 3 Cerejeira et al. 4 Cipriani et al. 5 Cooke et al. 6 Corbett et al. 7 Powell et al. 8 Vickland et al. 9 Wandering 9 ...
Objective. Dementia is one of the most common illnesses worldwide, and is one of the most important causes of disability in older people. Currently, dementia affects over 35 million people around the globe. It is expected that this number will increase to 65.7 million by 2030. Early detection, diagnosis and treatment to control the principal behaviour symptoms may help reduce these numbers and delay the progression to more advanced and dangerous stages of this disorder with resultant increase quality of life for those affected. The main goal of the present systematic literature review was to examine contemporary evidence relating to non-pharmacological therapy in the treatment of dementia. Methods. To achieve the study goal, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used. Results. This study identified the five most common behaviours in patients with dementia as aggression, wandering, agitation, apathy and sleep disturbances. Two non-pharmacological therapies were the most studied treatment: music therapy and aromatherapy. Ten other non-pharmacological therapies were also identified, but these lack a sufficient evidence-base. Conclusion. Although all the therapies identified could be used as part of the treatment of behavioural symptoms, there is insufficient evidence relating to the indications, appropriate use and effectiveness of these therapies to apply in each behavioural treatment. Thus, the present study has demonstrated a significant research gap. What is known about the topic? Despite the widespread use of many different types of therapies, there is limited evidence regarding the efficacy of non-pharmaceutical therapies deployed in the management of behaviours of concern manifested by some people who suffer with dementia in all its forms. What does this paper add? This systematic review examines contemporary evidence from the literature to determine whether there is an evidence base available that would underpin the use of these therapies. This report on a PRISMA systematic review of the available literature demonstrates that only two therapies have some evidence to underpin the use of these non-pharmaceutical therapies and that a significant research gap is exists. What are the implications for practitioners? The implications for practitioners is that significant research effort is required to determine the efficacy of many of the therapies that are currently deployed, and thus many of the therapies used lack an evidence base at this time.
... In this study, the use of the Tinetti Scale (8) and MSE (9)(10) made it possible to trace a nursing diagnosis by the perceived needs and psychomotor deficits observed at the first assessment, and then to outline a plan of care, which is, implement psychomotor activities. In terms of assessment, an integrative review study in the Public Domain Portal and in the CAPES database of Thesis that analyzed instruments that assess mobility, among them the Tinetti scale, showed that several studies using scales claimed to have a more reliable assessment of mobility when more than one instrument is simultaneously adopted, focusing on early detection and prevention of falls (19) . ...
O presente estudo teve como objetivo analisar o efeito de atividades psicomotoras sobre equilíbrio em idosos com Déficit Cognitivo Leve. Trata-se de pesquisa quase experimental realizada em duas instituições públicas de saúde, com 43 idosos, residentes em Niterói e Rio de Janeiro/RJ, nos meses de abril a julho/2014. Realizaram-se dez sessões de atividades psicomotoras e avaliações com as escalas antes e após atividades realizadas. Osinstrumentos utilizados foram: Escala de Tinetti e Escala Motora para Terceira Idade (EMTI). Oprojeto foi aprovado pelo Comitê de Ética (Protocolo nº 531.807/2014). Através do Teste Kruskal-Wallis, nível de confiança 95%, significância 0,05, existe diferença significativa entre as avaliações realizadas. Na primeira avaliação,Tinetti apresentou 22 idosos (51,16%), média 17,22 pontos, com alto risco para quedas; 11 idosos (25,58%) com risco moderado. O equilíbrio – EMTI apresentou média 79,81 pontos, equivalente a classificação inferior. E nasegunda avaliação,Tinetti apresentou apenas cinco idosos (11,62%) com alto risco para quedas e 28 idosos (65,11%) com risco moderado para quedas e média 20,67 pontos. Dez idosos não apresentaram risco para quedas. O equilíbrio – EMTI obteve média 92,37 pontos mudando para classificação normal médio. Diante dos resultados,evidenciou-seque as atividades psicomotoras favorecem o equilíbrio dos idosos com Déficit Cognitivo Leve.
Background
Wandering behaviour affects a significant portion of dementia patients, ranging from 15% to 80%, presenting a serious safety concern and adding to caregivers' burden. Recent studies emphasise the effectiveness of non‐pharmacological interventions over pharmacological ones due to their minimal side effects. Consequently, in current literature there has been a surge of interest in exploring non‐pharmacological methods for managing wandering.
Purpose
This integrative literature review aims to deepen comprehension of wandering behaviour, presents recent studies on non‐pharmacological approaches, and inspires further research in this field.
Methods
Electronic data collection spanned from 2019 to 2024, sourcing 20 relevant articles from PubMed and Scopus databases using search terms such as ‘dementia’, ‘Alzheimer's disease’, ‘wandering’, and ‘management’. A thematic analysis methodology was employed to identify non‐pharmacological treatment themes for managing wandering. This approach involves scrutinising and synthesising themes within the dataset. Qualitative data analysis focused on significant phrases and keywords, grouping them to derive relevant themes.
Results
Recent literature extensively explores non‐pharmacological methods for managing wandering. These include understanding behaviours, identifying and targeting high‐risk groups, facilitating safe wandering, addressing environmental factors, promoting exercise and activity, and offering caregiver support.
Conclusions
This study significantly advances understanding of wandering behaviour and highlights recent research on non‐pharmacological interventions. The findings suggest the potential for providing safe and effective treatment to wandering dementia patients, thereby alleviating stress for both patients and caregivers.
Objective
This systematic review identified key components of risk assessment for people with dementia, examined attitudes toward risk identification and risk assessment, and appraised existing risk assessment tools.
Methods
Systematic searches of five databases on two platforms (EBSCO, OVID) and gray literature databases (Open Grey, Base) were conducted. Studies were screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis.
Results
Our review found people with dementia, their family carers, and healthcare professionals differed in how risk is conceptualized, with views being shaped by media perceptions, personal experiences, socio-cultural influences, dementia knowledge, and dementia severity. We found that mobilization (causing falls inside and getting lost outside) is the most frequently identified risk factor. Our findings show people with dementia are generally risk-tolerant, while healthcare professionals may adopt risk-averse approaches because of organizational requirements. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute toward adverse risk events. We discovered that most studies about risk and risk assessment scales did not consider insight of the person with dementia into risks although this is important for the impact of a risk. No risk instrument identified had sufficient evidence that it was useful.
Conclusion
Accurate risk assessment and effective communication strategies that include the perspectives of people with dementia are needed to enable risk-tolerant practice. No risk instrument to date was shown to be widely acceptable and useful in practice.
Background: Getting lost is a serious problem for elders with dementia. In North America, the Wayfinding Effectiveness Scale (WES) evaluates wayfinding effectiveness in persons with cognitive impairment. In Taiwan, such approach had not been implemented. As a consequence, this study translated the original scale into Chinese and tested its psychometric properties for family caregivers to evaluate persons with cognitive impairment in northern Taiwan.
Methods: It was a cross-sectional study design. Participants were 180 dyads (persons with cognitive impairment and their family caregivers, PWCIs and FCGs) from two memory disorder clinics at two teaching hospitals and from local community long-term care service programs.
Results: Forward/back translation was applied to develop the Chinese Wayfinding Effectiveness Scale (CWES). Factor analyses yielded a six-factor solution (explained variance = 66.77%): finding a destination and path in (1) familiar environments and (2) unfamiliar environments; sense of direction with (3) analytic strategies and (4) global strategies; (5) landmark and distance in familiar/unfamiliar environments; and (6) using a map in familiar/unfamiliar environments. One single-loaded factor item was deleted, yielding a 29-item scale. Construct validity using hypothesis testing was demonstrated by significant correlation coefficients between the total scale and its six subscales, among the total scale and the Chinese Mini-Mental Status Exam (CMMSE) and Chinese Neuropsychiatric Inventory (CNPI), and among five subscales and the CMMSE and CNPI. Only one subscale had subpar validity, suggesting future minor revision by a larger sample.
Conclusion: The Chinese Wayfinding Effectiveness Scale (CWES) is a valid instrument to measure wayfinding effectiveness in persons with cognitive impairment in Taiwan.
Dementia is characterized by significant cognitive deterioration, behavioral and psychological symptoms, and expanding disability. The well-being of people with dementia is influenced by the support provided by caregivers and health professionals. Especially in the past two decades, advancements in digital technology have helped reshape the way care and treatment are delivered. The main goal of the chapter is to describe technological solutions aimed at supporting the independence and safe participation of people with dementia in meaningful activities, as well as promoting their involvement in engaging experiences that seek to delay cognitive decline and diminish behavioral and psychological symptoms. These technologies include distributed systems, robotics, wearable devices, application software, and virtual reality.
Objectives
Falls and neuropsychiatric symptoms (NPS) are common among long-term care residents with cognitive impairment. Despite the high prevalence of falls and NPS, little is known about their association. The aim of our study was to explore how NPS, particularly the severity of NPS and specific NPS subgroups, are associated with falls and how psychotropics modify this association.
Design
Longitudinal cohort study.
Setting and Participants
In total, 532 long-term care residents aged 65 years or older in Helsinki, Finland.
Methods
NPS were measured with Neuropsychiatric Inventory (NPI) at baseline. Participants were grouped into 3 groups: no significant NPS (NPI points 0‒3), low NPS burden (NPI 4‒12), and high NPS burden (NPI >12). The number of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment.
Results
Altogether, 606 falls occurred during the follow-up year. The falls led to 121 injuries, 42 hospitalizations, and 20 fractures. Falls and injuries increased significantly with NPS burden (P < .001): 330 falls in the high NPS group (n = 184), 188 falls in the low NPS group (n = 181), and 88 falls in the no significant NPS group (n = 167). The risk of falling showed a curvilinear association with NPI total score. Of NPS subgroups, psychosis and hyperactivity were associated with a higher incidence rate ratio of falls, whereas apathy had a protective association even after adjustment for age, sex, and mobility. Affective symptoms were not associated with falls. Psychotropics did not modify the association between NPS burden and falls.
Conclusions and Implications
The results of this study show that NPS, especially NPS severity, may predict falls and fall-related negative consequences. Severity of NPS should be taken into account when assessing fall risk in long-term care residents with cognitive impairment.
Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.
Objective:
Examine mortality and associations with baseline characteristics among Veterans with early dementia.
Methods:
Participants included dyads of community-based Veterans with early dementia and their caregivers (N=143) enrolled in a previous longitudinal study. Department of Veterans Health Affairs' electronic records were used to retrospectively collect Veteran mortality outcomes, over a 6-year period. Measures included baseline: demographics, dementia-related factors, other comorbid conditions, functioning, and medication use. Associations with baseline characteristics and mortality were examined with bivariate analyses and a series of Cox proportional hazard models.
Results:
Over 6 years of study follow-up, 53.1% of participants died. The mean time to death was 3.09 years, with a range of 54 days to 5.91 years. Female sex, better cognition, and higher scores on the Tinetti Gait and Balance scale were protective factors in the final multivariable model, adjusting for other characteristics.
Conclusions:
While newly diagnosed with early dementia, over half of our sample died in the 6-year follow-up period, with the average death occurring only 3 years after initial diagnosis. The finding of lower mortality associated with better performance on gait/balance testing indicates an important opportunity for focused interventions and early detection of gait and balance changes early during cognitive decline.
L’approccio sistemico alla gestione dei rischi in sanitàE. Trinchero Rischio clinico e sicurezza del paziente: presente e futuroS. Tardivo, M. Capasso Rischio clinico: livelli di staffing infermieristico ed esiti correlati alle cure infermieristicheG. Pentella, L. Tesei Il ruolo delle competenze non tecniche (non technical skill) nella dinamica del rischio clinicoF. Moretti, M. Rimondini Rischio clinico e carico di lavoro: alcuni spunti di riflessioneP. Gnerre, A. Fontanella, D. Montemurro, C. Palermo Il punto di vista di un Direttore Generale internistaG. Scannapieco, E. Croci Il punto di vista di un Direttore Sanitario internistaF. Orlandini Il punto di vista di un Direttore Sanitario igienistaC. Bovo Il punto di vista di un Direttore di Medicina InternaS. De Carli La metà oscura del rischio clinico: i sinistri in medicina internaF. Corradi La corretta identificazione del pazienteR. Gallo, F. Bertoncini, C. Gatta Fase diagnostica: evitare misdiagnosi e ritardiM. Giorgi-Pierfranceschi Sicurezza in terapia farmacologicaE. Romano Novità nella prevenzione delle caduteR. Re, G. Ferrotti Protezione dalle infezioni correlate all’assistenzaA. Maffettone, C. Peirce, S. Di Fraia Safe HandoverR. Rapetti Prevenzione dei rischi in Medicina Interna, casi particolari: atti autolesivi, vagabondaggio, intrappolamento nel paziente ospedalizzatoR. Nardi, D. Tirotta, G. Pinna, G. Pirini Gestione ricoveri in appoggio e rischio clinicoM. La Regina, F. Guarneri, T. Bellandi, R. Tartaglia, A. Brucato, D. Manfellotto Innovazioni organizzative in Medicina Interna per la sicurezza del paziente: dall’Ambulatorio Integrato Diagnostico-Terapeutico alla Sezione di Decisione ClinicaR. Castello, A. Carli OssigenoterapiaM. La Regina VentiloterapiaM. La Regina Strumenti per una gestione sicura delle procedure invasiveM. La Regina La prevenzione del tromboembolismo venosoF. Pomero, E. Nicola, P. Salomone, R. Risso Sicurezza nella gestione della terapia anticoagulante oraleM. La Regina, F. Pomero Strumenti per una gestione sicura delle terapie inalatorieC. Tieri Strumenti per una gestione sicura della terapia ipoglicemizzanteT.M. Attardo Strumenti per una gestione sicura delle allergie a farmaci e delle interazioni farmacologicheT.M. Attardo Mobilizzazione dei pazientiG. Querci, A. Spadaro Il rischio clinico: conclusioniA. Fontanella
Wandering is often described as aimless and disruptive in long-term care (LTC) facilities. Kitwood's Enriched Model of Dementia challenges one to focus on the person, not the behavior. The current exploratory study addressed a gap in knowledge of wandering behavior by gaining the perspectives of older adults with mild to moderate dementia residing in LTC. Walking interviews were conducted with eight older adults. Six themes emerged from their perspectives: Walking as Enjoyable , Walking for Health Benefits , Walking as Purposeful , Walking as a Lifelong Habit , Walking as a Form of Socialization , and Walking to Be With Animals . These results suggest a reconceptualization of wandering behavior from aimless walking and disruption to a purposeful and beneficial activity.
[Res Gerontol Nurs. 2019; 12(5):239–247.]
Background:
Persons with dementia (PWD) reported missing are known to be at high risk for mortality. Analysis of online search engines' reports of missing PWD may show patterns in the data of this relatively common event and the broad patterns relevant to mortality risk factors.
Methods:
We searched Google news for PWD reported missing for 2015. Demographics, personal details, and outcomes were recorded.
Results:
Of 673 cases, 67 were found deceased, 525 alive, and the remainder had unknown outcomes. Mortality did not differ significantly by race/ethnicity for cases with known outcomes, but cases with unknown outcomes were significantly overrepresented among non-Caucasians (P<0.001; analysis of variance). Duration missing predicted mortality (P<0.001; χ), and mortality was lower if a photograph was provided (P<0.05; χ). Five states had no reports and some appeared to have fewer reports that would be expected based on estimates of dementia prevalence.
Conclusions:
Duration missing was the strongest predictor of mortality. Likelihood of mortality was not predicted by use of missing person alerts, and this may be a consequence of inconsistent reporting and follow-up of cases across states. Prevalence and mortality may likewise be underestimated because of the variability in usage and reporting of relevant search terms and definitions. Online resources and social media can provide information about trends and outcomes related to missing persons with dementia, but greater consistency is needed in definitions, searching, and reporting.
Purpose:
The aim of the study was to examine the characteristics of wandering associated with preserved versus worsened activities of daily living (ADL) function.
Design:
Longitudinal prospective design. Twenty-two cognitively impaired residents of an assisted living facility with over 450 observations were followed up to 8 months.
Methods:
Hierarchical linear modeling techniques examine how wandering activity (episodes, distance traveled, gait speed), measured by a real-time locating system, may affect ADL (the Barthel index, the Functional Independence Measure [FIM]).
Findings:
Wandering episodes were associated with increased ADL (B = 0.11, p ≤ .05, FIM); wandering distance (B = -4.52, p ≤ .05, the Barthel index; B = -2.14, p ≤ .05, FIM) was associated with decreased ADL.
Conclusion:
Walking an average of 0.81 miles per week with 18 or fewer wandering episodes is associated with decreased ability to perform ADL.
Clinical relevance:
Tailored protocols that allow productive wandering with ongoing assessment for fatigue/other physiological needs to appropriately limit distance walked within wandering episodes are needed for this population.
The quality of dementia care rendered to individuals and families is contingent upon the quality of assessment and care planning, and the degree to which those processes are person-centered. This paper provides recommendations for assessment and care planning derived from a review of the research literature. These guidelines build upon previous recommendations published by the Alzheimer's Association, and apply to all settings, types, and stages of dementia. The target audience for these guidelines includes professionals, paraprofessionals, and direct care workers, depending on their scope of practice and training.
Objectives
The robotic seal, PARO, has been used as an alternative to animal-assisted therapies with residents with dementia in long-term care, yet understanding of its efficacy is limited by a paucity of research. We explored the effects of PARO on motor activity and sleep patterns, as measured by a wearable triaxial accelerometer.
Study design
Cluster-randomised controlled trial, involving 28 facilities in Queensland, Australia. Nine facilities were randomised to the PARO group (individual, non-facilitated, 15-min sessions three afternoons per week for 10 weeks), 10 to a plush toy (PARO with robotic features disabled) and nine to usual care.
Main outcome measures
Changes in day- and nighttime motor activity and sleep after the 10-week intervention, as measured by SenseWear® armbands, worn by participants continuously for 24 h at baseline, during two single intervention days in weeks 5 and 10 respectively, and post-intervention (week 15). Analyses followed intention-to-treat, using repeated-measures mixed-effects models.
Results
After 10 weeks, the PARO group showed a greater reduction in daytime step count than usual care (p = 0.023), and in nighttime step count (p = 0.028) and daytime physical activity (p = 0.026) compared with the plush toy group. At post-intervention, the PARO group showed a greater reduction in daytime step count than the plush toy group (p = 0.028), and at nighttime compared with both the plush toy group (p = 0.019) and the usual-care group (p = 0.046). The PARO group also had a greater reduction in nighttime physical activity than the usual-care group (p = 0.015).
Conclusions
PARO may have some effect on motor activity of older people with dementia in long-term care, but not on sleep patterns.
Australian New Zealand Clinical Trials Registry (ACTRN12614000508673).
Managing wandering behavior of people with dementia (PWD) has become increasingly imperative for these reasons: its high prevalence (60%) among PWD, its negative outcomes such as falls or elopement, and its burden on caregivers. In this chapter, we discuss the emergence of sensors, techniques, and applications for managing wandering behavior of PWD. First, we briefly present the 5Ws1H (WHO, WHAT, WHERE, WHEN, WHY, HOW) conceptual map of wandering science including stakeholders (WHO), measurements of wandering (WHAT), environments in which wandering takes place (WHERE), detection of wandering (WHEN), causes of wandering (WHY), interventions of wandering (HOW). Second, we introduce a framework that identifies specific groups of mHealth and eHealth assistive technologies for managing dementia-related wandering. Third, we review existing technological works that address these 4 domains in the 5Ws1H conceptual map: WHAT-WHERE-WHY-HOW. In particular, we explore mHealth sensors to geo-fence and prevent elopement, mHealth devices to track and locate PWD who wander, information services to assist caregivers, eHealth tools to measure dimensions of dementia-related wandering, and mHealth tools that analyze proximal factors as well as study background factors. Based on this review, we further discuss research and design issues, human factors, ethics, security and privacy that need to be considered when implementing mHealth applications for wandering management. We conclude the chapter by highlighting the future research work in this area.
The wandering behavior of persons with dementia is a common problem in long-term care. However, in the design of interventions, the emphasis is on safety, and little consideration has been given to the meaning of the behavior for the person who wanders. This paper uses the Need-driven Dementia-compromised Behavior (NDB) model to demonstrate that the expression of wandering is unique to a given person in a particular context or situation. Elements of the model illustrate how particular patterns and amounts of wandering may reflect different bases of the behavior, such as global cognitive decline, visual spatial deficits, or perseveration. Differing bases for wandering would consequently call for different intervention strategies. Studies about wandering that examine the phenomenon in greater detail and consider more than its overall amount or related outcomes, such as eloping, are needed. Findings from such studies can help health care professionals to better detect probable causes of wandering in the dinical setting and to design appropriate interventions that target an individual's unique wandering experience.
Wandering represents one of many behavioural problems occurring in people with dementia. To consider the phenomenon of wandering behaviour in demented patients, we conducted searches using Medline and Google Scholar to find relevant articles, chapters, and books published since 1975. Search terms used included 'wandering', 'behavioural and psychological symptoms', 'dementia', 'nursing', and 'elopements'. Publications found through this indexed search were reviewed for further relevant references. The term 'wandering' covers different types of behaviour, including aimless movement without a discernible purpose. It is associated with a variety of negatives outcomes. The aetiology of wandering is poorly understood and it remains an unsolved riddle. Wandering is an acutely distressing problem worldwide, both for the patients and caregivers, and it is a major reason for nursing home admission. Evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited. It is possible that management of coexistent psychopathology would help to ameliorate this problematic behavioural disorder.
Personality psychologists from a variety of theoretical perspectives have recently concluded that personality traits can be summarized in terms of a 5-factor model. This article describes the NEO Personality Inventory (NEO–PI), a measure of these 5 factors and some of the traits that define them, and its use in clinical practice. Recent studies suggest that NEO–PI scales are reliable and valid in clinical samples as in normal samples. The use of self-report personality measures in clinical samples is discussed, and data from 117 "normal" adult men and women are presented to show links between the NEO–PI scales and psychopathology as measured by D. N. Jackson's (1989) Basic Personality Inventory and L. Morey's (1991) Personality Assessment Inventory. The authors argue that the NEO–PI may be useful to clinicians in understanding the patient, formulating a diagnosis, establishing rapport, developing insight, anticipating the course of therapy, and selecting the optimal form of treatment for the patient. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Although the term wandering is routinely used by clinicians, researchers, and informal caregivers (ICs), the meaning of this term varies depending on the source of the definition and the context in which it is used. The purpose of this study was to examine the terms ICs used to describe different scenarios that have been identified in literature as "wandering," determine their perception of risk, and compare their definitions of wandering with the perspectives of researchers. Structured interviews were conducted with 128 ICs of older adults with dementia. Informal Caregivers rarely used the term wandering to label different scenarios that had been previously identified in the literature as wandering. Responses to a survey of 17 wandering experts did not reflect agreement on a definition for wandering. These findings suggest that a broad set of terms should be used to describe this potentially dangerous behavior when health care providers communicate with ICs.
The disruptive behavior of persons with dementia is a problem of considerable clinical interest and growing scientific concern. This paper offers a view of these behaviors as expressions of unmet needs or goals and provides a comprehensive conceptual framework to guide further research and clinical practice. Empiricalfindings and clinical impressions related to wandering, vocalizations and aggression to support and illustrate the framework are presented Peer Reviewed http://deepblue.lib.umich.edu/bitstream/2027.42/66887/2/10.1177_153331759601100603.pdf
A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers.
A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework.
Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies.
Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.
This study evaluated the frequency, predictors, and effects of wandering in a population-based sample of 193 individuals with
Alzheimer's disease (AD). Although wandering occurred in subjects at all levels of cognitive impairment, analysis of variance
indicated that for the group as a whole, greater frequency of wandering was associated with significantly more impairment
in cognition, day-to-day functioning, and behavior. Caregiver distress also increased significantly with increased frequency
of wandering. Logistic regression modeling identified functional impairment and disruptive behavior problems as the strongest
independent predictors of wandering occurring within the past week. Cluster analysis revealed four characteristic groups of
wanderers that represented a continuum of wandering frequency, each having a unique pattern of other behavioral disturbances.
Based on this analysis, we recommend further evaluation and the development of possible treatment strategies that address
the individual differences found among AD patients who wander.
The purpose of this study was to examine cause of death in persons with dementia (PWDs) who have become lost in the community. The study was a retrospective review of 93 US newspaper articles describing PWDs being found dead in the community after leaving their caregiving situations unattended. Of these PWDs, 87 percent were found dead in natural, secluded, unpopulated areas, such as woods, fields, ditches, and bodies of water. They were generally found less than a mile from where they left, but often were not found for extended periods. Males and persons from community-based residential facilities appear to be at higher risk of dying after leaving unattended than females and those living at home.
The aim of this study was to evaluate the relationship of wandering and wayfinding and validate the Revised Algase Wandering Scale - Community Version (RAWS-CV) using a community sample of persons with dementia. Adult caregivers (n = 266) completed the RAWS-CV and the Wayfinding Effectiveness Scale (WES). Four aspects of wandering were confirmed (persistent walking, repetitive walking, spatial disorientation, eloping behavior), and two new aspects were also validated (negative outcomes, mealtime impulsivity). The spatial disorientation subscale of the RAWS-CV had significant (p < 0.01) negative correlations with all WES subscales. The global strategies and simple wayfinding goals subscales of the WES correlated significantly with all RAWS-CV subscales except repetitive walking and mealtime impulsivity. ANOVAs comparing wayfinding at 4 levels of wandering revealed differences only for the simple wayfinding goals subscale. Studies examining the relationship of wandering and wayfinding at various levels of cognitive impairment are suggested to further understand these phenomena.
Wandering is a commonly observed behavior among older adults with Alzheimer's disease (AD) and other types of dementia. When wandering around becomes wandering away, older adults with dementia are at high risk of injury. This exploratory, qualitative study described the circumstances, environmental risks, and injuries sustained in 62 elopements from long-term care facilities by elderly residents with dementia. Content analysis of the reports of the elopements identified patterns that included: 1) a lack of effective precautions to prevent elopement when residents had indicated an intent to elope, had repeatedly attempted to elope, or had a history of elopement; 2) a lack of awareness by the staff of resident location; and 3) ineffective use of alarm devices intended to alert staff to elopement attempts.
The Performance-Oriented Mobility Assessment (POMA) is a widely used instrument that provides an evaluation of balance and gait. It is used clinically to determine the mobility status of older adults or to evaluate changes over time. To support the use of the POMA for these purposes, the clinimetric properties (in particular, responsiveness) were determined.
Participants (78% female; mean age=84.9 years) were living in either self-care or nursing-care residences. Concurrent and discriminant validity were assessed with the total group (N=245), whereas reliability and responsiveness were determined with a subsample (n=30). Fall-related predictive validity was assessed with a subsample of 72 participants.
In addition to the POMA, several reference performance tests were administered. The POMA was assessed on 2 consecutive days by 2 raters (observers). The analyses included the calculation of Spearman rank correlation coefficients (R), limits of agreement (LOA) with Bland-Altman plots, minimal detectable changes at the 95% confidence level (MDC(95)), and sensitivity and specificity with regard to predicting falls. When possible, findings for the total scale (POMA-T) were complemented by findings for its balance subscale (POMA-B) and its gait subscale (POMA-G).
The interrater and test-retest reliability for the POMA-T and the POMA-B were good (R=.74-.93), whereas for the POMA-G, the reliability values, although high as well, were systematically slightly lower (R=.72-.89). The Spearman correlations with the reference performance tests (R=|.64|- |.68|) indicated satisfactory concurrent validity for the POMA-T and the POMA-B, but the corresponding findings for the POMA-G (R=|.52|- |.56|) were less convincing. The discriminant validity values of the 3 scales were about the same. The LOA for the POMA-T were on the order of -4.0 to 4.0 for test-retest agreement and -3.0 to 3.0 for interrater agreement. On the basis of the MDC(95) values, it was concluded that changes in POMA-T scores at the individual level should be at least 5 points and that those at the group level (n=30) should be at least 0.8 point to be considered reliable. Even when optimal cutoff points were used, sensitivity and specificity values (varying between 62.5% and 66.1%) for the POMA-T as well as for its 2 subscales indicated poor accuracy in predicting falls.
The POMA-T and its subscale POMA-B have adequate reliability and validity for assessing mobility in older adults. The POMA-T is useful for demonstrating intervention effects at the group level. Changes within subjects, however, should be at least 5 points before being interpreted as reliable changes. The accuracy of the POMA-T in predicting falls is poor.
To determine the effectiveness and cost-effectiveness of non-pharmacological interventions (excluding subjective barriers) in the prevention of wandering in people with dementia, in comparison with usual care, and to evaluate through the review and a qualitative study the acceptability to stakeholders of such interventions and identify ethical issues associated with their use.
Major electronic databases were searched up until 31 March 2005. Specialists in the field.
Selected studies were assessed and analysed. The results of two of the efficacy studies that used similar interventions, designs and outcome measures were pooled in a meta-analysis; results for other studies which reported standard deviations were presented in a forest plot. Owing to a lack of cost-effectiveness data, a modelling exercise could not be performed. Four focus groups were carried out with relevant stakeholders (n = 19) including people with dementia and formal and lay carers to explore ethical and acceptability issues in greater depth. Transcripts were coded independently by two reviewers to develop a coding frame. Analysis was via a thematic framework approach.
Ten studies met the inclusion criteria (multi-sensory environment, three; music therapy, one; exercise, one; special care units, two; aromatherapy, two; behavioural intervention, one). There was no robust evidence to recommend any non-pharmacological intervention to reduce wandering in dementia. There was some evidence, albeit of poor quality, for the effectiveness of exercise and multi-sensory environment. There were no relevant studies to determine the cost-effectiveness of the interventions. Findings from the narrative review and focus groups on acceptability and ethical issues were comparable. Exercise and distraction therapies were the most acceptable interventions and raised no ethical concerns. All other interventions were considered acceptable except for physical restraints, which were considered unacceptable. Considerable ethical concerns exist with the use of electronic tagging and tracking devices and physical barriers. Existing literature ignores the perspectives of people with dementia. The small number of participants with dementia expressed caution regarding the use of unfamiliar technology. Balancing risk and risk assessment was an important theme for all carers in the management of wandering.
There is no robust evidence so far to recommend the use of any non-pharmacological intervention to reduce or prevent wandering in people with dementia. High-quality studies, preferably randomised controlled trials, are needed to determine the clinical and cost-effectiveness of non-pharmacological interventions that allow safe wandering and are considered practically and ethically acceptable by carers and people with dementia. Large-scale, long-term cohort studies are needed to evaluate the morbidity and mortality associated with wandering in dementia for people both in the community and in residential care. Such data would inform future long-term cost-effectiveness studies.
An operational definition of dementia-related wandering is proposed to aid in clinical recognition, to promote research precision and validity, and to provide a pathway toward standardization of language in wandering science.
(1) One-hundred-and-eighty-three journal articles from multiple databases (Medline, OVID, CSA Journals, OCLC First Search, Google Scholar, PubMed, EBSCO) were reviewed to extract alternative terms and definitions for wandering or wandering-related behaviours; (2) terms and definitions were ordered alphabetically into a glossary; (3) a consensus approach was used to group glossary terms with related meanings into possible domains of wandering; (4) four domains (locomotion, drive, space and time) were found sufficient to encompass all wandering definitions; (5) wandering terms were placed into a conceptual map bounded by the four domain concepts and (6) a new provisional definition of wandering was formulated.
An empirically-based, operational definition improves clinical and research approaches to wandering and explicates historical inattention to certain beneficial aspects of the behaviour.
Adoption of the proposed operational definition of wandering behaviour provides a platform upon which dementia care may be improved and standardized language may evolve in wandering science.
Objectives. This retrospective cohort study examined the association between resident characteristics and the development of wandering behavior. Methods. Subjects included a total of 8982 residents from the states of Mississippi, Texas, and Vermont who had baseline and 3-month follow-up Minimum Data Set assessments between 1 January 1996 and 31 December 1997. Results. Residents who had a short-term memory problem (Odds Ratio (OR) = 3.05), had pneumonia (OR = 3.15), asked repetitive questions (OR = 2.19), had a long-term memory problem (OR = 2.06), exhibited dementia (OR = 19.4), constipation (OR = 1.82), expressed sadness or pain (OR = 1.65), and used antipsychotic medication (OR = 1.70), were at an increased risk for developing wandering behavior compared to residents without these characteristics. Residents with functional impairment(OR = 0.28) and women(OR = 0.61)were less likely to develop wandering behavior. Conclusions. Results of this study may be useful in constructing causal theories for the development of wandering behavior. Copyright (C) 2000 John Wiley & Sons, Ltd.
The prevention of fall-related injuries in patients with Alzheimer-type dementia (ATD) is hampered by an incomplete understanding of their causes. We studied falls and fractures in 157 ATD patients, including 117 with three-year follow-up. Initially all but one patient could walk; 31% reported falls. During follow-up, 50% either fell or became unable to walk. The fracture rate during follow-up (69/1000/y) was more than three times the age- and sex-adjusted fracture rate in the general population. Features of both ATD and comorbid conditions contributed to the risk of falls and fractures. In particular, patients who experienced toxic reactions to drugs on entry into the study were more likely to report they had fallen prior to entry (odds ratio, 4.9; 95% confidence interval, 1.78 to 13.3), and patients who wandered were more likely to sustain fractures (odds ratio, 3.6; 95% confidence interval, 1.25 to 10.4) during the follow-up period, including hip fractures for which the odds ratio of 6.9 (95% confidence interval, 1.66 to 28.6) was unexpectedly high. Preventive measures may be possible, including controlling wandering, avoiding toxic reactions to drugs, and treating comorbid illnesses.
(JAMA 1987;257:1492-1495)
Wandering represents one of many behavioural problems occurring in people with dementia. To consider the phenomenon of wandering behaviour in demented patients, we conducted searches using Medline and Google Scholar to find relevant articles, chapters, and books published since 1975. Search terms used included 'wandering', 'behavioural and psychological symptoms', 'dementia', 'nursing', and 'elopements'. Publications found through this indexed search were reviewed for further relevant references. The term 'wandering' covers different types of behaviour, including aimless movement without a discernible purpose. It is associated with a variety of negatives outcomes. The aetiology of wandering is poorly understood and it remains an unsolved riddle. Wandering is an acutely distressing problem worldwide, both for the patients and caregivers, and it is a major reason for nursing home admission. Evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited. It is possible that management of coexistent psychopathology would help to ameliorate this problematic behavioural disorder.
Wandering in dementia causes major difficulties for both patients and their carers. The term ‘wandering’ however, is vague and has no specific meaning. The behaviour of 29 patients in the community with dementia who had been classed as ‘wanderers’ was studied. The subjects were assessed using a semistructured interview with a carer. The findings show that the term ‘wandering’ covers a wide range of distinct behavioural abnormalities. A descriptive typology of wandering is proposed and the rates of each type are given. It is suggested that five fundamental components underlie the various types of wandering.
Objective
This study explored the relationship between observable emotional expression and wandering behaviors of people with dementia (PWD). MethodsA secondary data analysis was conducted of a multi-site study that used a cross-sectional design with repeated measures nested within subjects. Participants included 142 PWD residing in 17 nursing homes and six assisted-living facilities in Michigan and Pennsylvania who were randomly assigned to six 20-min videotaped observation periods, conducted on two non-consecutive days. Poisson hierarchical linear modeling was used to examine associations between emotional expression and wandering. ResultsParticipants exhibited an average of 13.5 (standard deviation [SD]12.4) episodes of positive emotional expression per observation; only 1.5 (SD +/- 2.3) episodes of negative emotional expression per observation were noted. The mean wandering rate was 2.9 episodes (SD +/- 6.9) per hour. Positive emotional expression was positively related to wandering rates, whereas negative emotional expression and higher cognitive status were negatively related to wandering rates after controlling for other predictors (age, education, gender, facility type, mobility, and time of day). Conclusions
Both positive and negative emotional expressions, along with cognitive status, should be considered when developing interventions to improve wandering behaviors of PWD. Copyright (c) 2013 John Wiley & Sons, Ltd.
To examine wandering behaviour in elderly demented persons in the community setting with respect to dementia characteristics and other factors that might influence wandering behaviour; to generate a statistical model to assess the relative importance of these various factors in predicting wandering behaviour. Cross-sectional, case-control investigation. University-affiliated outpatient neuropsychiatric assessment center. Six hundred and thirty-eight consecutive community-residing new patients with dementia referred for evaluation. Comprehensive neuropsychiatric evaluation, including rating with Mini-Mental State Examination; General Medical Health Rating; Comell Scale of Depression in Dementia and caregiver interview. Wandering behaviour occurred in 17.4% of participants. It was significantly more prevalent in patients with Alzheimer Dementia (AD), patients with dementia of longer duration, and patients with more severe dementia. Wandering behaviour was associated with moderate to severe depression, delusions, hallucinations, and sleep disorder. Other significant associations of wandering behaviour included use of neuroleptic medication and male gender. After statistical adjustment for other variables, duration of dementia, severity of dementia and presence of sleep disorder retained significant statistical association with wandering behaviour. Wandering behaviour among community-residing elderly dementia patients is associated with a number of factors, some of which may be subject to modification. It is possible that management of coexistent psychopathology, particularly of sleep disorder, and of the underlying disease process of AD would help to ameliorate this problematic behavioural disorder. Further investigation is warranted into the relationship between neuroleptic medication and wandering behaviour and into possible alternative measures to control agitation in elderly dementia patients. Copyright
There is still significant scope for improvement in knowledge on wandering in dementia and in the care of persons with dementia who wander. Although progress in research-derived knowledge is evident over the last 15 years, the current state of practice is influenced by an immature research base where the clarification of what wandering is still needs to be achieved. This is fuelled by research which to date, has framed wandering as a problem behaviour and generally starts from the premise that it needs to be prevented or severely controlled. People with dementia may think and feel differently about wandering, as will be suggested in this paper. The voices of those who have experiential expertise of dementia and wandering need to be included in the debate on wandering to influence both nursing research and practice. In regard to the practice context, it is suggested that there is little evidence to suggest that screening for wandering, assessment of wandering, person-centred and evidence-based care planning and interventions or evaluation are yet the norm for older persons with dementia. Thus, these areas must be the priorities for the immediate future. Whilst at a theoretical level, there are three key issues that require attention in the future: the orientation of research on wandering including reconceptualizing wandering to address the lack of theoretical frameworks to explain wandering, addressing the need some care settings might have with application of research and recognition of the experiential expertise of older persons with dementia.
Adverse consequences following elopement among older people with dementia have been widely reported but the phenomenon of elopement has been under-researched. This study aimed to examine patterns of elopement incidents, search processes and subsequent prevention strategies and to explore factors that predict elopement among community-dwellers with dementia.
Twenty subjects with a recent history of elopement and 25 subjects without any history of elopement completed the study. Their cognitive status, dementia severity and behavioral manifestations were evaluated. Family informants were interviewed to gather data on demographic characteristics, clinical conditions, caring patterns, lifestyle, history of elopement, and information about any elopement incidents.
Two-thirds of subjects had moderate severity of dementia (Clinical Dementia Rating ≥ 2). The elopers did not differ from the non-elopers in demographics, caring arrangements, clinical conditions or lifestyle patterns. Eighty percent of eloped subjects had a prior history of elopement. Logistic regression analyses suggested that manifestation of behavioral symptoms predicted elopement (OR = 1.410). Analysis of the 68 elopement incidents revealed that the vast majority of family caregivers failed to recognize any emotional/behavioral clues prior to elopement. Immediate and multiple search strategies were adopted, with eloped subjects mostly found near the point last seen. Yet, subsequent preventive strategies adopted were largely conventional.
Although elopement is difficult to predict, there is a need to enhance and sensitize caregivers' understanding of elopement as related to dementia and more effective preventive strategies. Public education on dementia could also serve to engage lay people more effectively in the search process of eloped persons with dementia.
The assessment of risk of injury in the home is important for older adults when considering whether they are able to live independently. The purpose of this systematic review is to determine the frequency of injury for persons with dementia and the general older adult population, from three sources: fires/burns, medication self-administration errors and wandering. Relevant articles (n=74) were screened and 16 studies were retained for independent review. The studies, although subject to selection and information bias, showed low proportions of morbidity and mortality from the three sources of injury. Data did not allow direct comparison of morbidity and mortality for persons with dementia and the general older adult population; however, data trends suggested greater event frequencies with medication self-administration and wandering for persons with dementia. Assessment targeting these sources of injury should have less emphasis in the general older adult population compared to persons with dementia.
To explore the extent of and factors associated with male residents who change wandering status post nursing home admission.
Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior.
One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States.
Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004.
MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents' admission to the nursing home and a minimum of two other time points at quarterly intervals.
The majority (86%) of the sample were classified as non-wanderers at admission and most of these (94%) remained non-wanderers until discharge or the end of the study. Fifty-one per cent of the wanderers changed status to non-wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status.
A resident's change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.
This study aimed to explore relationships of premorbid personality and behavioral responses to stress with wandering behavior of persons with dementia in long-term care facilities. Ambulatory residents (N = 108) with dementia were selected from 21 long-term care facilities. The Mini-Mental State Examination, the NEO Five-Factor Personality Inventory, the Behavioral Responses to Stress Scale, and the Revised Algase Wandering Scale-Nursing Home Version (RAWS-NH) were used as data collection tools. When the MMSE and age were controlled, regression analyses revealed that premorbid extroversion and premorbid negative verbalization stress response were significant negative predictors for the overall RAWS-NH and some subscales.
Despite being identified as a significant clinical phenomenon, wandering of persons with dementia (PWDs) has not been studied in Korea. As an initial trial, various factors chosen from the literature for their predictive relationships to wandering of Korean PWDs were evaluated in this study.
A total of 160 PWDs residing in 14 long-term care facilities participated in this study. The Mini-Mental State Exam (MMSE), Physical Activities of Daily Living (PADL) and Korean-translated Revised Algase Wandering Scale (Nursing Home version) (KRAWS-NH) were used to assess participants' degree of cognitive impairment, functional ability and wandering behaviour on six dimensions: persistent walking (PW), specific patterns (SP), spatial disorientation (SD), escape behaviour (EB), attention shift (AS) and negative outcomes (NO). Demographic, personal and environmental data were also collected.
The MMSE score was a significant negative predictor for KRAWS-NH overall and subscales except for EB; while age, PADL and history of falls were positive predictors for SD and NO. Total number of residents in a room was a significant negative predictor for EB and AS.
Different factors found in PWDs may contribute to different aspects of wandering behaviour. Further studies on factors influencing multiple facets of wandering in various cultural settings are warranted.
Two studies concerning pacing by nursing home residents are presented. The first was a cross-sectional survey of 402 residents,
which found that 39% of the subjects were pacers. In comparison to residents who did not pace, the pacers had fewer medical
diagnoses, better appetites, and had resided in the facility for fewer years. Additionally, pacing was positively related
to cognitive impairment and to past life-threatening experiences. Results of the second study, an observational study of six
cognitively impaired residents who paced frequently, showed that these residents paced more when the environmental conditions
were conducive to pacing (e.g., adequate lighting, enough room within which to pace). We believe that pacing is a reflection
of good health within the nursing home population and suggest that caregivers may want to encourage rather than inhibit this
behavior in some nursing home residents
The prevention of fall-related injuries in patients with Alzheimer-type dementia (ATD) is hampered by an incomplete understanding of their causes. We studied falls and fractures in 157 ATD patients, including 117 with three-year follow-up. Initially all but one patient could walk; 31% reported falls. During follow-up, 50% either fell or became unable to walk. The fracture rate during follow-up (69/1000/y) was more than three times the age- and sex-adjusted fracture rate in the general population. Features of both ATD and comorbid conditions contributed to the risk of falls and fractures. In particular, patients who experienced toxic reactions to drugs on entry into the study were more likely to report they had fallen prior to entry (odds ratio, 4.9; 95% confidence interval, 1.78 to 13.3), and patients who wandered were more likely to sustain fractures (odds ratio, 3.6; 95% confidence interval, 1.25 to 10.4) during the follow-up period, including hip fractures for which the odds ratio of 6.9 (95% confidence interval, 1.66 to 28.6) was unexpectedly high. Preventive measures may be possible, including controlling wandering, avoiding toxic reactions to drugs, and treating comorbid illnesses.
Many people experience a decline in mobility with aging. The multiple chronic diseases and disabilities responsible for this decline also may predispose to falling. This decline is well recognized by clinicians caring for elderly patients. The Canadian Task Force on the Periodic Health Examination not only recognized the problem, but concluded that assessing physical, social, and psychologic functions as they impact on 'Progressive Incapacity with Aging' was the most important assessment for patients over age 75. Prominent among their list of potentially preventable impairments were locomotory, sensory, and cognitive functions, each of which is intricately related to mobility. The Canadian Task Force further stated that protection of abilities should be emphasized over diagnosis. They believed that establishing the optimal content of the assessment was a high research priority. The purpose of the following discussion is to address the question of content of a functional mobility assessment appropriate for elderly patients. The limitations of relying solely on either a disease-oriented or a gait analytic approach are outlined. A practical performance-oriented assessment of mobility is described that incorporates useful features of both approaches. The recommended evaluation centers on the more effective use of readily (and frequently) obtained clinical data. Although limited to a discussion of ambulation as the expected mode of mobility (necessary because of space limitations), many of the concepts apply to other modes as well (eg, wheelchair).
To propose an alternative view of personality change in dementia by presenting existing evidence for the continuity of personality.
As the population continues to age, dementing illnesses will account for a greater proportion of morbidity and mortality; the care of these people will have a significant effect on the health care system.
Life-span perspective of personality continuity. SCOPE METHOD: Review of current literature on personality in dementia using Medline, 1980-1994; CINAHL, 1990-1994; and Psych Lit., 1980-1994.
Although there are systematic shifts in personality with dementia, individuals tend to maintain their unique pattern of premorbid personality traits.
The personalities of dementia patients seem to reflect adaptive patterns that served them in the past.
Use of a life-span perspective can enhance individualized care for demented patients and advance theory development.
This retrospective cohort study examined the association between resident characteristics and the development of wandering behavior.
Subjects included a total of 8982 residents from the states of Mississippi, Texas, and Vermont who had baseline and 3-month follow-up Minimum Data Set assessments between 1 January 1996 and 31 December 1997.
Residents who had a short-term memory problem (Odds Ratio (OR) = 3.05), had pneumonia (OR = 3.15), asked repetitive questions (OR = 2.19), had a long-term memory problem (OR = 2.06), exhibited dementia (OR = 19.4), constipation (OR = 1.82), expressed sadness or pain (OR = 1.65), and used antipsychotic medication (OR = 1.70), were at an increased risk for developing wandering behavior compared to residents without these characteristics. Residents with functional impairment (OR = 0.28) and women (OR = 0.61) were less likely to develop wandering behavior.
Results of this study may be useful in constructing causal theories for the development of wandering behavior.
This article analyzes the natural history of wandering behavior throughout the course of dementia.
Prospective, 10-year, longitudinal study of wandering behavior in dementia, with autopsy follow-up.
Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK.
Eighty-six people with dementia who were living at home with a carer and who were able to walk unaided at entry to study. Measures: At 4-monthly intervals, the carers were interviewed using the Present Behavioural Examination to assess wandering behavior in detail; participants with dementia were assessed cognitively. Nine types of "wandering" behavior were distinguished.
Changes in wandering behavior were not generally related to gender, age, or time since onset of dementia. Onset of different types of wandering behavior showed some relationship with cognitive state. Various forms of increased walking first appeared during moderate dementia, each type typically persisting for 1 to 2 years. Late dementia was characterized by decreased walking and immobility.
Wandering behavior in dementia can cause great problems for carers. There are different causes for such changes, some of which are related to cognitive ability, for example increased confusion results in ineffectual "pottering" and getting lost. Increased walking at night corresponds with disruption of diurnal rhythm.
Wandering has been described as one of the most challenging behaviours to manage and yet a search of the literature in the last two decades yields only a limited number of papers that specifically studied wandering.
This paper reviews the current literature on wandering in relation to the nature of the phenomenon, attempts to classify the behaviour, the extent of the problem, the profile of those who wander, postulations about its aetiology, and intervention strategies being employed.
Eight literature databases were searched for the last 40 years up to February 2003 using 'wandering' and 'dementia' as combined keywords. A total of 133 articles was included in the review.
The prevalence of wandering behaviour was difficult to assess and no conclusions could be reached. The typical wanderer depicted in the literature was relatively young in the older population, more cognitively impaired, more likely to be a man, might have experienced sleep problems, had a more active premorbid lifestyle, and used more psychotropic medications. While studies agreed that wanderers are more cognitively impaired, their findings did not necessarily agree on other attributes. Three major approaches, namely the biomedical, psychosocial and person-environment interaction perspectives, in conceptualizing wandering behaviour can be identified from the literature. Medications, activity programmes, behavioural modification and environmental manipulation have been used as interventions but none has so far demonstrated unequivocal effectiveness.
Knowledge generated through research remains insufficient to explain fully why and when wandering occurs. Variability in how the phenomenon was defined and studied, and the small size of the samples made generalizability of findings difficult. Future research should incorporate a clearer definition of wandering; a specific targeted population with representative sample size; appropriate subject identification strategies; focussed interventions, and better control conditions.
Providing care for persons with dementia presents several serious challenges. Among these is the possibility that a person with dementia will become lost in the community and face the risk of injury or death. Caregivers often cite anxiety about this possibility as a reason for placing their loved ones in a professional-care setting. Our case study and review of research show that all persons with dementia are at risk, regardless of age, past behavior, and sex. Thus, health care providers have an important role to play in educating caregivers about this risk and assisting them in preventing or responding to such situations. In addition, health care providers should ensure that their respective professional-care facilities have appropriate measures in place to prevent and respond to these eventualities. Finally, health care providers can educate local law enforcement personnel about dementia in general and more specifically about research-based strategies for searching for persons with dementia who have become lost in the community.
Wandering occurs in 15-60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices.
To determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia.
A systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought.
(i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable.
In order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials.
The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS).
Retrospective, clustered secondary data analysis. Setting: National Veterans Health Administration (VHA) long-term care nursing homes (N = 136).
The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period.
A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE).
There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller.
This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.
We evaluated the predictive value of wandering behavior at baseline for nutritional status, disability, institutionalization, and mortality in 686 Alzheimer disease community-dwelling subjects enrolled in the prospective REAL.FR study, France. Wandering behavior was defined using the Neuro-Psychiatric Inventory. The Mini-Nutritional Assessment and Katz Activity of Daily Living (ADL) scale were administered every 6 months during the 2 years of the study. Dementia severity was assessed using the Mini-Mental State Examination. Behavioral disturbances, comorbidities, medication, health care support, and burden status of the caregiver were assessed at the baseline visit. Outcomes of the 83 (12.2%) wanderers were compared with those of the nonwanderers. In the whole sample 30.1%/year subjects lost weight, 27.8%/year worsened their nutritional status, 55.1%/year decreased their ADL score, 11%/year reduced their ability to walk, 13.5%/year were institutionalized, and 6.2%/year died. Wanderers differed from nonwanderers by a higher frequency of decline of the ADL score (P<0.001), and institutionalization (P<0.001). Adjusted for baseline characteristics, risk of worsening the nutritional status, weight loss, decreased ADL score, and death were not statistically different between wanderers and nonwanderers. Risk for undernutrition and death are not increased in wanderers. Their higher risk of ADL disabilities and institutionalization are partly explained by their baseline characteristics.
Passive behavior (PB) in persons with Alzheimer's disease (PWAD) has been overlooked despite recognition that it occurs on a daily basis and is often resistant to interventions. The purpose of this study was to describe how the experience of passivity was for the caregiver and the PWAD, factors that precipitated PB, caregiver responses that promoted engagement, and caregiver responses that intensified PB, as well as activities initiated by caregivers over the past month that reduced passivity in the person with dementia (PWD). Fifty caregivers of community-dwelling persons with mild (n = 15), moderate (n = 16), and severe (n = 19) Alzheimer's disease participated in a semi-structured interview. Data were analyzed using Colaizzi's Phenomenological Thematic Extraction and descriptive statistics. Caregivers identified decreased levels of activity, decreased verbalization, withdrawal, less socialization, and decreased interest in activities as examples of PBs. For caregivers, the experience of coping with PBs engendered frustration with their loved ones' cognitive deterioration, difficulty in watching and accepting loss of function, fatigue, sadness, and using coping skills. Paradoxically, both being alone and increased environmental stimuli precipitated PB. Feelings of helplessness and loss of control by the person also caused PB. The most successful interventions to promote engagement were: giving cues and assistance, initiating the task, giving guidance, and providing enjoyable activities. Responses that hindered engagement included: 'correcting' or putting stress on the person, rushing activities, and repeating directions. Faith, humor, patience, and contact with friends and family were identified as positive approaches. Caregiver interventions demonstrated synchrony with selected background and proximal variables in the Need-driven Dementia-compromised Behavior (NDB) model.
This study evaluates three versions of the Wayfinding Effectiveness Scale (WES), developed to differentiate problems of wayfinding and wandering behavior of community-residing elders with dementia (EWD), in 266 dyads (EWD and caregiver) recruited from Alzheimer's Association chapters. Factor analyses yield a five-factor solution (explained variance = 62.6%): complex wayfinding goals, analytic strategies, global strategies, simple wayfinding goals, and being stimulus bound. Overall, internal consistencies are high: WES (.94-.95), and subscales are stable across all versions. Test-retest reliability is acceptable for the overall WES and two subscales (complex and simple wayfinding goals) for the care recipient current behavior version. Construct validity is supported by the pattern of correlations among subscales and analyses of variance (ANOVAs) showing significant differences among the care recipient (current vs. prior behavior) and caregiver versions overall and for all subscales. Results support the WES as a valid and reliable measure of wayfinding effectiveness in persons with dementia.
Wandering behaviour of persons with dementia in Korea: investigation of related factors
- Ja Song
- Ym Lim
- Gr Hong
Song JA, Lim YM, Hong GR. 2008. Wandering behaviour of persons with dementia in Korea: investigation of related factors. Aging Ment Health 12(3):
366–373.
Wandering behaviour in people with dementia
- Cky Lai
- D G Arthur
Lai CKY, Arthur DG. 2003. Wandering behaviour in people with dementia. J Adv
Nurs 44: 173-182.
Persons with dementia who become lost in the community: a case study, current research, and recommendations
- M A Rowe
- N G Feinglass
- M E Wiss
Rowe MA, Feinglass NG, Wiss ME. 2004. Persons with dementia who become lost in
the community: a case study, current research, and recommendations. In Mayo
Clinic Proceedings (Vol. 79, No. 11, pp. 1417-1422). Elsevier.
Resident characteristics associated with wandering in nursing homes
- Kiely
Wandering in hospitalized older adults: identifying risk is the first step in this approach to preventing wandering in patients with dementia
- Rowe