Risk assessment of wandering behavior in mild dementia.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Mapping the maze of terms and definitions in dementia-related wandering.

PURPOSE: 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. DESIGN AND METHODS: (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. RESULTS: An empirically-based, operational definition improves clinical and research approaches to wandering and explicates historical inattention to certain beneficial aspects of the behaviour. IMPLICATIONS: 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.

Keeping wandering nursing home residents at the table: improving food intake using a behavioral communication intervention.

The purpose of this multiple case design study (n = 3) with an embedded experiment was to determine the effect of the systematic use of a behavioral nursing intervention on the mealtime behavior of nursing home residents with probable Alzheimer's disease. It was hypothesized that the systematic behavioral intervention would increase time spent seated during the meal and proportion of food consumed while decreasing the frequency of table-leaving events during mealtime. The intervention was designed to impact the proximal factors of physiological need and social interaction from the Need-Driven Behavior Model. Results demonstrate that all cases were able to sit at the table longer and eat more food during the intervention, while body weight for all cases remained stable throughout the study. Two of the three cases left the table fewer times during the intervention. There were no statistically significant changes in proportion of fluids consumed in any case.

Validation of the Algase Wandering Scale (Version 2) in a cross cultural sample.

This study examined the psychometric properties of an expanded version of the Algase Wandering Scale (Version 2) (AWS-V2) in a cross-cultural sample. A cross-sectional survey design was used. Study subjects were 172 English-speaking persons with dementia (PWD) from long-term care facilities in the USA, Canada, and Australia. Two or more facility staff rated each subject on the AWS-V2. Demographic and cognitive data (MMSE) were also obtained. Staff provided information on their own knowledge of the subject and of dementia. Separate factor analyses on data from two samples of raters each explained greater than 66% of the variance in AWS-V2 scores and validated four (persistent walking, navigational deficit, eloping behavior, and shadowing) of five factors in the original scale. Items added to create the AWS-V2 strengthened the shadowing subscale, failed to improve the routinized walking subscale, and added a factor, attention shifting as compared to the original AWS. Evidence for validity was found in significant correlations and ANOVAs between the AWS-V2 and most subscales with a single item indicator of wandering and with the MMSE. Evidence of reliability was shown by internal consistency of the AWS-V2 (0.87, 0.88) and its subscales (range 0.88 to 0.66), with Kappa for individual items (17 of 27 greater than 0.4), and ANOVAs comparing ratings across rater groups (nurses, nurse aids, and other staff). Analyses support validity and reliability of the AWS-V2 overall and for persistent walking, spatial disorientation, and eloping behavior subscales. The AWS-V2 and its subscales are an appropriate way to measure wandering as conceptualized within the Need-driven Dementia-compromised Behavior Model in studies of English-speaking subjects. Suggestions for further strengthening the scale and for extending its use to clinical applications are described.

Nursing theory across curricula: a status report from Midwest nursing schools.

This article reports on an informal survey conducted for the Theory Development Section of the Midwest Nursing Research Society. Its purposes were to describe current practices in teaching nursing theory at three levels of curricula and to compare these practices between nursing programs in liberal arts colleges and research universities, between schools with and without doctoral programs, and between faculty with nursing and nonnursing doctorates who teach nursing theory. Findings indicate greatest consistency of practices at baccalaureate and doctoral levels, though few baccalaureate programs have required courses in nursing theory. Few differences were found between types of schools, but faculty with nursing doctorates tended to emphasize theory-practice linkages at the baccalaureate level. Further study that uses this work as a platform is suggested.

The Algase Wandering Scale: initial psychometrics of a new caregiver reporting tool.

This paper reports on the Algase wandering scale (AWS), a 28-item questionnaire, based on five dimensions of wandering. With factor analysis, an eight-factor solution explained nearly 70 percent of the variance in ratings for 151 long-term care subjects and confirmed three of the structuring dimensions. Reliability of the AWS was examined for internal consistency and for inter-rater reliability. The AWS had an alpha of .86; subscale alphas ranged between .88 (persistent walking) and .57 (routinized walking). Inter-rater reliabilities, estimated through cross-rater comparisons of the AWS and subscales with a four-point judgement of wandering status, were moderately strong and no significant differences existed between two sets of raters. Validity of the AWS and its subscales was supported by examining their ability to differentiate wanderers and nonwanderers, by positive correlation with measures of cognitive impairment and with multiple parameters of observed wandering, and by negative or no correlations with nonwandering locomotion. Although the AWS may be a useful measure of wandering in long-term care settings, validation of its factor structure and evaluation in cross-cultural samples is needed.

Impact of cognitive impairment on wandering behavior.

The purpose of this study was to explore cognitive impairment as a predictor of wandering rhythm and pattern in a sample of 25 demented residents from two long-term care settings. Parameters of rhythm indicating cycle frequency and structure were examined for wandering patterns (random, lapping, and pacing) and for nonwandering (direct) ambulation. All measures of cognitive impairment (Mini-Mental State Exam, Mattis Dementia Rating Scale, and a neuropsychologist's clinical rating) were significant predictors of parameters signifying frequency of wandering for random and lapping patterns but not for the pacing pattern. In addition, for nonwandering ambulation, cognitive impairment predicted some parameters of cycle structure (mean locomoting and nonlocomoting phase durations) but not those denoting frequency of ambulation. Results indicate that cognitive impairment plays an important role in determining the frequency of wandering cycles, but other factors may better explain parameters that characterize its cycle structure.

Resident characteristics associated with wandering in nursing homes.

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.

Fear and anxiety: a simultaneous concept analysis.

TOPIC: A simultaneous concept analysis of fear and anxiety. PURPOSE: To develop a process model that reflects distinct characteristics of fear and anxiety. SOURCES: Existing biopsychology empirics and theory from peer review with and external to nursing literature. CONCLUSIONS: Fear and anxiety are distinct diagnoses guided by separate brain mechanisms. The author offers a process model for further critique by peers and clinical populations.

Wandering in dementia.

In this paper, published research studies addressing the phenomenon of wandering in dementia are reviewed. Empirical findings of 108 studies are categorized and summarized to reveal dimensions of wandering behavior, significance of wandering as a clinical phenomenon, correlates of wandering, and tested intervention strategies. Implications for improving methodological rigor of future studies are offered and gaps in the current knowledge base are identified.

Wandering. A dementia-compromised behavior.

The wandering behavior of individuals with dementia is a puzzling behavior, and strategies for responding to it often are poorly grounded. However, advances in the understanding of neuro-cognitive factors contributing to wandering now may provide important clues for designing nursing approaches. In this article, such advances are summarized, and implications and strategies for practice are delineated.

Estimates of stability of daily wandering behavior among cognitively impaired long-term care residents.

Direct observation and time-study techniques were used with a sample of 25 ambulatory, cognitively impaired subjects drawn from two long-term care settings to evaluate wandering behavior. The purposes of this study were (a) to describe the 24-hour distribution of wandering and direct ambulating cycles, (b) to examine the stability of wandering behavior over a 3-day interval, (c) to evaluate whether wandering during a 2-hour epoch is representative of that of a 24-hour day, and (d) to evaluate whether large-scale integrated (LSI) activity meters can substitute as an index or proxy for direct observation in the study of wandering behavior. Subjects displayed a daily average of 20.1 cycles encompassing 43.9 minutes of wandering ambulation and 28.8 cycles encompassing 40.4 minutes of direct ambulation. Wandering behavior was present in all subjects. However, wandering was highly variable from subject to subject. For a given subject, wandering was only moderately stable over a 3-day interval, but more so than direct ambulation. Similarly, a standard 2-hour epoch was moderately representative of daily wandering ambulation, but more so than for direct ambulation. Finally, LSI meters, when applied at the ankle and worn over longer (24-hr) rather than shorter (2-hr) intervals, are a promising means to index wandering behavior.

Interdisciplinary team training in geriatrics: reaching out to small and medium-size communities.

Since 1989, six teams in the state of Michigan have been involved in a team training program designed to promote the development of geriatric services in small to medium-size communities. The program was enthusiastically received by participants, but after 18 months, only half of the teams had implemented clinical services for older adults. Monitoring the progress of the teams over 18 months and analyzing the activities of two teams revealed that financially stable and supportive sponsoring agencies and the community were critical factors in the implementation of interdisciplinary clinical services in geriatrics. Future team training programs trying to promote the development of geriatric services in small to medium-size communities should try to address these issues through community organization interventions.

Everyday indicators of impaired cognition: development of a new screening scale.

Development of the Everyday Indicators of Impaired Cognition (EIIC) Scale to assess nursing home residents for performance errors in four domains of cognitive functioning is reported. The EIIC had strong content validity, with indices ranging from .7 to 1.0. Factor analyses of data from two independent samples (N = 198, N = 107) confirmed four factors: abstract thinking, judgement, language, and spatial skills. Cronbach's alpha for subscales ranged from .67 to .92; test-retest reliabilities ranged from .49 to .80 with higher reliabilities occurring when time of retest matched time of original testing. Overall EIIC scores correlated to the short Memory-Orientation-Concentration (MOC) test and the Mini-Mental Status Examination (MMSE) at values supporting convergent validity (r = .67 and -.74, respectively). Evidence for divergent validity is a small, negative, nonsignificant correlations (r = -.15, -.18) of the EIIC at Times 1 and 2 to the Bradburn Affect Balance Scale.

Rosemary Ellis' views on the substantive structure of nursing.

According to the late Rosemary Ellis, the most pressing priority of nursing scholars is to explicate the substantive structure of our discipline. Drawing largely from her unpublished work, this paper summarizes the views of Ellis on the nature of nursing's substantive structure and raises implications for the development of nursing theory.

A century of progress: today's strategies for responding to wandering behavior.

1. In an effort to protect wanderers, nurses have overused physical restraints. Such practices have been reinforced by the potential for lawsuits charging negligence when wandering results in negative outcomes. 2. Wandering is movement changing over time and, thus, is a nonlinear ultradian rhythm, with locomoting and nonlocomoting phases. As a rhythm, an individual's wandering pattern is stable over a 1-week period. 3. Because most travel is direct, most ambulation, even for known wanderers, may not be wandering at all. Among inefficient travel patterns, lapping was the most frequently observed. 4. Behavior modification, grids, camouflage, and other environmental interventions are preferable to chemical or physical restraint in attempting to reduce unwanted or unsupervised exits by wanderers. These methods are not fail-proof, however, and do not replace careful supervision of wanderers by personnel.

Cognitive discriminants of wandering among nursing home residents.

Dimensions of cognitive impairment that best discriminated between wandering and nonwandering ambulatory subjects were studied. Cognitive impairment was measured along four dimensions: abstract thinking, language, judgement, and spatial skills. Wanderers had higher overall levels of cognitive impairment and poorer performance on all cognitive dimensions. The dimension of language was the most important higher order cognitive skill differentiating wanderers from nonwanderers; basic cognitive skill deficits (memory, orientation, concentration) and medical bases of cognitive impairment also contributed to the distinction between the groups. Overall classification rates obtained by linear classification function (LCF) analyses were only slightly better than chance rates. However, LCF rates for nonwanderers ranged from 93% to 95%, suggesting greater homogeneity in the cognitive impairments specific to this group.