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Clinical perspectives

A guide to understanding and managing wandering behaviour

You may download this document in PDF format:

PDF printable version of the What can we learn? - Clinical perspectives attachment to missing residents report (PDF 81 KB)

From the Office of Aged Care Quality and Compliance
(Aged Care Complaints Scheme)

About this report

This report has been prepared for approved aged care providers to assist them with understanding wandering behaviour. It outlines possible interventions that can manage wandering behaviour and reduce the number of residents that go missing from a service as a result of wandering.

Understanding wandering, cognitive impairments and dementia

Dementia

is the loss of intellectual functions such as thinking, remembering and reasoning of sufficient severity to interfere with a person’s daily functioning. Alzheimer’s disease is the most common cause of dementia (Futrell et al 2010).

Cognitive impairment

is when problems with thought processes occur. It can include loss of higher reasoning, forgetfulness, learning disabilities, concentration difficulties, decreased intelligence, and other reductions in mental functions. Cognitive impairment may be present at birth or can occur at any point in a person’s lifespan (Klasco 2011).

It is important to note that not everyone with cognitive impairment has a form of dementia. There are many reasons for someone to experience cognitive impairment. Common causes include side effects from medicines; drug-drug interactions; dehydration; infection; as well as extreme anxiety and/or unrelieved pain.

Wandering

is usually defined as meandering, aimless or repetitive locomotion but may also include purposeful locomotion that causes a social problem such as getting lost, leaving a safe environment or intruding in inappropriate places (Futrell et al 2010).

Wandering behaviour can manifest itself as lapping, pacing patterns, escape attempts, and getting lost unless accompanied. It is important to note that whilst wandering is closely associated with dementia, not everyone with a diagnosis of dementia will wander. Wandering is most commonly associated with moderate to severe dementia.

The issue

Wandering is a complex behaviour which effects between 11% of residents in general residential aged care and up to 60% of residents in specialist dementia units with cognitive impairment being identified as a major risk factor (Hodgkinson et al, 2007; Futrell et al 2010).

While wandering itself is a normal human activity that has many positive health benefits for older people, undesirable wandering such as exit-seeking behaviour can be problematic in the residential aged care setting (Hodgkinson et al, 2007; Wigg, 2010).

Triggers for wandering can be environmental conditions (heat, cold or unfamiliar surroundings), sensory stimulation (lighting, smells or sounds) or internal conditions (such as physiological needs and confusion) and commonly occur in the period immediately following admission to a residential aged care service.

Wandering can be a result of goal driven behaviour – hunger, thirst or the need to use a toilet – resulting in getting lost. Wandering is often interpreted as an expression of need. For example: fear ‘I’ve been left’ or anxiety ‘I want to go home’. There is increasing recognition that some people have a need to move which may be associated with the rhythms in the day.

Risk factors

The information in the report ‘Aged care residents who go missing: what can we learn from compulsory reports’ indicates there are multiple risk factors that contribute to the likelihood that a resident may go missing. These include where they have:

• a cognitive impairment
• a history of wandering
• recently entered a service
• been receiving respite care in a service.

In addition, the report found a combination of elements can increase the likelihood a resident can go missing. These factors include:

• residents who are able to walk independently and are cognitively impaired
• residents with a history of wandering that are not in a secure environment
• residents that are new entrants and are cognitively impaired.

Interventions to reduce wandering behaviours

The evidence shows that there is no single cause for wandering so there is no single solution.

The management of wandering behaviours are similar to the management of other clinical presentations:

• Has a comprehensive assessment been conducted?
  • Has there been an accurate medical diagnosis?
  • Is the resident capable of walking independently?
  • Are wandering behaviours part of the presentation of a disease?
  • What are the triggers for wandering behaviour? Note: there may be more than one trigger and more than one wandering behaviour.
• Does the wandering have an impact on other care recipients or pose a risk to the individual?
• Is there a management plan in place for the care recipient that addresses the wandering behaviours?
• Is the management plan regularly reviewed so that effectiveness of strategies can be assessed and altered as required?
• If wandering is ongoing or causing other people anxiety, has the care recipient been referred to a specialist service or practitioner?

Screening for any actual and/or potential risks of wandering behaviour is the first step to managing wandering behaviour. A focus on screening all new residents is encouraged but is particularly important for residents presenting with a cognitive impairment (Dewing 2005).

Once a resident has been identified as being at risk of wandering behaviour, a full assessment would help to ensure that appropriate management strategies are identified that are specific to the resident’s needs.

It is important to describe the wandering behaviours in ways which enable accurate description of the behaviours and which are non-stigmatising. Words such as ‘interfering’, ‘sneaking out’ and ‘trespassing’ do not allow for an accurate description of the wandering behaviours and therefore the development of management strategies.

Examples of accurate descriptions of wandering behaviours include shadowing others, getting lost in (room or corridor), unescorted exits, leaving the table in mealtimes, etc. These descriptions enable care staff to plan individualised care that promotes safe wandering and minimises the risks associated with undesirable wandering behaviours.

The research highlights four possible categories of intervention for the management of wandering behaviour on a case-by-case basis:

Category	Actions
Environmental Modifications	Placing gridlines on the floor in front of doors Covering or camouflaging exit doors Providing a secure place for residents to wander safely Taking care with furniture placement Providing tactile wall art to increase visual appeal Providing stimulation cues such as pictures and signs
Technology & Safety	Using technology to locate and monitor resident movement such as movement sensors which turn on lights Using pressure mats Using verbal alarm systems instead of aversive noise alarms
Physical & Psychological	Setting up a walking group and regular exercise Providing music therapy Providing adequate supervision – which may include 1:1 supervision for short periods or immediately following admission Decreasing disturbing stimuli Promoting safe wandering
Caregiver Support and Education	Providing education and training to staff Promoting a facility-based approach that includes identification, a wandering prevention program, and interaction with staff

Approved providers may consider using any combination of these intervention strategies to reduce the number of residents that go missing from a service due to wandering behaviours.

Contact us for more information:
Aged Care Complaints Branch
Office of Aged Care Quality and Compliance
Email agedcomplaintscomms@health.gov.au
Website: http://agedcarecomplaints.govspace.gov.au

References and resources

Resources

Dementia Behaviour Management Advisory Service - A nationwide network of services providing support and assessment of people with Dementia – in most states staffed by Alzheimer’s Australia.
http://www.dbmasqld.org.au or www.alzheimers.org.au

Department of Health & Ageing. Decision Making Tool: Responding to issues of restraint in aged care.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-decision-restraint.htm

NSW Health. Aged Care - Working with People with Challenging Behaviours in Residential Aged Care Facilities.
http://www.health.nsw.gov.au/policies/gl/2006/GL2006_014.html

Wilkes L, Jackson D, Mohan S & Wallis M. Close observation by ‘specials’ to promote the safety of the older person with behavioural disturbances in the acute care setting. Contemporary Nurse: A Journal for the Australian Nursing Profession 2010;36:1-2.

References

Dewing J. Screening for wandering among older persons with dementia. Nursing Older People 2005;17:No. 3.

Futrell M, Devereaux Melillo K & Remington R. Evidence Based Guideline: Wandering. Journal of Gerontological Nursing 2010;36:No. 2.

Hodgkinson B, Koch S, Nay R & Lewis M. Managing the wandering behaviour of people living in a residential aged care facility. International Journal of Evidence-Based Healthcare 2007;5:406-436.

Klasco R. Cognitive Impairment. Better Medicine; accessed at www.bettermedicine.com on 5 August 2011.

Wigg J. Liberating the wanderers: using technology to unlock doors for those living with dementia. Sociology of Health & Illness 2010;32 No. 2:288-303.
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