From The Blog

Wandering Behavior From the Perspectives of Older Adults With Mild to Moderate Dementia in Long-Term Care

Wandering Behavior From the Perspectives of Older Adults With Mild to Moderate Dementia in Long-Term Care

Abstract

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. 20xx; xx(x):xx–xx.]

Wandering has been defined as the inability of older adults with dementia to find their way while pursuing a need or goal (Algase et al., 1996). The behavior has also been referred to as a normal human activity that people engage in during their lifetime (Halek & Bartholomeyczik, 2012). Wandering is associated with terms such as “elopement, endangered, taking care, getting lost and following up” (Halek & Bartholomeyczik, 2012, p. 406). In long-term care (LTC) homes, also known as nursing or personal care homes, wandering is commonly referred to as aimless walking. When health care providers perceive wandering as a problem and disruptive to their care routines, they may want to control or prevent the behavior (Dewing, 2005; Halek & Bartholomeyczik, 2012; Wigg, 2010). However, preventing residents from wandering could mean their losing the associated benefits of walking, including improved circulation and oxygenation and decreased risk of contractures (Lai & Arthur, 2003).

Wandering has been associated with depression and is an indicator for risks for falls and mortality if residents leave the LTC home and are exposed to extreme temperatures or walk into busy streets (Ali et al., 2016; Klein et al., 1999; Rowe et al., 2011). Residents with dementia may go into other residents’ rooms (also called boundary transgression) or intrude into their personal space with ensuing altercations, loss of privacy, risk of physical harm, and becoming lost, all of which impact residents’ quality of life (MacAndrew, Fielding, Kolanowski, O’Reilly, & Beattie, 2017; Shinoda-Tagawa et al., 2004; Snellgrove, Beck, Green, & McSweeney, 2013). Residents who wander could experience wayfinding difficulty, which is associated with consequences such as falls (MacAndrew, Beattie, O’Reilly, Kolanowski, & Windsor, 2017).

Interventions for wandering have prevented the behavior using physical and pharmacological restraints (Dewing, 2011). Apart from the known harmful effects of restraints, such as pressure sores, anxiety, physical violence, falls, and high morbidity and mortality rates, the intervention is also ineffective (Engberg, Castle, & McCaffrey, 2008; Gill et al., 2007; Raetz, 2013; Robinson et al., 2006). Nonpharmacological interventions are a safer option and include the use of electronic tagging and tracking devices, behavioral approaches, exercise, music therapy, aromatherapy, camouflage (e.g., covering the door knob with a piece of cloth or fabric) and strips of tape (i.e., placed in front of exit doors), non-subjective barriers (e.g., locked units), and environmental modifications (Dewing, 2011; Robinson et al., 2006).

Creating a positive caring environment can reduce the risks associated with wandering (Gu, 2015). Apart from having adequate staffing to supervise residents who wander, incorporating wandering paths can support individuals who wander. Wandering paths are “the circulation space the residents use for moving around,” such as hallways with a continuous path or circular loop and simple visual cues or artwork/objects to support therapeutic walking (Silverstein, Tobin, & Flaherty, 2002, p. 81). Marquardt, Bueter, and Motzek’s (2014) systematic review reported that visual cues, such as signposting, were effective in helping residents wayfind.

Managing wandering should be person-centered and take a team approach involving health care providers, families, and residents who express the behavior (Robinson et al., 2007). However, little is known about wandering from the perspectives of older adults with dementia in LTC homes. Although previous research with older adults with dementia has shown it is possible to ask about their perspectives and receive their answers, little research has been done directly with older adults who wander (Dewing, 2006; Tanner, 2012; Whitlatch, Feinberg, & Tucke, 2005).

The current exploratory study aimed to gain a better understanding about wandering behavior through the perspectives of older adults with mild to moderate dementia in LTC. The research question was: How do older adults with mild to moderate dementia in LTC perceive their own wandering behavior?

The theoretical framework that guided the study was the Enriched Model of Dementia by Kitwood (1993). This model challenges the traditional way of thinking by focusing on older adults rather than their dementia or its symptoms. The model suggests that there are other factors such as health and physical fitness, biography or life history, personality, and social psychology that affect an older adult with dementia apart from the neurological impairment caused by changes in the brain. The model proposes that the neurological impairment and these other factors affect how an individual with dementia acts, feels, and thinks (Brooker & Surr, 2005; Kitwood, 1993). For the current study, asking older adults about their perspectives of walking took into account factors such as biography and history of walking prior to the onset of dementia.

Ethical Approval

Ethical approval for the study was obtained from the University of Manitoba Education Nursing Research Ethics Board and the Winnipeg Regional Health Authority. Ongoing verbal consent was obtained from participants. Family members also gave informed written consent on behalf of their relatives.

Method

Setting/Sample

The study was conducted at two LTC homes in Winnipeg, Manitoba. Both LTC homes offer personal care (e.g., meals, assistance with activities of daily living, professional health services, laundry and housekeeping services) for >150 older adults, and one home had a specialized dementia care unit. Both LTC homes have linear (not circular) hallways with locked units (with keypads) and patio/gardens (with keypads).

A purposive sample of eight participants met the inclusion criteria: residents with mild to moderate dementia (based on a Cognitive Performance Scale [CPS] score of 1 to 3) with wandering behavior; age 65 or older with ability to answer simple questions based on clinical judgment; living in a LTC home for >2 months; and having a family member who visits more than once per month who also consented to participate in the study. LTC home staff identified residents with mild to moderate dementia by using their CPS scores from the Minimum Data Set. The researcher did not have access to participants’ individual CPS scores. A CPS score of 1 is assigned for “borderline intact,” 2 for “mild impairment,” and 3 for “moderate impairment” (Canadian Institute for Health Information, 2013). Family members broadly included friends as long as they could consent on behalf of participants and knew their life histories. Exclusion criteria were residents who were experiencing severe anxiety, had walking impairment or psychosis, tended to shadow, and were wards of the provincial government’s Public Trustee Office.

LTC home staff assisted in screening participants by completing the Dewing (2005) Wandering Screening Tool (part B). The screening tool comprises two parts: A (pre-dementia) and B (currently) with questions for yes/no answers. Items on part A described the participant’s past wandering/walking activity. Items on Part B ask about shadowing (yes/no), boundary transgression, and attempted or actual elopement from the LTC home. The screening tool was developed by Dewing (2005) and has not been empirically tested. Permission was granted by Dewing to use her tool. Data were collected between August 29, 2017 and November 6, 2017.

Data Collection and Analysis

The current study used interpretive description, a qualitative research methodology with emphasis on generating knowledge for application in applied health disciplines (Thorne, 2016). The epistemological standpoint of interpretive description is embedded in the principle of naturalistic inquiry, which allows researchers to study participants in their natural state as indicated in the current study (Thorne, 2016). Interpretive description provides an analytic logical qualitative approach to clinical description in an interpretive way by identifying key themes and patterns within expressed subjective perspectives (Thorne, 2016; Thorne, Kirkham, & O’Flynn-Magee, 2004). The use of interpretive description in a study goes beyond reporting or describing data and allows researchers to develop an interpretive account of data by further exploring the meaning of key themes and patterns in a study (Thorne et al., 2004).

Participant demographic data were collected from family members during an interview. Family members were also asked about their relatives’ walking behavior, but these findings are not presented herein. The entire study is available at the University of Manitoba repository (access http://hdl.handle.net/1993/33251).

The researcher (A.A.) spent 1 to 2 days to get to know participants and become familiar with their routines prior to conducting the walking interview. The amount of time spent with each participant prior to the interview varied from 30 minutes to 120 minutes depending on their receptivity and engagement in other activities. One walking interview per participant was performed to capture the moment of walking. Saturation determined the decision to stop interviews when the researcher heard similar perspectives repeatedly during the walking interviews.

A Sony^® digital audio recorder with a clip style omnidirectional microphone (small lapel) clipped onto the researcher’s jacket was used to record conversations between the researcher and participants. Closed and open-ended probing questions were asked. For example, participants were asked: “Are you going somewhere? (“Where are you going?”), “Do you enjoy walking?” (“Why do you enjoy it?” “Or not enjoy it?”), and “How are you feeling about walking right now?” The walking interview included participant observation and the researcher observed participants’ nonverbal behaviors (e.g., facial expressions, body language, interaction with others) and recorded these behaviors in her journal. The journal, including self-reflection notes, was kept during the course of the study to record and reflect on observations during and after the walk and provided a description of context. The walking interviews with participants depended on participants’ receptivity and lasted between 20 and 38 minutes.

Data analysis involved concurrent data collection and analysis and iterative process (Thorne et al., 2004). The researcher reviewed audio recordings and transcripts after each data collection to make sense of the data and develop additional probes. Ideas generated from the iterative process were noted as patterns and highlighted on the transcript and reflective journal by the researcher prior to coding. These ideas were discussed with the researcher’s advisor who also actively engaged in the data analysis.

The coding process was inductive and involved grouping data from the transcripts and reflective journal, including observational notes with similar characteristics. Data with similar characteristics were examined for alternative meanings of what could convey participants’ perspectives on wandering before they were highlighted and assigned a code. The use of creative coding, such as colors designating specific codes, helped with the inductive process (Thorne et al., 2004). Initial coding of the data was performed independently by the researcher and then jointly by the researcher and her advisor. Codes were compared for similarities and differences and were further discussed until a consensus was reached.

Codes of participants’ perspectives on wandering were collated to examine key themes across participants. Similarly, discussions between the researcher and advisor related to emerging themes and sub-themes led to consensus (Thorne et al., 2004).

To ensure the credibility and confirmability of the findings, the researcher maintained reflexivity and kept an audit trail of the interview and participant observation data as documented in the reflective journal to confirm patterns emerging from the data. The researcher also clarified interpretations that might have impacted data analysis. The researcher noted in her journal her personal biases, preconceptions, and past and present clinical experiences that might have affected her interpretation of the data and reviewed this process with her advisor.

Findings

Sample Characteristics

Participant demographic information is presented in Table 1. Of eight participants, four (50%) were men and four (50%) were women, and their ages ranged from 80 to 95 years with the majority (n = 5, 62.5%) between 81 and 90 years (mean age = 86.6 years). Participants were predominantly married (n = 5, 62.5%), and the remainder were divorced, single, and widowed. The years of admission of participants ranged from 2015 to 2017; five were admitted between May and August 2017, whereas the remaining three participants were admitted in 2016 and 2015, s uggesting that most participants were new to the LTC home during data collection. Four (50%) participants were staying in locked units of the LTC homes.

Per their family members, most participants had a history of being a regular walker, whether as a hobby or part of their daily life. In addition, all participants had a history of being extremely sociable or known to have an outgoing personality, enjoying interaction with individuals, and being involved in several social and volunteer activities.

Participants’ Perspectives on Wandering

Six themes comprise the interpretive description of participants’ perspectives on wandering: (a) Walking as Enjoyable, (b) Walking for Health Benefits, (c) Walking as Purposeful, (d) Walking as a Lifelong Habit, (e) Walking as a Form of Socialization, and (f) Walking to Be With Animals. Participants’ quotes formed the sub-themes (Table 2). In the themes, wandering is reported as walking because walking is more commonly understood by residents. All participants were assigned pseudonyms.

Walking as Enjoyable. All participants reported that they enjoyed walking. Specific words used to describe walking were “good,” “enjoy,” “fun,” “fresh air,” “the breeze,” and “good pastime.” Richard said, “I just enjoy [walking]… it’s a good pastime.” Another participant, Sam, reported that he walked every day, and when the researcher asked if he liked walking every day he responded, “Good, it makes me feel good, yeah yeah…walking is good for me, I’ve been walking around for quite a while now so.” Dave was able to link his reason for enjoying his walking to the current season of the year, stating, “…I like walking and fresh air and the breeze.” Sarah described what she liked about walking in relation to her sense of smell: “Well…it smells good.”

Walking for Health Benefits. This theme describes participants’ perspectives on walking because of the health benefits they derived from walking. John stated, “Well I enjoy [walking] because it’s good exercise.” Similarly, when the researcher asked Helen why she walked, she stated, “Hmm, exercise.”

Other participants mentioned that they walked because they wanted to keep fit and stay healthy. Richard, who used to be an athlete, reported that he enjoyed walking because “…it keeps your legs in shape. …As an athlete you’re used to walking a lot and yeah…I like keeping in shape.” Lisa, in her description of the need to walk to stay mentally healthy stated, “Yeah…[because] you have to walk, too, if you don’t walk it’s [not] good. You going to be cuckoo.”

Dave expressed his desire to keep walking to stay healthy and to keep him away from the LTC home. He also reported that he had been sedentary and needed to walk to prevent further complications:

[I walk] for my health reasons…well I try and, I do it because they tell me it’s good for you. And I want to stay healthy and stay away from these places. I spend a lot of time in that chair, I spend too much time, I spend too much time sitting like that…. These things can develop and then you haven’t fully recovered, and you come down here and you walk.

Walking as Purposeful. This theme represents walking for a purpose and describes where participants reported they were going during the interview, including looking for someone or something. Some participants indicated a desire to go home to see their family or be with their spouse and children. Sam said, “I’m going to go home and see my, see my wife and three kids and that’s it, maybe will be coming back, I don’t know, I don’t know what to do yet…I just enjoy going home now.” Helen, who had aphasia, was unable to tell the researcher specifically what she was looking for when walking. When asked if she was always looking for something or someone when walking she responded, “So many times.”

During the walking interview, Richard stated that he was going to the door, which might indicate a desire to leave. Richard’s family also mentioned that he had made several attempts to leave the LTC home. His walking activity was described as “walking to escape.” When the researcher asked Richard where he was going he responded, “To the door.”

Walking as a Lifelong Habit. This theme describes walking as related to a lifelong habit and was routinely expressed by participants. Participants reported that walking was a normal activity that had been part of their day-today life since they were younger. Barbara said, “Well, I’m used to [walking].” John also mentioned, “I have done lots of walking in my life you know. I walked a lot in my life you know. Well, I usually walk a lot…. every morning I usually go and walk, several hours.”

Two participants, Richard and Sam, who used to be athletes, reported that they were used to walking. Sam used to be a marathon runner and stated:

When I go out now, I’ll be walking pretty fast, even run a little bit. That’s what I do all the time. I used to run. Well ran or walked…but I’ve slowed down a bit, slowed down. I do a lot of walking and a bit of running.

According to Richard, “I walked a lot…I enjoyed walking as an athlete.”

Walking as a Form of Socialization. This theme describes participants’ perspectives on walking to socialize with others. Participants reported that they walked for socialization and liked walking with other residents in the LTC home. Other reasons for walking included having time to engage others in conversations. John stated, “Well you got time to talk…if you have something to say…express your viewpoints and see, see if you’re going the right road I guess and that’s about all.” Dave mentioned that he was “a social guy” who “can talk and get involved with discussions.” Sam stated, “Well I have friends down there hey…as I’m walking, I meet people, how are you, and all that stuff yeah… you know we walk around here, you meet, you meet.”

Sarah and Barbara mentioned that they walked because of their friends. When asked by the researcher why she walked Sarah said, “A friend of mine [chuckle].” Similarly, Barbara stated why she walked: “Well, I have a good group there.”

Walking to Be With Animals. This theme describes participants’ desire to be with animals while walking. One of the LTC homes had pets (a dog and bird). During the walking interview, some participants demonstrated interest in being with animals and stated that they enjoyed their company. Although these participants did not express directly that they walked to be with animals, while walking they stopped by to speak to and play with the pets. To a question about when he liked to walk, Dave responded “Oh, when the birds are chirping.”

Participants’ Concerns

During the walking interview, some participants expressed concerns. Dave expressed concerns related to a loss of privacy when walking: “…the only thing is if I want privacy, I find it hard because I know so many people, they all want to say hello, which is okay…and I’m a social guy.” Dave also expressed his concern about living in a LTC home and Alzheimer’s disease, including its effects on other residents living in the LTC home:

I’m worried because…this place here is not my favorite kind of place…. Living together with people like this guy and people who are incapacitated and ill and that’s what you got here right…the majority of people are like that…. It’s not the best kind of environment for you…the people that bother me when I see the worse, is people with Alzheimer’s, terrible disease…there’s no cure…

Sam expressed concerns about the noise level and crowding in the LTC home: “There [are] too many people…everyone’s yapping and yapping, it’s too much… this is confusing, this area.” The environmental triggers for Sam’s wandering might be crowding and noise, as suggested by Algase, Beattie, Antonakos, Beel-Bates, and Yao (2010). Apart from mentioning that there were too many people, Sam was observed to be moving away from the place that he reported was “confusing.”

Researcher’s Reflection

A reflective journal was kept throughout the study to record and reflect on observations prior to and during the walk and observations of wandering as well as nonverbal behaviors of participants. Observed nonverbal behaviors included facial expressions and emotions as related to wandering and interaction with others. Participants’ facial expressions and emotions varied and reflected being happy, confused, bored, and anxious. Positive emotional expressions have been linked with wandering in older adults with dementia (Lee, Algase, & McConnell, 2014). Only one participant was anxious about getting out to meet his family (wife and children) who were waiting for him at home. This is an excerpt from the researcher’s journal:

Lisa is a very pleasant, happy woman. She loved and really enjoyed walking…. She also loved the company of animals. We stopped by to see a dog and the bird during her walk. She talked a lot about herself, family, and the staff during the interview…and how she loved the [LTC home].

Although some participants were unsure about where they were, the majority were observed to be interacting in a positive way with other residents and staff. Interestingly, the researcher observed that some participants, mainly women, walked together in groups.

During the walking interview, some participants entered other residents’ rooms and required cues and supervision, whereas others attempted to exit the LTC home. Other participants seemed to have difficulty with wayfinding around the LTC home and would walk into obstacles and walls. The physical environment of the LTC homes (e.g., linear hallways) could have contributed to wayfinding difficulty for some participants.

The researcher observed that LTC home staff encouraged some participants to walk and also supervised, served snacks (including fluids at scheduled times), and provided cues to rest. For example, John was observed to be running out of breath and needed to be reminded to rest to catch his breath.

Discussion

There are limited empirical studies on the perspectives of individuals with dementia who wander. The health benefits of walking as a form physical activity are not unusual findings and are consistent with previous research. Several studies reported that physical exercise improves circulation and oxygenation, prevents contractures, promotes cognitive function, and reduces depression and risks of developing cardiovascular and metabolic diseases, osteoporosis, and falls (Lai & Arthur, 2003; Lindwall, Rennemark, Halling, Berglund, & Hassmén, 2006; McPhee et al., 2016; Rolland et al., 2000; Taylor et al., 2004).

One noteworthy finding was that participants engaged in wandering to maintain mental health, considering wandering has been associated with depression in the literature (Kiely, Morris, & Algase et al., 2000; Klein et al., 1999). Participants related walking as being healthy, and Lisa suggested her need to stay mentally healthy through walking. This finding suggests a need to develop research questions that explore walking in relation to mental health benefits as well as physical improvement.

Although the literature has well documented that wandering is viewed as problematic and challenging by health care providers (Dewing, 2005; Halek & Bartholomeyczik, 2012; Lai & Arthur, 2003; Wigg, 2010), participants in the current study perceived wandering differently and reported it as enjoyable. Previous work by Robinson et al. (2007) examined the perspectives of individuals with mild dementia and reported that wandering was perceived as enjoyable by participants. However, the current study expanded the inclusion criterion to include residents with mild to moderate dementia in LTC homes.

Walking as enjoyable suggests that some participants need to leave the closed environment of the LTC home to enjoy the outdoors. Most LTC homes, including the sites for the current study, have locked units and door alarms to monitor or control the movement of residents, especially those at risk of leaving. Although locked units can provide a sense of safety and security, this restriction can also be an indication of power over accessing and exiting the LTC home and subsequently make residents feel entrapped and excluded (Tufford, Lowndes, Struthers, & Chivers, 2018). Therefore, walking may be an expression of control (autonomy) and agency for residents (Dewing, 2011). The current study raises questions on the need for more studies on the benefits of walking as an expression of autonomy.

Another finding is walking as purposeful because it was done to achieve a goal. Some participants repeatedly stated that they had to be somewhere and “would be back later.” Research has suggested that wandering may indicate a search for a familiar person (e.g., spouse, child) or place (e.g., previous home), something that is lost, or the need to perform a former role or responsibility, especially for those who used to be athletes or wanted to get to a former work-place (Algase et al., 1996; Brooker & Surr, 2005; Silverstein et al., 2002). However, wandering has been defined more often as “aimless” (Cipriani, Lucetti, Nuti, & Danti, 2014; Lai & Arthur, 2003). The definition of wandering as aimless needs to be explored because this is limited to other’s perspectives and does not seem to include older adults’ perspectives.

Interestingly, walking was also perceived as a means to leave the LTC home, which may signify a purposeful activity. Walking to escape is a major concern to family members and health care providers because it is associated with risks for safety (Aud, 2004; Rowe & Bennett, 2003). However, walking may have therapeutic effects of relieving boredom and could be a means of older adults occupying themselves, which could bring a sense of purpose (Algase et al., 1996; Andrews, 2017; Robinson et al., 2006). Wandering, including walking to escape, should not be labeled as a problem because this focuses on the behavior rather than the underlying need (Algase et al., 1996).

Wandering could be a lifelong habit that older adults with dementia engage in (Dewing, 2011). Consistent with the literature, walking was a lifelong habit for some participants in the current study. Individuals who used to walk regularly in the past, either for work, leisure, or as a means of coping with stress, are more likely to wander in search of stimulation (Algase et al., 1996; Andrews, 2017; Dewing, 2005).

The need for social interaction may be a stimulus for wandering. Participants in the current study were drawn to others. It has been suggested that dementia may affect an older adult’s level of social engagement (Algase et al., 1996). Most participants in the current study maintained moderate or higher levels of social engagement and were observed to engage and interact positively with other residents and staff in the LTC home.

Wandering is reported to be more common among men (Kiely et al., 2000; Klein et al., 1999). In the current study, some participants, mostly women, were more likely to walk together in small groups. These women verbalized that they enjoyed walking with other residents and also encouraged others to walk with them. Women who exhibit wandering may be more comfortable walking in groups with benefits of support and socialization. More studies are needed to examine potential gender differences on wandering behavior.

Walking to be with animals (e.g., pets) is a new finding and indicates participants’ interest in enjoying the company of animals. Studies examining the effects of animal-assisted therapy (AAT) on older adults with dementia concluded that AAT improves socialization and decreases agitated behaviors (Perkins, Bartlett, Travers, & Rand, 2008; Sellers, 2006). However, no studies have reported seeking animals and wandering behavior.

Limitations

The current study had three major limitations. First, the study used a purposive sample of ambulatory residents with mild to moderate dementia who could respond to simple questions. Residents with later stages of dementia were not recruited. Although the intent of the researcher was to better understand the perspectives of residents with mild to moderate dementia, wandering is also common among residents with severe dementia.

Second, the researcher’s perspective and preconceptions about wandering might affect her interpretation of the data. To minimize any personal bias, procedures were put in place, such as coding independently and then jointly with the advisor who is an experienced researcher, and maintaining a reflective journal (including observational notes) throughout the study.

Third, the researcher was not able to accurately discern what might be the optimal time for the walking interviews. Time spent with participants prior to the interview helped with this decision but it is not known how data might have been different if other interview times had been selected. Most participants seemed to enjoy having a companion while walking. Some demonstrated agitation and the researcher’s presence may have contributed to this agitation.

Recommendations for Practice

The findings of the current study suggest the need for a reconceptualization of wandering behavior from aimless walking and disruption to an enjoyable, purposeful, beneficial, and socializing activity. The negative perspective associated with wandering needs to be critically questioned and challenged. As demonstrated in the current study, residents with mild to moderate dementia were able to provide their perspectives on how walking was mainly a positive experience. Learning from residents’ perspectives on wandering can help develop a broader interpretation of wandering. One way is for health care providers to ask residents expressing wandering behavior simple questions about why they walk. Knowing the life history, including any walking history of newly admitted residents, is recommended. In addition, residents and their families should be involved in developing an individualized plan of care related to wandering behavior.

Considering the benefits of walking, supervised walking programs inside and outside of the LTC home should be encouraged, with collaboration among staff, residents, and family members. Although walking is beneficial to residents, it is worth noting that walking can become excessive and residents may be at risk of developing dehydration, malnutrition, and other complications associated with excessive walking. Therefore, testing interventions to promote safe and healthy walking for residents and minimize risks associated with walking rather than an overall prevention strategy should be explored.

The physical and social environments play key roles as residents adjust to their lives in LTC homes. Health care providers should attend to environmental triggers, including noise and crowding, and their effects on residents. More research on the effects of the social environment on residents’ wandering behavior is needed. The goal of promoting socialization among residents should not be to reduce wandering behavior. Rather, walking should be encouraged to promote socialization. This new finding suggests that residents may engage in walking to find or be with animals. Therefore, further studies on the therapeutic use of pets in fostering residents’ interaction with animals and walking should be explored.

Conclusion

The current study focused on the perspectives of older adults with dementia in LTC homes. From their perspectives, walking was an activity that was enjoyable, beneficial, purposeful, and socializing. Wandering was also an expression of unmet needs, such as a desire to be with family, to relieve boredom, or to continue a lifelong habit. Now that “expert” perspectives of older adults who wander have been elicited, the behavior can be reconceptualized, most importantly, from being disruptive to an activity that is meaningful.

Risks associated with wandering are still present and a concern. However, risks should not be the entire focus. Care should be person-centered. The less wandering behavior is seen as a problem, the more its benefits will be seen. Indeed, older adults with dementia are experts in the area of wandering behavior. Health care providers must learn from them and correspondingly change their thinking to support the benefits of walking.

References

• Algase, D.L., Beattie, E.R.A., Antonakos, C., Beel-Bates, C.A. & Yao, L. (2010). Wandering and the physical environment. American Journal of Alzheimer’s Disease & Other Dementias, 25, 340–346. doi:10.1177/1533317510365342 [CrossRef]
• Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. & Beattie, E. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer’s Disease & Other Dementias, 11(6), 10–19. doi:10.1177/153331759601100603 [CrossRef]
• Ali, N., Luther, S., Volicer, L., Algase, D., Beattie, E., Brown, L. & Joseph, I. (2016). Risk assessment of wandering behavior in mild dementia. International Journal of Geriatric Psychiatry, 31, 367–374. doi:10.1002/gps.4336 [CrossRef]
• Andrews, J. (2017). “Wandering” and dementia. British Journal of Community Nursing, 22, 322–323. doi:10.12968/bjcn.2017.22.7.322 [CrossRef]
• Aud, M.A. (2004). Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. American Journal of Alzheimer’s Disease & Other Dementias, 19, 361–368. doi:10.1177/153331750401900602 [CrossRef]
• Brooker, D. & Surr, C. (2005). Dementia care mapping: Principles and practice (2nd ed.). Bradford, UK: Bradford Dementia Group.
• Canadian Institute for Health Information. (2013). Describing outcome scales (RAI-MDS 2.0). Retrieved from https://www.cihi.ca/en/outcome_rai-mds_2.0_en.pdf
• Cipriani, G., Lucetti, C., Nuti, A. & Danti, S. (2014). Wandering and dementia. Psychogeriatrics, 14, 135–142. doi:10.1111/psyg.12044 [CrossRef]
• Dewing, J. (2005). Screening for wandering among older persons with dementia. Nursing Older People, 17(3), 20–22, 24. doi:10.7748/nop2005.05.17.3.20.c2372 [CrossRef]
• Dewing, J. (2006). Wandering into the future: Reconceptualizing wandering “a natural and good thing.”International Journal of Older People Nursing, 1, 239–249. doi:10.1111/j.1748-3743.2006.00045.x [CrossRef]
• Dewing, J. (2011). Dementia care: Assess wander walking and apply strategies. Nursing & Residential Care, 13, 494–496. doi:10.12968/nrec.2011.13.10.494 [CrossRef]
• Engberg, J., Castle, N.G. & McCaffrey, D. (2008). Physical restraint initiation in nursing homes and subsequent resident health. The Gerontologist, 48, 442–452. doi:10.1093/geront/48.4.442 [CrossRef]
• Gill, S.S., Bronskill, S.E., Normand, S.L., Anderson, G.M., Sykora, K., Lam, K. & Rochon, P.A. (2007). Antipsychotic drug use and mortality in older adults with dementia. Annals of Internal Medicine, 146, 775–786. doi:10.7326/0003-4819-146-11-200706050-00006 [CrossRef]
• Gu, L. (2015). Nursing interventions in managing wandering behavior in patients with dementia: A literature review. Archives of Psychiatric Nursing, 29, 454–457. doi:10.1016/j.apnu.2015.06.003 [CrossRef]
• Halek, M. & Bartholomeyczik, S. (2012). Description of the behaviour of wandering in people with dementia living in nursing homes: A review of the literature. Scandinavian Journal of Caring Sciences, 26, 404–413. doi:10.1111/j.1471-6712.2011.00932.x [CrossRef]
• Kiely, D.K., Morris, J.N. & Algase, D.L. (2000). Resident characteristics associated with wandering in nursing homes. International Journal of Geriatric Psychiatry, 15, 1013–1020. doi:10.1002/1099-1166(200011)15:11<1013::AID-GPS226>3.0.CO;2-X [CrossRef]
• Kitwood, T. (1993). Person and process in dementia. International Journal of Geriatric Psychiatry, 8, 541–545. doi:10.1002/gps.930080702 [CrossRef]
• Klein, D.A., Steinberg, M., Galik, E., Steele, C., Sheppard, J.M., Warren, A. & Lyketsos, C.G. (1999). Wandering behaviour in community-residing persons with dementia. International Journal of Geriatric Psychiatry, 14, 272–279. doi:10.1002/(SICI)1099-1166(199904)14:4<272::AID-GPS896>3.0.CO;2-P [CrossRef]
• Lai, C.K.Y. & Arthur, D.G. (2003). Wandering behaviour in people with dementia. Journal of Advanced Nursing, 44, 173–182. doi:10.1046/j.1365-2648.2003.02781.x [CrossRef]
• Lee, K.H., Algase, D.L. & McConnell, E.S. (2014). Relationship between observable emotional expression and wandering behavior of people with dementia. International Journal of Geriatric Psychiatry, 29, 85–92. doi:10.1002/gps.3977 [CrossRef]
• Lindwall, M., Rennemark, M., Halling, A., Berglund, J. & Hassmén, P. (2006). Depression and exercise in elderly men and women: Findings from the Swedish national study on aging and care. Journal of Aging and Physical Activity, 15, 41–55. doi:10.1123/japa.15.1.41 [CrossRef]
• MacAndrew, M., Beattie, E., O’Reilly, M., Kolanowski, A. & Windsor, C. (2017). The trajectory of tolerance for wandering-related boundary transgression: An exploration of care staff and family perceptions. The Gerontologist, 57, 451–460. doi:10.1093/geront/gnv136 [CrossRef]
• MacAndrew, M., Fielding, E., Kolanowski, A., O’Reilly, M. & Beattie, E. (2017). Observing wandering-related boundary transgression in people with severe dementia. Aging & Mental Health, 21, 1197–1205. doi:10.1080/13607863.2016.1211620 [CrossRef]
• Marquardt, G., Bueter, K. & Motzek, T. (2014). Impact of the design of the built environment on people with dementia: An evidence-based review. Health Environments Research & Design Journal, 8, 127–157. doi:10.1177/193758671400800111 [CrossRef]
• McPhee, J.S, French, D.P, Jackson, D., Nazroo, J., Pendleton, N. & Degens, H. (2016). Physical activity in older age: Perspectives for healthy ageing and frailty. Biogerontology, 17, 567–580. doi:10.1007/s10522-016-9641-0 [CrossRef]
• Perkins, J., Bartlett, H., Travers, C. & Rand, J. (2008). Dog-assisted therapy for older people with dementia: A review. Australasian Journal on Ageing, 27, 177–182. doi:10.1111/j.1741-6612.2008.00317.x [CrossRef]
• Raetz, J. (2013). A nondrug approach to dementia. Journal of Family Practice, 62, 548–557.
• Robinson, L., Hutchings, D., Corner, L., Beyer, F., Dickinson, H., Vanoli, A. & Bond, J. (2006). A systematic literature review of the effectiveness of non-pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technology Assessment, 10(26), 1–126. doi:10.3310/hta10260 [CrossRef]
• Robinson, L., Hutchings, D., Corner, L., Finch, T., Hughes, J., Brittain, K. & Bond, J. (2007). Balancing rights and risks: Conflicting perspectives in the management of wandering in dementia. Health, Risk & Society, 9, 389–406. doi:10.1080/13698570701612774 [CrossRef]
• Rolland, Y., Rival, L., Pillard, F., Lafont, C., Rivére, D., Albaréde, J. & Vellas, B. (2000). Feasibility [corrected] of regular exercise for patients with moderate to severe Alzheimer disease. The Journal of Nutrition, Health & Aging, 4, 109–113.
• Rowe, M.A. & Bennett, V. (2003). A look at deaths occurring in persons with dementia lost in the community. American Journal of Alzheimer’s Disease & Other Dementias, 18, 343–348. doi:10.1177/153331750301800612 [CrossRef]
• Rowe, M.A., Vandeveer, S.S., Greenblum, C.A., List, C.N., Fernandez, R.M., Mixson, N.E. & Ahn, H.C. (2011). Persons with dementia missing in the community: Is it wandering or something unique?BMC Geriatrics, 11, 28. doi:10.1186/1471-2318-11-28 [CrossRef]
• Sellers, D.M. (2006). The evaluation of an animal assisted therapy intervention for elders with dementia in long term care. Activities, Adaptation, & Aging, 30, 61–77. doi:10.1300/J016v30n01_04 [CrossRef]
• Shinoda-Tagawa, T., Leonard, R., Pontikas, J., McDonough, J.E., Allen, D. & Dreyer, P.I. (2004). Resident-to-resident violent incidents in nursing homes. JAMA, 291, 591–598. doi:10.1001/jama.291.5.591 [CrossRef]
• Silverstein, N.M., Tobin, T.S. & Flaherty, G. (2002). Dementia and wandering behavior: Concern for the lost elder. New York, NY: Springer.
• Snellgrove, S., Beck, C., Green, A. & McSweeney, J.C. (2013). Resident-to-resident violence triggers in nursing homes. Clinical Nursing Research, 22, 461–474. doi:10.1177/1054773813477128 [CrossRef]
• Tanner, D. (2012). Co-research with older people with dementia: Experience and reflections. Journal of Mental Health, 21, 296–306. doi:10.3109/09638237.2011.651658 [CrossRef]
• Taylor, A.H., Cable, N.T, Faulkner, G., Hillsdon, M., Narici, M. & Van Der Bij, A.K. (2004). Physical activity and older adults: A review of health benefits and the effectiveness of interventions. Journal of Sports Sciences, 22, 703–725. doi:10.1080/02640410410001712421 [CrossRef]
• Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.). New York, NY: Routledge Taylor & Francis.
• Thorne, S., Kirkham, S.R. & O’Flynn-Magee, K. (2004). The analytic challenge in interpretive description. International Journal of Qualitative Methods, 3(1), 1–11. doi:10.1177/160940690400300101 [CrossRef]
• Tufford, F., Lowndes, R., Struthers, J. & Chivers, S. (2018). “‘Call security’: Locks, risk, privacy and autonomy in long-term residential care.”Ageing International, 43, 34–52. doi:10.1007/s12126-017-9289-3 [CrossRef]
• Whitlatch, C.J., Feinberg, L.F. & Tucke, S.S. (2005). Measuring the values and preferences for everyday care of persons with cognitive impairment and their family caregivers. The Gerontologist, 45, 370–380. doi:10.1093/geront/45.3.370 [CrossRef]
• Wigg, J.M. (2010). Liberating the wanderers: Using technology to unlock doors for those living with dementia. Sociology of Health & Illness, 32, 288–303. doi:10.1111/j.1467-9566.2009.01221.x [CrossRef]

Table 1

Sociodemographics of Long-Term Care (LTC) Home Participants (N = 8)

Table 2

Themes and Sub-Themes for Participants’ Perspectives on Walking/Wandering

Figures/Tables

References

References

• Algase, D.L., Beattie, E.R.A., Antonakos, C., Beel-Bates, C.A. & Yao, L. (2010). Wandering and the physical environment. American Journal of Alzheimer’s Disease & Other Dementias, 25, 340–346. doi:10.1177/1533317510365342 [CrossRef]
• Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. & Beattie, E. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer’s Disease & Other Dementias, 11(6), 10–19. doi:10.1177/153331759601100603 [CrossRef]
• Ali, N., Luther, S., Volicer, L., Algase, D., Beattie, E., Brown, L. & Joseph, I. (2016). Risk assessment of wandering behavior in mild dementia. International Journal of Geriatric Psychiatry, 31, 367–374. doi:10.1002/gps.4336 [CrossRef]
• Andrews, J. (2017). “Wandering” and dementia. British Journal of Community Nursing, 22, 322–323. doi:10.12968/bjcn.2017.22.7.322 [CrossRef]
• Aud, M.A. (2004). Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. American Journal of Alzheimer’s Disease & Other Dementias, 19, 361–368. doi:10.1177/153331750401900602 [CrossRef]
• Brooker, D. & Surr, C. (2005). Dementia care mapping: Principles and practice (2nd ed.). Bradford, UK: Bradford Dementia Group.
• Canadian Institute for Health Information. (2013). Describing outcome scales (RAI-MDS 2.0). Retrieved from https://www.cihi.ca/en/outcome_rai-mds_2.0_en.pdf
• Cipriani, G., Lucetti, C., Nuti, A. & Danti, S. (2014). Wandering and dementia. Psychogeriatrics, 14, 135–142. doi:10.1111/psyg.12044 [CrossRef]
• Dewing, J. (2005). Screening for wandering among older persons with dementia. Nursing Older People, 17(3), 20–22, 24. doi:10.7748/nop2005.05.17.3.20.c2372 [CrossRef]
• Dewing, J. (2006). Wandering into the future: Reconceptualizing wandering “a natural and good thing.”International Journal of Older People Nursing, 1, 239–249. doi:10.1111/j.1748-3743.2006.00045.x [CrossRef]
• Dewing, J. (2011). Dementia care: Assess wander walking and apply strategies. Nursing & Residential Care, 13, 494–496. doi:10.12968/nrec.2011.13.10.494 [CrossRef]
• Engberg, J., Castle, N.G. & McCaffrey, D. (2008). Physical restraint initiation in nursing homes and subsequent resident health. The Gerontologist, 48, 442–452. doi:10.1093/geront/48.4.442 [CrossRef]
• Gill, S.S., Bronskill, S.E., Normand, S.L., Anderson, G.M., Sykora, K., Lam, K. & Rochon, P.A. (2007). Antipsychotic drug use and mortality in older adults with dementia. Annals of Internal Medicine, 146, 775–786. doi:10.7326/0003-4819-146-11-200706050-00006 [CrossRef]
• Gu, L. (2015). Nursing interventions in managing wandering behavior in patients with dementia: A literature review. Archives of Psychiatric Nursing, 29, 454–457. doi:10.1016/j.apnu.2015.06.003 [CrossRef]
• Halek, M. & Bartholomeyczik, S. (2012). Description of the behaviour of wandering in people with dementia living in nursing homes: A review of the literature. Scandinavian Journal of Caring Sciences, 26, 404–413. doi:10.1111/j.1471-6712.2011.00932.x [CrossRef]
• Kiely, D.K., Morris, J.N. & Algase, D.L. (2000). Resident characteristics associated with wandering in nursing homes. International Journal of Geriatric Psychiatry, 15, 1013–1020. doi:10.1002/1099-1166(200011)15:11<1013::AID-GPS226>3.0.CO;2-X [CrossRef]
• Kitwood, T. (1993). Person and process in dementia. International Journal of Geriatric Psychiatry, 8, 541–545. doi:10.1002/gps.930080702 [CrossRef]
• Klein, D.A., Steinberg, M., Galik, E., Steele, C., Sheppard, J.M., Warren, A. & Lyketsos, C.G. (1999). Wandering behaviour in community-residing persons with dementia. International Journal of Geriatric Psychiatry, 14, 272–279. doi:10.1002/(SICI)1099-1166(199904)14:4<272::AID-GPS896>3.0.CO;2-P [CrossRef]
• Lai, C.K.Y. & Arthur, D.G. (2003). Wandering behaviour in people with dementia. Journal of Advanced Nursing, 44, 173–182. doi:10.1046/j.1365-2648.2003.02781.x [CrossRef]
• Lee, K.H., Algase, D.L. & McConnell, E.S. (2014). Relationship between observable emotional expression and wandering behavior of people with dementia. International Journal of Geriatric Psychiatry, 29, 85–92. doi:10.1002/gps.3977 [CrossRef]
• Lindwall, M., Rennemark, M., Halling, A., Berglund, J. & Hassmén, P. (2006). Depression and exercise in elderly men and women: Findings from the Swedish national study on aging and care. Journal of Aging and Physical Activity, 15, 41–55. doi:10.1123/japa.15.1.41 [CrossRef]
• MacAndrew, M., Beattie, E., O’Reilly, M., Kolanowski, A. & Windsor, C. (2017). The trajectory of tolerance for wandering-related boundary transgression: An exploration of care staff and family perceptions. The Gerontologist, 57, 451–460. doi:10.1093/geront/gnv136 [CrossRef]
• MacAndrew, M., Fielding, E., Kolanowski, A., O’Reilly, M. & Beattie, E. (2017). Observing wandering-related boundary transgression in people with severe dementia. Aging & Mental Health, 21, 1197–1205. doi:10.1080/13607863.2016.1211620 [CrossRef]
• Marquardt, G., Bueter, K. & Motzek, T. (2014). Impact of the design of the built environment on people with dementia: An evidence-based review. Health Environments Research & Design Journal, 8, 127–157. doi:10.1177/193758671400800111 [CrossRef]
• McPhee, J.S, French, D.P, Jackson, D., Nazroo, J., Pendleton, N. & Degens, H. (2016). Physical activity in older age: Perspectives for healthy ageing and frailty. Biogerontology, 17, 567–580. doi:10.1007/s10522-016-9641-0 [CrossRef]
• Perkins, J., Bartlett, H., Travers, C. & Rand, J. (2008). Dog-assisted therapy for older people with dementia: A review. Australasian Journal on Ageing, 27, 177–182. doi:10.1111/j.1741-6612.2008.00317.x [CrossRef]
• Raetz, J. (2013). A nondrug approach to dementia. Journal of Family Practice, 62, 548–557.
• Robinson, L., Hutchings, D., Corner, L., Beyer, F., Dickinson, H., Vanoli, A. & Bond, J. (2006). A systematic literature review of the effectiveness of non-pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technology Assessment, 10(26), 1–126. doi:10.3310/hta10260 [CrossRef]
• Robinson, L., Hutchings, D., Corner, L., Finch, T., Hughes, J., Brittain, K. & Bond, J. (2007). Balancing rights and risks: Conflicting perspectives in the management of wandering in dementia. Health, Risk & Society, 9, 389–406. doi:10.1080/13698570701612774 [CrossRef]
• Rolland, Y., Rival, L., Pillard, F., Lafont, C., Rivére, D., Albaréde, J. & Vellas, B. (2000). Feasibility [corrected] of regular exercise for patients with moderate to severe Alzheimer disease. The Journal of Nutrition, Health & Aging, 4, 109–113.
• Rowe, M.A. & Bennett, V. (2003). A look at deaths occurring in persons with dementia lost in the community. American Journal of Alzheimer’s Disease & Other Dementias, 18, 343–348. doi:10.1177/153331750301800612 [CrossRef]
• Rowe, M.A., Vandeveer, S.S., Greenblum, C.A., List, C.N., Fernandez, R.M., Mixson, N.E. & Ahn, H.C. (2011). Persons with dementia missing in the community: Is it wandering or something unique?BMC Geriatrics, 11, 28. doi:10.1186/1471-2318-11-28 [CrossRef]
• Sellers, D.M. (2006). The evaluation of an animal assisted therapy intervention for elders with dementia in long term care. Activities, Adaptation, & Aging, 30, 61–77. doi:10.1300/J016v30n01_04 [CrossRef]
• Shinoda-Tagawa, T., Leonard, R., Pontikas, J., McDonough, J.E., Allen, D. & Dreyer, P.I. (2004). Resident-to-resident violent incidents in nursing homes. JAMA, 291, 591–598. doi:10.1001/jama.291.5.591 [CrossRef]
• Silverstein, N.M., Tobin, T.S. & Flaherty, G. (2002). Dementia and wandering behavior: Concern for the lost elder. New York, NY: Springer.
• Snellgrove, S., Beck, C., Green, A. & McSweeney, J.C. (2013). Resident-to-resident violence triggers in nursing homes. Clinical Nursing Research, 22, 461–474. doi:10.1177/1054773813477128 [CrossRef]
• Tanner, D. (2012). Co-research with older people with dementia: Experience and reflections. Journal of Mental Health, 21, 296–306. doi:10.3109/09638237.2011.651658 [CrossRef]
• Taylor, A.H., Cable, N.T, Faulkner, G., Hillsdon, M., Narici, M. & Van Der Bij, A.K. (2004). Physical activity and older adults: A review of health benefits and the effectiveness of interventions. Journal of Sports Sciences, 22, 703–725. doi:10.1080/02640410410001712421 [CrossRef]
• Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.). New York, NY: Routledge Taylor & Francis.
• Thorne, S., Kirkham, S.R. & O’Flynn-Magee, K. (2004). The analytic challenge in interpretive description. International Journal of Qualitative Methods, 3(1), 1–11. doi:10.1177/160940690400300101 [CrossRef]
• Tufford, F., Lowndes, R., Struthers, J. & Chivers, S. (2018). “‘Call security’: Locks, risk, privacy and autonomy in long-term residential care.”Ageing International, 43, 34–52. doi:10.1007/s12126-017-9289-3 [CrossRef]
• Whitlatch, C.J., Feinberg, L.F. & Tucke, S.S. (2005). Measuring the values and preferences for everyday care of persons with cognitive impairment and their family caregivers. The Gerontologist, 45, 370–380. doi:10.1093/geront/45.3.370 [CrossRef]
• Wigg, J.M. (2010). Liberating the wanderers: Using technology to unlock doors for those living with dementia. Sociology of Health & Illness, 32, 288–303. doi:10.1111/j.1467-9566.2009.01221.x [CrossRef]

Authors

Ms. Adekoya is Instructor, Nursing Department, School of Health Sciences and Community Services, Red River College, and Dr. Guse is Adjunct Professor, College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Funding was provided by the Manitoba Centre for Nursing and Health Research (MCNHR) Fort Garry Legion Poppy Trust Fund Research Grant.

The authors acknowledge the support of Mona McLeod and the contributions of MCNHR to the success of this study.

Address correspondence to Adebusola A. Adekoya, MN, RN, Instructor, Nursing Department, School of Health Sciences and Community Services, Red River College, 75 Colbourne Drive, Winnipeg, MB R3Y 0K6; e-mail: ajibola_ynk@yahoo.co.uk.

Posted on August 27, 2019.