A Wanderer's Lounge Program for nursing home residents with Alzheimer's disease

Alzheimer's disease and outdoor space: Issues in environmental design

As special care units for individuals with Alzheimer's disease become established, there is a growing interest in creating outdoor space to complement the interior program. At present, little information exists concerning appropriate design principles for outdoor spaces. This paper discusses the design implications for outdoor environments based upon the changes in physical and mental abilities that are associated with aging and Alzheimer's disease. Methods of compensating for limited physical and mental capabilities are explored, including the provision of prosthetic supports and orientation aids to increase an individual's independence and sense of well being.

A case study on the effects of a retrofitted dementia special care unit on resident behaviors

The need to demonstrate the efficacy of special care units (SCUs) is of primary concern to consumers who increasingly demand accountability for health delivery services. The present study describes the characteristics of a SCU and measures the effects on resident outcomes using an ex-post facto design. Fifteen residents diagnosed with dementia were evaluated on five variables-combativeness, falls, restraint use, weight, and ADL skills-before and after admission to the SCU. The results of paired T-tests revealed that restraint use significantly decreased (p < .05) and activities of daily living (ADL) skills significantly increased (p < .01). An increase in falls was near significance. No change was found in weight or combativeness.

Managing the wandering behaviour of people living in a residential aged care facility

Background  Wandering behaviour is frequently seen in older people with cognitive impairment. The prevalence of patients exhibiting wandering behaviour has been estimated to be 11.6% on traditional units and 52.7% on Alzheimer's units. Wandering is one of the core behavioural characteristics that impact on familial carers and is likely to influence the decision to place a family member in an aged care environment. Considering the possible risks associated with wandering behaviour, the successful identification and management of wandering is essential. Wandering is also a problem for caregivers in the institutionalised setting, in terms of containment, usually being addressed by securing the environment. There has been some research conducted to assist in the understanding and management of wandering behaviour; however, the findings have been diverse resulting in a level of confusion about the best approaches to take. Objectives  This review aims to present the best available evidence on the management of wandering in older adults who reside in an aged care facility (both high and low care). Search strategy  An extensive search of keywords contained in the title and abstract, and relevant MeSH headings and descriptor terms was performed on the following databases: MEDLINE, CINAHL, PsychINFO, AGELINE, Cochrane Library, Embase, APAIS Health, Current Contents, Dare, Dissertation Abstracts, Personal Communication, Social Science Index. Selection criteria  Papers were selected if they focused on the treatment of wandering in an institutional setting. Some studies were not specifically examining wanderers over the age of 65 years as per the protocol requirements, but were included as it was felt that their findings could be applied to this age group. Data collection and analysis  Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results  Searches identified one care protocol, two systematic reviews and 24 other studies that satisfied the inclusion criteria. The following recommendations are divided into four categories of interventions (environmental, technology and safety, physical/psychosocial, and caregiving support and education) with only Level 1, 2 or 3 evidence presented. Environmental modifications  Gridlines placed in front of doors or covering exit door doorknobs or panic bars may be effective at reducing exit-seeking behaviour (Level 3b). Technology and safety  Mobile locator devices may be effective at enabling quick location of wandering residents (Level 3c). Physical/psychosocial interventions  Implementation of a walking group or an exercise program may reduce the incidence of disruptive wandering behaviour (Level 3b). Use of air mat therapy may reduce wandering behaviour for at least 15 min post therapy (Level 2). Providing music sessions (and reading sessions) may keep residents from wandering during the period of the session (Level 3b). Caregiving support and education  There is no evidence to support any interventions. Conclusions  The majority of the available research for which the guidelines are based upon was derived from observational studies or expert opinion (Level of evidence 3 or 4). More rigorous research is required to demonstrate the efficacy of these recommendations.

Managing the wandering behaviour of people living in a residential aged care facility

BACKGROUND

Wandering behaviour is frequently seen in older people with cognitive impairment. The prevalence of patients exhibiting wandering behaviour has been estimated to be 11.6% on traditional units and 52.7% on Alzheimer's units. Wandering is one of the core behavioural characteristics that impact on familial carers and is likely to influence the decision to place a family member in an aged care environment. Considering the possible risks associated with wandering behaviour, the successful identification and management of wandering is essential. Wandering is also a problem for caregivers in the institutionalised setting, in terms of containment, usually being addressed by securing the environment. There has been some research conducted to assist in the understanding and management of wandering behaviour; however, the findings have been diverse resulting in a level of confusion about the best approaches to take.

OBJECTIVES

This review aims to present the best available evidence on the management of wandering in older adults who reside in an aged care facility (both high and low care).

SEARCH STRATEGY

An extensive search of keywords contained in the title and abstract, and relevant MeSH headings and descriptor terms was performed on the following databases: MEDLINE, CINAHL, PsychINFO, AGELINE, Cochrane Library, Embase, APAIS Health, Current Contents, Dare, Dissertation Abstracts, Personal Communication, Social Science Index.

SELECTION CRITERIA

Papers were selected if they focused on the treatment of wandering in an institutional setting. Some studies were not specifically examining wanderers over the age of 65 years as per the protocol requirements, but were included as it was felt that their findings could be applied to this age group.

DATA COLLECTION AND ANALYSIS

Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary.

RESULTS

Searches identified one care protocol, two systematic reviews and 24 other studies that satisfied the inclusion criteria. The following recommendations are divided into four categories of interventions (environmental, technology and safety, physical/psychosocial, and caregiving support and education) with only Level 1, 2 or 3 evidence presented.

ENVIRONMENTAL MODIFICATIONS

Gridlines placed in front of doors or covering exit door doorknobs or panic bars may be effective at reducing exit-seeking behaviour (Level 3b).

TECHNOLOGY AND SAFETY

Mobile locator devices may be effective at enabling quick location of wandering residents (Level 3c).

PHYSICAL/PSYCHOSOCIAL INTERVENTIONS

Implementation of a walking group or an exercise program may reduce the incidence of disruptive wandering behaviour (Level 3b). Use of air mat therapy may reduce wandering behaviour for at least 15 min post therapy (Level 2). Providing music sessions (and reading sessions) may keep residents from wandering during the period of the session (Level 3b).

CAREGIVING SUPPORT AND EDUCATION

There is no evidence to support any interventions.

CONCLUSIONS

The majority of the available research for which the guidelines are based upon was derived from observational studies or expert opinion (Level of evidence 3 or 4). More rigorous research is required to demonstrate the efficacy of these recommendations.

Wandering behaviour in people with dementia

BACKGROUND

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.

AIM

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.

METHOD

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.

FINDINGS

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.

CONCLUSION

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.

The effects of a walking/talking program on communication, ambulation, and functional status in residents with Alzheimer disease

The purpose of this study was to investigate the effects of a walking/talking program on residents' communication, ambulation, and level of function when there were two residents to one care provider (2:1). A randomized control trial design was used. Subjects were residents with Alzheimer disease in three geriatric long-term care facilities in Metropolitan Toronto. Residents who met the inclusion criteria were randomly assigned to one of three groups: walk-and-talk group (30 min, 5 times per week for 16 weeks, walking/talking in pairs), talk-only group (30 min, 5 times per week for 16 weeks, talk only in pairs), or no intervention. The outcome measures were the Functional Assessment of Communication Skills for Adults, the 2-min walk test, and London Psychogeriatric Rating Scale. Residents who received the walk-and-talk intervention did not demonstrate statistically significant differences in the outcome variables measured posttest when compared with residents who received the talk-only intervention or no intervention, even after controlling for individual differences. Variability in the outcomes measured posttest is explained by differences in the residents' level of cognitive impairment before the study rather than by study group membership. These findings are contradictory to those of previous studies.

A randomized trial of dementia care in nursing homes

OBJECTIVE

To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia.

DESIGN

Randomized controlled clinical trial with 6-month follow-up.

SETTING

A 250-bed community nursing home.

PATIENTS

The nursing home was screened to identify patients with dementia and behavior disorders. A total of 118 patients were eligible for randomization. Of these, 89 (75.4%) were randomized, and 81 of these (91.0%) completed the trial.

INTERVENTION

The A.G.E. dementia care program consisted of Activities, Guidelines for psychotropic medications, and Educational rounds. The control treatment was usual nursing home care.

MEASUREMENTS

Behavior disorders, antipsychotic drug and physical restraint use, patient activity levels, and cognitive and functional status.

RESULTS

After 6 months, 12 of 42 (28.6%) intervention patients exhibited behavior disorders compared with 20 of 39 (51.3%) controls (OR = 0.38; 95% CI [0.15, 0.95]; P = .037). Controls were more than twice as likely to receive antipsychotics (OR = 2.55, 95% CI [0.96, 6.76]; P < .056), to be restrained during activity times (OR = 2.98, 95% CI [1.10, 8.04]; P < .028), and to be restrained on nursing units (OR = 2.14, 95% CI [0.9, 5.3]; P < .10). Intervention patients were much more likely to participate in activities (OR = 13.71; 95% CI [4.51, 41.73]; P = .001).

CONCLUSIONS

The A.G.E. program reduces the prevalence of behavior disorders and the use of antipsychotic drugs and restraints. It is practical, feasible, and appears to improve the lives of patients with dementia in nursing homes.

Wandering: a proposed definition

1. Two typologies of wandering behavior, "continuous" and "sporadic" can be distinguished when time-in-motion is used as a criteria. 2. Interventions for "continuous wanderers" should emphasize modification of the environment while organized activities and verbal communication techniques should be stressed for the "sporadic wanderer." 3. Empirical research is needed that studies the different needs of wanderers based on the percentage of time spent in motion.

Problematic Wandering Behavior in the Cognitively Impaired Elderly: A Single-Subject Case Study

Three psychosocial factors that may influence wandering behavior have been previously identified: lifelong patterns of coping with stress, previous work roles, and a need to search for persons or places associated with security. Strategies for managing wandering behavior include environmental modifications, planned activities, physical exercise, and attention to psychosocial history. However, limited attention has been given to testing psychosocial approaches that could be used by nursing home staff when interacting with residents who wander. The findings of this study suggest that providing sufficient staff time for interacting with residents, programs that address residents' needs for activity and rest, and appropriate environmental modifications should occur in conjunction with the decreased use of antipsychotic medications and physical restraints.

A Low Intensity Exercise/Movement Program for Patients with Alzheimer’s Disease: The TEMP-AD Protocol

The purpose of this study was twofold: (a) develop and assess the suitability of a program of physical activity for an institutionalized population with Alzheimer’s disease (AD) and (b) evaluate the exercise/movement program’s impact on behavior of patients with AD. Twenty-two AD patients participated in a 40-min exercise/movement program for 28 days. The results showed that the program reduced the agitated behaviors of patients with AD by more than half (χ2= 101,df= 1,P< .0001; Cramer’s V = .23). The study confirmed that the exercise/movement program was both feasible and desirable for patients with AD, and that it reduced some of the adverse behaviors of the patients.

Disruptive, Institutionalized Elderly: A Cost-Effective Intervention

1. Psychomotor agitation can be decreased without the use of physical or chemical restraints. 2. A structured activity program can be integrated into the treatment plan of disruptive patients. 3. Nurses working in long-term care settings are in positions to be advocates for change.

Nursing home quality: a framework for analysis

Previous efforts to evaluate nursing home quality have been hampered by the lack of a conceptual model that specifies the major components and specifically associates measurable indicators with quality. An extensive literature review reveals many fragmented pieces of information, but no framework in which to fit the pieces together. The model presented here identifies four major dimensions of nursing home quality: (a) staff intervention, (b) physical environment, (c) nutrition/food service, and (d) community relations. These dimensions go beyond traditional "quality of care" by including quality-of-life considerations as well. The dimensions are each further divided into two subdimensions. I propose that measurable indicators for each of these eight subdimensions can be combined to make an effective and comprehensive quality measure.