Electronic tagging of people with dementia who wander

Effectiveness of Interventions for Preventing People With Dementia Exiting or Getting Lost

BACKGROUND AND OBJECTIVES

People with dementia are at risk of exiting premises unsupervised, eloping, or getting lost, potentially leading to harmful or distressing consequences. This review aimed to estimate the effectiveness of interventions for preventing people with dementia from exiting or getting lost.

RESEARCH DESIGN AND METHODS

A systematic review of English sources was undertaken. Health care (EMBASE, BNI, Medline, PubMed, CINAHL, PsycINFO, AMED, HTA, CENTRAL) and gray literature (OpenGrey) databases were searched using prespecified search terms. Additional studies were identified by hand-searching bibliographies of relevant reviews and included studies. Wide inclusion criteria were set to capture a range of intervention types. Data extraction and risk of bias assessment were completed independently by two reviewers. Methods were preregistered on PROSPERO.

RESULTS

Individual and overall risk of bias was too high for statistical meta-analyses. A narrative synthesis was therefore performed. Twenty-five studies with 814 participants were included, investigating a range of nonpharmacological interventions aiming to prevent exiting, facilitate retrieval, educate participants, or a combination of these. Seventeen (68%) of the included studies had critical risks of internal bias to outcomes, providing no useful evidence for the effectiveness of their respective interventions. The remaining 8 (32%) studies had serious risks of bias. Narrative synthesis of results yielded no overall robust evidence for the effectiveness of any interventions.

DISCUSSION AND IMPLICATIONS

No evidence was found to justify the recommendation of any interventions included in this review. Future studies should focus on high-quality, controlled study designs.

Electronic tracking devices in dementia care: A systematic review of argument-based ethics literature

BACKGROUND

Wandering is a behavioral symptom of dementia that often results in patients eloping from home or care facilities, leading to high-risk situations for injury or death. To mitigate this serious problem, caregivers use electronic tracking devices (ETDs) to manage wandering. As these devices can track, record, and monitor wearers, profound ethical questions are raised related to their use in this vulnerable population. The objective of this review was to identify the ethical frames, concepts, and arguments used in the normative literature that focused on ETDs in dementia care.

METHODS

We conducted a systematic literature review of normative literature that focused on ETDs in dementia care.

RESULTS

Twenty-two articles met the inclusion requirements. The majority of articles utilized a principlist approach, with arguments concerning ETDs largely falling under the four principles of biomedical ethics: respect for autonomy, non-maleficence, beneficence, and justice. Privacy and informed consent were specifically emphasized. The normative literature recognizes that ETDs may have a dual effect, potentially bolstering or eroding the values connected to each principle.

CONCLUSIONS

The prevailing use of principlism in the normative literature on ETDs indicates that there is a need to pursue new ethical approaches and expand upon the few non-principlist approaches already in use. In addition, many of the ethical issues around ETD use involve value-laden questions present during their design. Therefore, future ethical orientations or frameworks should account for ethical questions that exist along the design continuum on the use of ETDs.

Inclusion of Older Adults in the Research and Design of Digital Technology

Digital technology holds a promise to improve older adults' well-being and promote ageing in place. However, there seems to be a discrepancy between digital technologies that are developed and what older adults actually want and need. Ageing is stereotypically framed as a problem needed to be fixed, and older adults are considered to be frail and incompetent. Not surprisingly, many of the technologies developed for the use of older adults focus on care. The exclusion of older adults from the research and design of digital technology is often based on such negative stereotypes. In this opinion article, we argue that the inclusion rather than exclusion of older adults in the design process and research of digital technology is essential if technology is to fulfill the promise of improving well-being. We emphasize why this is important while also providing guidelines, evidence from the literature, and examples on how to do so. We unequivocally state that designers and researchers should make every effort to ensure the involvement of older adults in the design process and research of digital technology. Based on this paper, we suggest that ageism in the design process of digital technology might play a role as a possible barrier of adopting technology.

Fake bus stops for persons with dementia? On truth and benevolent lies in public health

Fake bus stops are one strategy to keep persons with dementia (PwD) from wandering. By setting up authentic looking shelters and benches in hallways or gardens, nursing homes create the illusion of bus stops, for the purpose of preventing wandering PwD from leaving the facility and getting lost. By attracting wandering PwD to sit down and wait for the bus, they can be supervised more easily by caregivers. However, concerns are expressed that the use of fake bus stops could cause more harm than good for PwD, due to their deceptive nature and the potential stigmatisation of individuals seated at a fake bus stop. This article discusses the ethical aspects of using fake bus stops and outlines considerations prior to setting up fake bus stops in nursing homes in keeping with good clinical practice in dementia care. Moreover, the article assesses whether or not fake bus stops can be ethically justifiable, and if so, how they can be ethically justified and implemented in Israeli and other facilities for PwD.

Supporting ethical use of electronic monitoring for people living with dementia: Social work's role in assessment, decision-making, and review

Walking outdoors supports health and well-being, but some people living with dementia are at increased risk of getting lost and of harm while missing. Electronic monitoring can potentially play an important preventative role by enabling the person's location to be continuously monitored by caregivers. However, there are considerable ethical concerns arising from electronic monitoring. This paper explores these thematically, drawing attention to its implications for autonomy and liberty; privacy; dignity; the rights and needs of caregivers and families; beneficence and nonmaleficence. Following from this, key questions for consideration in social work assessment are identified. The ethical issues necessitate assessment of the person's unique circumstances and preferences and that of their caregivers, and careful ethical deliberation in decision-making. Social work can play an important role in facilitating inclusive assessment and decision-making, leading to consensus on intervening with electronic monitoring. The need for the ongoing review following implementation is discussed to track whether decisions need modification in light of the experience of usage. In conclusion, while legislative instruments and professional codes of ethics frame social work practice responses, there is need for a nuanced debate about ethical use of electronic monitoring and specific guidance to inform assessment, decision-making, and review.

Innovation for elderly with dementia – localization technology transfer

Purpose

The purpose of this paper is to contribute to the discussion of transferring modern technology from industries such as logistics to the life of elderly in a way that they can understand, accept and make use of it.

Design/methodology/approach

This is a conceptual discussion based on findings from a series of projects in healthcare, IT development and consultancy. The key methodologies considered include technology assessment, scenario development, listening to people with dementia and their caregivers and non-participant observation, as well as reviews of good practice, policy and literature.

Findings

The transfer considerations showed unreasonable price differences of similar hardware used for localization between the logistics and the elderly market. Bluetooth low energy (BLE) was identified as a promising localization technique. A gap in the marketing of technology for the elderly was identified, virtually fencing the elderly market.

Practical implications

A lack of transparency fosters market skimming, resulting in deadweight loss for society and technology being restrained from less-solvent consumers. Corrective actions like entrepreneurship facilitation and consumer education should be considered to overcome this market failure. To persevere in a consequently more competitive market, changes in marketing should be considered.

Originality/value

The work assesses the presence of the innovativeness–needs paradox of Everett Rogers in the field of innovation for the elderly on the basis of an example and identifies the resulting market failure. It suggests a market-entry mode and briefly lays out the marketing modes for market penetration.

Tracking down a solution: exploring the acceptability and value of wearable GPS devices for older persons, individuals with a disability and their support persons

PURPOSE

To explore the acceptability and value of three wearable GPS devices for older persons and individuals with a disability and safety concerns when accessing the community.

METHODS

This pilot study explored six wearers' and their support persons' experience of using three different wearable GPS devices (a pendant, watch, and mini GPS phone), each for a two-week period.

RESULTS

Participants identified safety as the main value of using a wearable GPS device. The acceptability and value of these devices was strongly influenced by device features, ease of use, cost, appearance, the reliability of the GPS coordinates, the wearer's health condition and the users familiarity with technology. Overall, participants indicated that they preferred the pendant.

CONCLUSIONS

Wearable GPS devices are potentially useful in providing individuals who have safety concerns with reassurance and access to assistance as required. To ensure successful utilization, future device design and device selection should consider the user's familiarity with technology and their health condition. This study also revealed that not all wearable GPS devices provide continuous location tracking. It is therefore critical to ensure that the device's location tracking functions address the wearer's requirements and reason for using the device. Implications for Rehabilitation The acceptability and usability of wearable GPS devices is strongly influenced by the device features, ease of use, cost, appearance, the reliability of the device to provide accurate and timely GPS coordinates, as well as the health condition of the wearer and their familiarity with technology. Wearable GPS devices need to be simple to use and support and training is essential to ensure they are successfully utilized. Not all wearable GPS devices provide continuous location tracking and accuracy of location is impacted by line of sight to satellites. Therefore, care needs to be taken when choosing a suitable device, to ensure that the device's location tracking features are based on the wearer's requirements and value behind using the device.

Is Big Brother Watching You? Responding to Tagging and Tracking in Dementia Care

The increased availability of electronic assistive technologies, particularly tagging and tracking technology, raises questions for occupational therapists working in dementia care. As experts in environmental adaptation to support participation, occupational therapists need to be clear about what technologies are available to address wandering behaviour, how emerging technologies could be used in their practice and how they will respond proactively to the ethical issues involved in these technologies. Occupational therapists need to join the national debate in order to ensure that ethical, person-centred practice is used to reduce the risk of big brother style monitoring and to support the independent functioning of their service users.

Supporting people with dementia to walkabout safely outdoors: development of a structured model of assessment

People with dementia while missing are at risk of harm including death. Yet, welfare concerns arise when freedom to walkabout outdoors is restricted and in particular, getting lost is a risk factor for admission to long-term care. Accurate methods of assessing the risks posed to community-dwelling people with dementia from getting lost are needed to ensure intervention is proportionate. Currently available assessment tools focus upon the identification of dementia-related changes in a person's walking behaviour, traditionally referred to as 'wandering'. 'Wandering' and getting lost are conceptually distinct; measures of 'wandering' are not sufficient to support the assessment of risk while walking outdoors. The objective of this study was to develop an assessment schedule that can evaluate safety in community-dwelling people with dementia who walkabout outdoors. A structured assessment schedule was generated from research on the aetiology of getting lost, a review of existing assessment tools, an observational study of incidents of getting lost and qualitative data from families experiencing this issue. A content validity study was then undertaken with a panel of 17 health and social care practitioners and researchers in the field. A schedule of 7 domains and 38 items was generated, 33 of which were deemed valid by the expert panel. Panel feedback suggests the schedule needs to be used flexibly to reflect an individual's unique living circumstances. Reflecting the complex aetiology of getting lost, considerable challenges exist when assessing risk in this field. The implications of this study for practitioners are discussed with reference to the merits of narrative and structured models of assessment, and the balance between objective safety and subjective well-being that is required when making decisions about intervention. The direction of further research is examined as a means of supporting professional assessment of this complex issue.

Wandering and dementia

Wandering represents one of many behavioural problems occurring in people with dementia. To consider the phenomenon of wandering behaviour in demented patients, we conducted searches using Medline and Google Scholar to find relevant articles, chapters, and books published since 1975. Search terms used included 'wandering', 'behavioural and psychological symptoms', 'dementia', 'nursing', and 'elopements'. Publications found through this indexed search were reviewed for further relevant references. The term 'wandering' covers different types of behaviour, including aimless movement without a discernible purpose. It is associated with a variety of negatives outcomes. The aetiology of wandering is poorly understood and it remains an unsolved riddle. Wandering is an acutely distressing problem worldwide, both for the patients and caregivers, and it is a major reason for nursing home admission. Evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited. It is possible that management of coexistent psychopathology would help to ameliorate this problematic behavioural disorder.

The use of global positional satellite location in dementia: a feasibility study for a randomised controlled trial

BACKGROUND

Getting lost outside is stressful for people with dementia and their caregivers and a leading cause of long-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safe walking, reduce caregivers' anxiety and enable people with dementia to remain at home, there is little high quality evidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibility of recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about the feasibility of a randomised controlled trial (RCT).

METHODS

People with dementia who had been provided with GPS devices by local social-care services and their caregivers were invited to participate in this study. We undertook interviews with people with dementia, caregivers and professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL) and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephone questionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spent searching if participants became lost before and whilst using GPS.

RESULTS

Twenty people were offered GPS locations services by social-care services during the 8-month recruitment period. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eight people with dementia and 12 caregivers were interviewed. Most participants and professionals were very positive about using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaires were considered difficult and were therefore declined by some on follow-up. Social care records were time consuming to search and contained many omissions. Caregivers estimated that GPS reduced searching time although the accuracy of this was not objectively verified.

CONCLUSIONS

Our data suggest that a RCT will face challenges not least that widespread enthusiasm for GPS among social-care staff may challenge recruitment and its ready availability may risk contamination of controls. Potential primary outcomes of a RCT should not rely on caregivers' recall or questionnaire completion. Time spent searching (if this could be accurately captured) and days until long-term admission are potentially suitable outcomes.

A new tool to asses risk of wandering in hospitalized patients

This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age ≥ 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.

Aging society and gerontechnology: a solution for an independent living?

Recent studies report that the majority of older adults wish to live in their own homes, for as long as possible. This creates a growing interest in technologies to enable older people to remain living independently at home. The purpose of this article is to provide a narrative review of current technology appropriate for older adults' home use. The key research questions were as follow: 1- What is the evidence demonstrating that gerontechnologies are effective in enabling independent living? 2- What are devices designed specifically for frail elderly persons ? Several publications were identified about devices targeting social isolation (videophonic communication, affective orthotic devices or companion-type robots, personal emergency response systems [security]), autonomy loss (technologies for maintenance of autonomy in the activities of daily living) and cognitive disorders (cognitive orthotics, wandering management systems, telemonitoring). Very few articles dealt specifically with the frail older person. In particular, there was extremely limited evidence on use and efficacy of these devices within this population. There is a need to obtain a consensus on definition of the technologies, and also to revisit work strategies and develop innovative business models. To meet this goal, we need to create a network of technological companies, aging services organizations, end-users, academics, and government representatives to explore the real needs of the frail older population and to develop and validate new devices promoting aging at home.

The use of global positioning systems in promoting safer walking for people with dementia

Summary

There are about 5 million people in Europe who have dementia, approximately half of whom need daily care. A common reason why dementia sufferers are admitted to long-term care is because of “wandering”, i.e. leaving home without informing a carer, thereby potentially putting themselves at risk. Common methods of managing wandering include locking doors or alerting carers when a door is opened. A new method of managing wandering is by using electronic location devices. These depend on the satellite-based global positioning system (GPS). People can wear a location device in the form of a watch or pendant, or carry it like a mobile phone. This offers affected individuals the possibility of safe walking, with the reassurance that they can be found quickly if lost. However, it is not known how effective this method is and its use raises questions about safety and individual civil liberties. GPS location is a potentially useful method of managing wandering in dementia and there is considerable pressure on caregivers from commercial organisations to adopt the technique. Research is therefore required to determine which people are best suited for such devices, how effective they are in practice and what effect they have on important outcomes.

The place of surveillance technology in residential care for people with intellectual disabilities: is there an ideal model of application

BACKGROUND

The demand for (care) services for people with intellectual disabilities (ID) is on the rise, because of an expanding population of people with ID as resources are concurrently diminishing. As a result, service providers are increasingly turning to technology as a potential answer to this problem. However, the use and application of surveillance technology (ST) in the care for people with ID provokes conflicting reactions among ethicists and healthcare professionals, and no ethical consensus has been reached as of yet. The aim of this study was thus to provide an overview of how ST is viewed by (care) professionals and ethicists working in the field by investigating what the ideal application of ST in the residential care for people with ID might entail.

METHODS

Use was made of the concept mapping method as developed by Trochim; a computer-assisted procedure consisting of five subsequent steps: brainstorming, prioritising, clustering, processing by the computer and finally analysis. Various participants (ranging from ethicists, physicians to support workers) were invited on the basis of their intended (professional) background. Prior to this study, the views of care professionals on the (ideal) application of ST in the residential care of people with dementia have been consulted and analysed using concept mapping. A comparison between the two studies has been made.

RESULTS

Results show that the generated views represent six categories, varying from it being beneficial to the client; reducing restraints and it being based on a clear vision to (the need for) staff to be equipped; user friendliness and attending to the client. The results are presented in the form of a graphic chart. Both studies have produced very similar results, but there are some differences, as there appears to be more fear for ST among care professionals in the care for people with ID and views are expressed from a more developmental perspective rather than a person-centred perspective with regard to people with dementia.

CONCLUSIONS

When it comes to views on using technology both in dementia care and the care for people with ID, there appears to be an inherent duality, often rooted in the moral conflict between safety versus freedom or autonomy. What is more, elaboration on abstract concepts often presumed to be self-evident, whether ethical or not, has proven to be difficult. How ST is viewed and apprehended is not so much dependent of the care setting and care needs, but rather whether it is clear to everyone affected by ST, what one wants to achieve with ST.

Improving safety and operational efficiency in residential care settings with WiFi-based localization

OBJECTIVES

To assess the effectiveness of a wireless network (WiFi-based) localization system (devices mounted on resident wheelchairs) in decreasing caretaker time spent searching for residents and providing alerts of residents going outdoors in a skilled nursing facility.

DESIGN

A controlled study over two 2-month periods approved by the institutional review board.

SETTING

A long-term skilled nursing facility in Massachusetts specializing in multiple sclerosis previously instrumented with wireless network infrastructure.

PARTICIPANTS

Nineteen residents and 9 staff members at the facility for the first 2-month period; 9 residents and 3 staff members at the facility for the second 2-month period.

INTERVENTION

Software was installed on 4 staff computers to display the locations of residents enrolled in the study. This software was made available to enrolled staff for the second half of the first 2-month period and the entirety of the second 2-month study. In the second 2-month study, the software was modified to provide alerts if any 1 of 9 participating "high-risk"' residents went outdoors, and the accuracy of the alert system was evaluated.

MEASUREMENTS

In the first 2-month study, 9 staff members recorded the amount of time it took them to locate participating residents (as and when needed during the course of their daily activities). In the second 2-month study, 3 staff members recorded whether outdoor-alerts correctly identified a resident leaving the building or if it was a false alarm.

RESULTS

In both phases, participating staff members made frequent use of the system (44 searches and 215 outdoor alerts). Overall, the localization information decreased the average time needed to find residents by about two-thirds (from 311.1 seconds to 110.9 seconds). For outdoor alerts, the system had a false-alarm rate of 9.1% (under normal facility operations); systematic tests of the outdoor-alert system carried out by the authors had a false-negative, or missed-alarm, rate of 1.7%.

CONCLUSION

Using timely resident location information can provide significant gains for both operational efficiency (finding residents) and enhanced resident safety (outdoor alerts). This approach may provide an inexpensive alternative for facilities that have sufficient wireless infrastructure; future work should assess its effectiveness in additional settings.

Electronic tracking for people with dementia: An exploratory study of the ethical issues experienced by carers in making decisions about usage

Electronic tracking through GPS (global positioning system) is being used to monitor and locate people with dementia who are vulnerable to becoming lost. Through a review of the literature and an original study, this article examined ethical issues associated with use in a domestic setting. The qualitative study consisted of in-depth interviews with 10 carers who were using electronic tracking. The study explored the values, beliefs and contextual factors that motivated carers to use electronic tracking. It examined the extent of involvement of the person with dementia in decision-making and it explored the various ethical dilemmas encountered by carers when introducing the tracking system. As an issue that emerged from the interviews, specific attention was paid to exploring covert usage. From the study findings, recommendations have been made for research and practice about the use of electronic tracking in dementia care.

Human rights, citizenship and dementia care nursing

BACKGROUND

Human rights and citizenship are concepts widely used in health and social care literature. However, they are applied less frequently and less rigorously in dementia care. This paper briefly presents these concepts before exploring how they have been applied to dementia care policy and practice. We highlight areas of dementia care where human rights can be violated and citizenship can be denied. We suggest reasons why people with dementia can be denied their human and civil rights and discuss how such concepts provide a way to address cultural and practice change in dementia care.

AIMS AND OBJECTIVES

To demonstrate how these concepts can be used to challenge and improve dementia care nursing.

CONCLUSIONS

This paper contributes to emerging discussion about dementia care nursing by challenging conventional ways of understanding dementia and the care practices that result. Taking a rights-based approach allows nurses to examine inequity in services and address poor practice.

IMPLICATIONS FOR PRACTICE

Looking at dementia through the lenses of citizenship and human rights provides a way to broaden the scope of contemporary dementia care nursing, to enable nurses to challenge inequity and to develop and improve the direct nursing care offered to people with dementia.

Telecare, surveillance, and the welfare state

In Europe, telecare is the use of remote monitoring technology to enable vulnerable people to live independently in their own homes. The technology includes electronic tags and sensors that transmit information about the user's location and patterns of behavior in the user's home to an external hub, where it can trigger an intervention in an emergency. Telecare users in the United Kingdom sometimes report their unease about being monitored by a "Big Brother," and the same kind of electronic tags that alert telecare hubs to the movements of someone with dementia who is "wandering" are worn by terrorist suspects who have been placed under house arrest. For these and other reasons, such as ordinary privacy concerns, telecare is sometimes regarded as an objectionable extension of a "surveillance state." In this article, we defend the use of telecare against the charge that it is Orwellian. In the United States, the conception of telecare primarily as telemedicine, and the fact that it is not typically a government responsibility, make a supposed connection with a surveillance state even more doubtful than in Europe. The main objection, we argue, to telecare is not its intrusiveness, but the danger of its deepening the isolation of those who use it. There are ways of organizing telecare so that the independence and privacy of users are enhanced, but personal isolation may be harder to address. As telecare is a means of reducing the cost of publicly provided social and health care, and the need to reduce public spending is growing, the correlative problem of isolation must be addressed alongside the goal of promoting independence.

Ethics of using assistive technology in the care for community-dwelling elderly people: an overview of the literature

OBJECTIVES

This article provides an overview of the international literature on the most important ethical considerations in the field of assistive technology (AT) in the care for community-dwelling elderly people, focused on dementia.

METHOD

A systematic literature review was performed.

RESULTS

A total of 46 papers met the inclusion criteria. Three main themes were found. The first theme, personal living environment, involves the subthemes privacy, autonomy and obtrusiveness. The second theme, the outside world, involves the subthemes stigma and human contact. The third theme, the design of AT devices, involves the subthemes individual approach, affordability and safety. The often referred to umbrella term of 'obtrusiveness' is frequently used by many authors in the discussion, while a clear description of the concept is mostly absent.

CONCLUSION

When it comes to AT use in the care for elderly people living at home, ethical debate appears not to be a priority. The little discussion there relies heavily on thick concepts such as autonomy and obtrusiveness which seem to complicate the debate rather than clarify it, because they contain many underlying ambiguous concepts and assumptions. Most encountered ethical objections originate from the view that people are, or should be, independent and self-determinant. It is questionable whether the view is correct and helpful in the debate on AT use in the care for (frail) elderly people. Other ethical approaches that view people as social and reciprocal might be more applicable and shed a different light on the ethical aspects of AT use.

Ethical issues in the use of fall detectors

Fall detectors are a form of remote monitoring assistive technology that have the potential to enhance the wellbeing of adults at risk from falling. In this paper, the ethical issues raised by the use of fall detectors are examined. The fall detection devices currently available are outlined, and a summary of how these devices require social-care services, or family carers, to respond in particular ways, is provided. The ethical issues associated with the use of fall detectors are classified under four headings: autonomy, privacy, benefit, and the use of resources. These issues, we argue, arise out of the nature of the technology itself, and the way that this technology is integrated into the day-to-day support package of the person for whom it is provided. It is argued that manufacturers have a duty to provide information about the ‘ethical side-effects’ associated with the use of a particular device, and that the process of making a decision to provide a person with a fall detector should include a checklist of questions that is designed to enable decision makers to work through the ethical issues raised.

Elopement among community-dwelling older adults with dementia

BACKGROUND

Adverse consequences following elopement among older people with dementia have been widely reported but the phenomenon of elopement has been under-researched. This study aimed to examine patterns of elopement incidents, search processes and subsequent prevention strategies and to explore factors that predict elopement among community-dwellers with dementia.

METHODS

Twenty subjects with a recent history of elopement and 25 subjects without any history of elopement completed the study. Their cognitive status, dementia severity and behavioral manifestations were evaluated. Family informants were interviewed to gather data on demographic characteristics, clinical conditions, caring patterns, lifestyle, history of elopement, and information about any elopement incidents.

RESULTS

Two-thirds of subjects had moderate severity of dementia (Clinical Dementia Rating ≥ 2). The elopers did not differ from the non-elopers in demographics, caring arrangements, clinical conditions or lifestyle patterns. Eighty percent of eloped subjects had a prior history of elopement. Logistic regression analyses suggested that manifestation of behavioral symptoms predicted elopement (OR = 1.410). Analysis of the 68 elopement incidents revealed that the vast majority of family caregivers failed to recognize any emotional/behavioral clues prior to elopement. Immediate and multiple search strategies were adopted, with eloped subjects mostly found near the point last seen. Yet, subsequent preventive strategies adopted were largely conventional.

CONCLUSION

Although elopement is difficult to predict, there is a need to enhance and sensitize caregivers' understanding of elopement as related to dementia and more effective preventive strategies. Public education on dementia could also serve to engage lay people more effectively in the search process of eloped persons with dementia.

Readiness for Technology Use With People With Dementia

Technology is believed to have a potential for supporting significant others of people with dementia but little is known of their experiences and views of technology. The aim of this study is to explore how significant others relate to technology and to their relatives with dementia as technology users. The focus is on both their own use of technology as significant others and the use of technology by their relatives with dementia. Individual interviews and focus group discussions were undertaken and analyzed using a grounded theory approach. The significant others showed an overall readiness toward using technology in their present roles. Technology use in daily activities was perceived to be an important means to keeping retained abilities exercised but could also be perceived as a possible threat to health if activities were oversimplified. The significant others asked for flexible technology not perceived as stigmatizing, to be integrated into existing habits.

Ethical and practical concerns of surveillance technologies in residential care for people with dementia or intellectual disabilities: an overview of the literature

BACKGROUND

Technology has emerged as a potential solution to alleviate some of the pressures on an already overburdened care system, thereby meeting the growing needs of an expanding population of seriously cognitively impaired people. However, questions arise as to what extent technologies are already being used in residential care and how ethically and practically acceptable this use would be.

METHODS

A systematic literature review was conducted to explore what is known on the moral and practical acceptability of surveillance technologies in residential care for people with dementia or intellectual disabilities, and to set forth the state of the debate.

RESULTS

A total of 79 papers met the inclusion criteria. The findings show that application and use of surveillance technologies in residential care for vulnerable people generates considerable ethical debate. This ethical debate centers not so much around the effects of technology, but rather around the moral acceptability of those effects, especially when a conflict arises between the interests of the institution and the interests of the resident. However, the majority of articles lack in depth analysis. Furthermore, there are notable cultural differences between the European literature and American literature whereby in Britain there seems to be more ethical debate than in America. Overall however, there is little attention for the resident perspective.

CONCLUSION

No ethical consensus has yet been reached, underlining the need for clear(er) policies. More research is thus recommended to determine ethical and practical viability of surveillance technologies whereby research should be specifically focused on the resident perspective.

Families' and professional caregivers' views of using advanced technology to track people with dementia

in this study we examined the ethical aspects of the use of the Global Positioning Systems (GPS) to track people with dementia. The findings are based on qualitative data gathered from focus groups of family and professional caregivers. The most important theme was the need to balance patients' need for safety with the need to preserve their autonomy and privacy. The main potential benefit of the use of GPS was related to the peace of mind of the caregivers themselves. The findings also suggest that caregivers' views change according to the locus of responsibility of the caregivers for the safety of people with dementia. The caregivers give preference to patients' safety more than autonomy when they are responsible for the patients. When the patients are under the responsibility of other caregivers, they give preference to patients' autonomy more than their safety. Overall, the variety and the depth of the views of different stakeholders toward the use of electronic tracking for people with dementia presented in this article provide a meaningful contribution to the ethical debate on this topic.

Liberating the wanderers: using technology to unlock doors for those living with dementia

This paper focuses on surveillance technologies applied to wandering elders in dementia care facilities in the United States. Drawing on data collected in two long-term care settings, I examine how different forms of technology (e.g. and motion detectors) are used to monitor wanderers in the context of managing risk. In contrast to the locked facility that defined wandering as pathology, the care facility that defined wandering as purposeful and therapeutic improved wanderers' sense of wellbeing and agency. The comparison of the two environments challenges the medicalisation of wandering and suggests a need to redefine approaches to safe wandering that incorporate technologies that monitor but do not confine residents. I argue that surveillance technologies such as locked doors dehumanise and frighten individuals by halting their ability to exit. In contrast, surveillance technologies such as motion detectors may offer increased quality of life and health benefits by allowing individuals to wander safely in the company of a care provider. Efforts to allow individuals to wander safely challenge both the medicalisation of this behaviour as well as the tendency to emphasise its riskiness.

Discipline in chaos: Foucault, dementia and aging in India

In India, care work for people in late-stage dementia is primarily conducted in the home. Using source material from urban India and drawing on Foucauldian theory, we illustrate the significance of three power/knowledge scripts in this context: social and cultural notions of acceptable, public bodies; medicalized forms of care; and the cultural contexts of the individual caregivers. The caregiver is the embodiment of these discourses and is charged with the task of mapping discipline onto inherently undisciplinable bodies. A tension exists between the caregiver's struggle to contain the unruliness of the person with dementia and, simultaneously, to act as a broker between the world of the care-recipient and the social world. We conclude that although the caregiver is the starting point for the exercise of discipline, the three power/knowledge scripts that inform care work are as much about surveying, routinizing and mobilizing caregivers' bodies as they are about disciplining the bodies of people with dementia.

The use of advanced tracking technologies for the analysis of mobility in Alzheimer's disease and related cognitive diseases

Background

One of the more common behavioral manifestations of dementia-related disorders is severe problems with out-of-home mobility. Various efforts have been attempted to attain a better understanding of mobility behavior, but most studies are based on institutionalized patients and the assessment usually relies on reports of caregivers and institutional staff, using observational approaches, activity monitoring, or behavioral checklists. The current manuscript describes the research protocol of a project that measures mobility in Alzheimer's disease and related cognitive disorders in an innovative way, by taking advantage of advanced tracking technologies.

Methods/design

Participants are 360 demented persons, mildly cognitively impaired persons, and unimpaired controls aged ≥ 65 in Israel and Germany. Data regarding space-time activities will be collected via a GPS tracking kit for a period of 4 weeks in 3 waves (one year apart) with the same participants (using a repeated measures design). Participants will be interviewed by use of a battery of instruments prior to and following GPS data collection. Further, a family member will complete a questionnaire both before and after data tracking.

Statistical analyses will strive to explain differences in mobility based on a wide range of socio-structural, clinical, affect-related and environmental variables. We will also assess the impact of the use of advanced tracking technology on the quality of life of dementia patients and care givers, as well as its potential as a diagnostic tool. Systematic assessment of ethical issues involved in the use of tracking technology will be an integral component of the project.

Discussion

This project will be able to make a substantial contribution to basic as well as applied and clinical aspects in the area of mobility and cognitive impairment research. The innovative technologies applied in this study will allow for assessing a range of dimensions of out-of-home mobility, and provide better quality data.

Designing care environments for persons with Alzheimer's disease: visuoperceptual considerations

This article provides information about the projected need for specialist dementia care environments in the United Kingdom. It summarizes the adverse effects of poorly designed environments and acknowledges that, despite a range of residential models, none has been shown or agreed to be the best. It considers current efforts in the UK that might influence future care environments positively.

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.

Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review

BACKGROUND

Wandering occurs in 15-60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices.

OBJECTIVE

To determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia.

DESIGN

A systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought.

RESULTS

(i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable.

CONCLUSIONS

In order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials.