Donna L. Algase

Need-driven dementia-compromised behavior: An alternative view of disruptive behavior

The disruptive behavior of persons with dementia is a problem of considerable clinical interest and growing scientific concern. This paper offers a view of these behaviors as expressions of unmet needs or goals and provides a comprehensive conceptual framework to guide further research and clinical practice. Empiricalfindings and clinical impressions related to wandering, vocalizations and aggression to support and illustrate the framework are presented

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

Purpose: An operational definition of dementia-related wandering is proposed to aid in clinical recognition, to promote research precision and validity, and to provide a pathway toward standardization of language in wandering science. Design and Methods: (1) One-hundred-and-eighty-three journal articles from multiple databases (Medline, OVID, CSA Journals, OCLC First Search, Google Scholar, PubMed, EBSCO) were reviewed to extract alternative terms and definitions for wandering or wandering-related behaviours; (2) terms and definitions were ordered alphabetically into a glossary; (3) a consensus approach was used to group glossary terms with related meanings into possible domains of wandering; (4) four domains (locomotion, drive, space and time) were found sufficient to encompass all wandering definitions; (5) wandering terms were placed into a conceptual map bounded by the four domain concepts and (6) a new provisional definition of wandering was formulated. Results: An empirically-based, operational definition improves clinical and research approaches to wandering and explicates historical inattention to certain beneficial aspects of the behaviour. Implications: Adoption of the proposed operational definition of wandering behaviour provides a platform upon which dementia care may be improved and standardized language may evolve in wandering science.

The Algase wandering scale: Initial psychometrics of a new caregiver reporting tool

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

Getting Lost: Directed Attention and Executive Functions in Early Alzheimer’s Disease Patients

This study explores the link between directed attention (DA) and getting lost behavior (GLB) in early Alzheimer’s disease (AD) using a cross-sectional design with 3 groups. Based on their dementia levels, 116 community-dwelling participants were recruited from a teaching hospital in Taiwan and classified as the non-demented control, questionably demented, and mild AD groups. Statistical analyses include Pearson correlations, one-way ANOVA, and multiple regressions. Attentional impairments, consisting of distractibility, impulsivity, and executive function problems, significantly predict GLB in familiar and unfamiliar environments. Irritability and executive function problems are associated with mental difficulties in choosing a turn, whereas the use of way-finding strategies reduces GLB. Future interventions may include: (a) mental hygiene of aging; (b) programs targeted at improving attentional function and effective way-finding, and (c) inclusion of DA tests in a routine clinical neuropsychological examination for early detection and accurate diagnosis of dementia.

Resident characteristics associated with wandering in nursing homes

Objectives. This retrospective cohort study examined the association between resident characteristics and the development of wandering behavior.

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

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

Biomechanical activity devices to index wandering behaviour in dementia

Valid and reliable measures of wandering are needed to study this troubling behavior. Although researchers have used various perspectives, definitions, and approaches to study wandering, spontaneous ambulation is a key characteristic across all views. Biomechanical activity devices for capturing movement provide one way to index wandering. This study examined four devices with ambulatory nursing home residents with dementia (N = 178) who wore devices simultaneously during four observations. Among the Actillume, StepWatch, Step Sensor, and TriTrac-R3D, the StepWatch yielded data from the highest proportion of observations, explained the most variance (63.9 percent) among all instruments, and was acceptable to nursing staff. Although the Step Sensor was the staffs preferred device, its performance was least acceptable for research purposes. Results support use of the StepWatch in future studies of wandering.

Impact of Cognitive Impairment on Wandering Behavior

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

Wandering in dementia.

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

Publishing Pilot Intervention Work

Pilot intervention studies can be viewed as rehearsals for subsequent full-scale trials. They can help investigators fine-tune later larger studies as well as explore issues related to project management and budget. Pilot studies permit testing of sampling strategies, participant recruitment, intervention content, delivery methods, data collection, and analysis. They also allow researchers to experience the more practical aspects of implementing a study, such as determining the number of study staff members needed to handle recruitment and data collection or identifying special equipment needs. Because pilot study findings may be generalizable, publication is encouraged as long as the preliminary nature of the work is clearly indicated in both the abstract and the article. The present article provides an overview of the types of information that can be gleaned from pilot intervention studies that are suitable for publication.