Behaviours that need special skills and understanding within the care home setting-Wandering
The wandering resident needs specific understanding. The prevalence of wandering behaviour is difficult to assess but estimates suggest that it will occur in up to 25% of people suffering from dementia and this symptom is most common in the middle stage of dementia. Wandering is reported more often in Alzehimers disease than vascular dementia, however many people suffer from mixed dementia so there is no hard and fast rule.
I think it may be helpful to understand the pattern of wandering which I tend to break into several categories in an effort to consider how a specific intervention may be helpful these include
1) Residents who want to go home,
2) Residents who rummage,
3) Residents who roam through the unit or the home,
4) Residents who visit.
The understanding of wandering behaviour begins with a careful assessment of the problem. The team should carefully monitor the patient’s behaviour over a 7-10-day period, during which there are no new medical problems. Individuals who begin to wander after a prolonged period of stability may be suffering from some new complication – medical, psychiatric or cognitive. Delirium may produce the abrupt onset of wandering behaviour. Delirious patients may seem more confused and these individuals are at risk for falls or injury. When a resident’s behaviour changes rapidly we should always consider acute illness like UTI, chest infection or pain.
For those who are newly admitted to the home, we should try and determine the person’s activity level prior to admission and record this so staff can share understanding of the individual person. Those who were physically active prior to admission or those who spent a great deal of time outdoors are likely to require exercise on a regular basis outside the facility. I was talking to a psycho geriatrician earlier this year in Scotland who was explaining in one care home he visited they had experienced specific problems with certain residents until they had addressed the issue that these residents had come from farming communities and access to the outside was vital to their general health and mental wellbeing.
I am also reminded of two gentlemen, one who was very distressed but on discussion with his family he had spent a large portion of his younger life in the merchant Navy and as long as he could walk with a small packed bag he remained relatively calm. The other gentleman was often unsettled at night again on close history taken from his family it was noted that he had worked for many years in the print and this behaviour was his normal, he did not need medicating he needed us to adapt his environment to him.
This level of knowledge is not always possible, some individuals enter care with little history or may have been very private people on the whole but even knowing this gives a level of understanding to staff of how to approach the resident as an individual and ensure their needs are met.
I use the following descriptors when trying to consider what environmental manipulations may help, they are just a key to help me personally think about adjustments that my help the individual person.
Those who want to leave and go home – unable to orient themselves in the home, these individuals require constant reassurance and monitoring to maintain calm.
Some residents will wander around where they will check-in and repeat the pattern, i.e., orbiting. The team must determine whether the movement is continuous or episodic. Episodic movement by a person may represent hunger, urinary or faecal urgency, pain, fear or frustration. Alzheimer’s patients frequently eat small amounts at each meal and the patients are frequently hungry between meals. Restless patients may be hungry and multiple snacks may lessen this motor behaviour. Many patients drink insufficient quantities of liquids and wandering may result from thirst. Wandering may result from physical distress. Chronic pain occurs in approximately 25% of Alzheimer’s patients in homes and these individuals frequently lack the ability to request pain medications.
Residents may have episodes of wandering due to boredom or frustration. These individuals require specialized recreational programming. Behavioural interventions such as music groups, exercise programs, are a first step in dealing with restless patients. Music therapy can be highly effective in quieting excessive motor behaviour. The recreational programming is consistent with the patient’s pre home lifestyle.
Our life patterns are often purposeful it is so important to concentrate on what the individual can do and not on what they have lost. I am reminded of one resident who has very little language but in his working life was a commercial artist. I learnt a lot about myself that day; I had considered myself someone who was open minded so when I was told that this gentleman had started to draw I just thought “that’s good” when I looked at his work it was the most beautiful pencil sketch of a boat one that I could never in a month of Sunday’s produce……..my arrogance had forgotten that this very special man still housed his talent even if he would express it periodically.
Sun downing is agitation and restlessness occurring in the late afternoon or early evening. This behaviour responds poorly to medications. The use of tranquilizers or sleeping pills in the evening rarely normalizes the sleep pattern. The goal is to keep these patients safe, give reassurance and accommodate this wakeful period, which may then produce a period of restful sleep.
Some residents will wander through the home and enter into other resident’s space, maybe in an effort to socialize and visit. These residents are often bored, under-stimulated, or seeking human companionship. Visitors may benefit from structured recreational activities and increased human contact with family, friends, and staff.
What is clear for us as care providers is that learning as much as we can about each individual person and their pastimes and life patterns, will enable us to design individual interventions which are personal to themselves.
Every person who is part of a care team provides social intervention and the more our understanding of intervention grows the more care will grow.