Non-pharmacological interventions for wandering of people with dementia in the domestic setting.

BACKGROUND: A number of studies exist of interventions for wandering in the institutional setting, but much less work has been done on wandering in the domestic setting. The prevalence of wandering by people with dementia is difficult to assess; wandering is not a simple or static behaviour and the reasons why people wander remain unclear. In the absence of a theory of wandering and an agreed definition of wandering, it is difficult to discover effective strategies for managing wandering and difficult to design appropriate intervention strategies. Also, the same behaviour or type of wandering might occur for different reasons in different individuals; any theoretical formulation is going to have to allow for different triggers for the behaviour and so to get a 'one size fits all' kind of explanation is unlikely. Thus what we mostly encounter in this field is a 'trial and error' approach which does not always do justice to the complex interactions of personal and environmental factors that lead people with dementia to wander. While there seems to be a consensus in the literature that in the majority of cases non-pharmacological approaches may work as well as drug treatment and with fewer side effects, in practice clinicians often resort to drugs as the first line of treatment. This review reports the lack of evidence from RCTs and discusses the range of non-pharmacological interventions that have been carried out using other study designs. OBJECTIVES: To evaluate the effectiveness and safety of non-pharmacological interventions in reducing wandering in the domestic setting by people with dementia. The secondary objective is to highlight the quality and quantity of research evidence available and to set an agenda for future research. SEARCH STRATEGY: The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 11 May 2006 using the terms exit* or wander* or elopement or ambulat* or walk*. This Register contains records from all major healthcare databases and many ongoing trial databases and is updated regularly. SELECTION CRITERIA: Randomised clinical trials comparing intervention with no intervention or usual treatment ('standard care') or another intervention. DATA COLLECTION AND ANALYSIS: No suitable trials of non-pharmacological interventions for the prevention and management of wandering in the domestic setting were found. MAIN RESULTS: As no randomised controlled trials were found, no results can be reported. AUTHORS' CONCLUSIONS: There is an urgent need for randomised controlled trials of non-pharmacological interventions for wandering in the domestic setting.

Subjective barriers to prevent wandering of cognitively impaired people.

BACKGROUND: People with dementia often wander, at times putting themselves at risk and presenting challenges to carers and institutional staff. Traditional interventions to prevent wandering include restraint, drugs and locked doors. Cognitively impaired people may respond to environmental stimuli (sounds, images, smells) in ways distinct from healthy people. This has led to trials of visual and other selective barriers (such as mirrors, camouflage, grids/stripes of tape) that may reduce wandering. OBJECTIVES: We assess the effect of subjective exit modifications on the wandering behaviour of cognitively impaired people. The second objective is to inform the direction and methods of future research. SEARCH STRATEGY: The search strategy includes electronic searches of relevant bibliographic and trials databases, citation indices and relevant medical journals. SELECTION CRITERIA: Randomized controlled trials and controlled trials provide the highest quality evidence, but interrupted time series are also considered as they may contribute useful information. Participants are people with dementia or cognitive impairment who wander, of any age, and in any care environment - hospital, other institution, or their own home. Interventions comprise exit modifications that aim to function as subjective barriers to prevent the wandering of cognitively impaired people. Locks, physical restraints, electronic tagging and other types of barrier are not included. DATA COLLECTION AND ANALYSIS: The criteria for inclusion or exclusion of studies are applied independently by two reviewers. All outcomes that are meaningful to people making decisions about the care of wanderers are recorded. These include the number of exits or carer interventions, resource use, acceptability of the intervention and the effects on carer and wanderer anxiety or distress. heterogeneity of clinical area, of study design and of intervention was substantial. MAIN RESULTS: No randomized controlled or controlled trials were found. The other experimental studies that we identified were unsatisfactory. Most were vulnerable to bias, particularly performance bias; most did not classify patients according to type or severity of dementia; in all studies, outcomes were measured only in terms of wandering frequency rather than more broadly in terms of quality of life, resource use, anxiety and distress; no studies included patients with delirium; no studies were based in patients' homes. REVIEWER'S CONCLUSIONS: There is no evidence that subjective barriers prevent wandering in cognitively impaired people.