Nonpharmacological Interventions for Wandering in Dementia
For nursing home residents living with dementia, wandering behavior is common. Up to 70% will have at least one episode. When it happens, nursing home staff can be under pressure both to manage imminent safety needs and comply with new CMS guidance.
CMS F605 requires specific documentation surrounding the use of psychotropic medications. Along with other requirements, a provider may not initiate a psychotropic medication without having first attempted nonpharmacological interventions. Here is a deeper dive into nonpharmacological interventions for wandering.
Person-centered approach
Nonpharmacological interventions are grounded in person-centered care. This approach considers “the cause and meaning of the individual’s behavioral and psychological symptoms,” explain Scales and colleagues writing in The Gerontologist. A framework for addressing BPSDs recognizes that stressors on an individual lead to expressions. With cognitive and communication skills compromised, it is important to understand that the expressions may not look like what we might expect. The expressions could be apathy, pacing, aggression, or wandering.
When a resident walks around in a manner we might view as aimless, they may be trying to meet a need such as hunger, thirst, or human contact, explains a GuideStar blog about wandering. They could be disoriented or lost. They could be exiting a situation that’s causing them anxiety—like a noisy room. Without intervention, uncomfortable feelings and associated behaviors can escalate. For a resident who is wandering, the escalation may be seeking the exit, explain Scales et al.
This person-centered understanding is so important that some dementia experts, including the Alzheimer’s Society (UK), discourage the term “wandering”. They say, “This can be an unhelpful term because it suggests the person is walking with no purpose,” when in fact, there is a reason behind the behavior.
Nonpharmacological interventions
Many practices have been explored to help manage BPSDs in general—and wandering in particular. Here are some examples:
- Sensory practices, which can have a calming effect by engaging the senses. Examples are light massage or aromatherapy. “Rubbing lotion with lavender, geranium, rosemary, and mandarin oils into skin of the person with dementia decreased anxiety and wandering,” found Neubauer et al. in their review article.
- Exercise: A regimen such as 30 minutes per day “has shown very promising results for the reduction of many BPSD,” according to Dimitriou et al., and is recommended for reducing wandering behaviors.
- Music therapy, which “has been proven very effective for the reduction of some BPSDs,” according to Dimitriou et al. A typical approach is simply to play music the resident enjoys. This is often conducted in group settings, too. Residents may delight in singing along, tapping to the beat, dancing, or following a leader in seated dance moves.
- Reminiscence therapy, which means using photos, books, letters, or music to help a person engage with happy memories from their own life.
- Comfort items: For some individuals, a stuffed animal can provide an essential feeling of security. Much like a pet, it can also foster engagement.
Other important steps:
- Manage noise. Neubauer et al. report that when noise increases in the environment, so does wandering behavior.
- Engage with the resident one-on-one in a person-centered approach. Get to know the person you’re caring for.
- Use positive communication You can manage body language, approach a resident with care, question thoughtfully, and give instructions clearly, says the GuideStar blog on dementia communications.
Documentation
To comply with F605, it’s important to chart a complete path of assessment, diagnosis, care strategies, interventions, and monitoring. Consider this progress note example: “Resident observed near front entrance…Risperidone given. Resident calmed.” This documentation is missing: a diagnosis that justifies the medication, a behavior log or root cause analysis, and documentation of consent as well as monitoring. Appropriate documentation for nonpharmacological approaches to wandering would include an assessment, the technique(s) used, and a series of progress notes describing behavioral responses that indicate how interventions are working (or not working).
Behavioral health services
An effective approach to dementia care leans on behavioral health expertise. GuideStar clinical psychologists, licensed clinical social workers, and mental health counselors use clinical skills to identify root causes of behaviors. They use normed, validated assessment tools to deepen assessments and help meet documentation requirements.
To address challenging behaviors, they can recommend individualized behavioral strategies for a resident so that staff are ready with specific techniques for redirecting behaviors. They can coach care teams on how to implement interventions. Through an established schedule of on-site visits, they can assist with monitoring, modifications, and documentation.
Nonpharmacological interventions can often lead to better outcomes. In the event that medication may be warranted, everyone has peace of mind with a systematic, well-documented approach to care.