Health Technology Assessment 2006; Vol 10: number 26
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L Robinson,1* D Hutchings,1 L Corner,1 F Beyer,1 H Dickinson,1 A Vanoli,1 T Finch,1 J Hughes,2,3 C Ballard,4 C May1 and J Bond1
1 Centre for Health Services Research, University of Newcastle upon Tyne, UK
2 Old Age Psychiatry, North Tyneside General Hospital, Northumbria Healthcare Trust, UK
3 Institute for Ageing and Health, University of Newcastle upon Tyne, UK
4 Wolfson Centre for Age Related Disorders, Kings College, London, UK
* Corresponding author
Wandering occurs in around 1560% of people with dementia. It can be beneficial, providing exercise and improving circulation, but may be problematic to both people with dementia and their carers, causing physical harm, emotional distress and early institutionalisation. Non-pharmacological interventions are recommended, but there is limited evidence for their effectiveness and ethical concerns exist around some. This review considers the following non-pharmacological interventions: physical barriers/restraints, electronic devices (tagging and tracking), distraction therapies (music, walking/exercise), sensory therapies (massage, aromatherapy, multi-sensory environments), behavioural therapies, carer interventions and environmental modifications.
The objectives were to determine, through a systematic review, the effectiveness and cost-effectiveness of non-pharmacological interventions (excluding subjective barriers) in the prevention of wandering in people with dementia, in comparison with usual care, and to evaluate through the review and a qualitative study the acceptability to stakeholders of such interventions and identify ethical issues associated with their use.
Data searching continued up until 31 March 2005.
Studies to evaluate the effectiveness of interventions included randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-and-after studies, cohort studies (both prospective and retrospective) and casecontrol studies (both prospective and retrospective).
Studies to evaluate cost-effectiveness of interventions included those costing the intervention strategies or wandering behaviour and full economic evaluations assessing the intervention strategies.
Studies to evaluate acceptability/ethical issues included surveys of opinion, qualitative studies and discussion papers.
Studies could be published in any language.
Included studies could take place in any care environment and involved participants with dementia (DSM or ICD diagnostic criteria) and acquired cognitive impairment. Primary outcome measures included any measure of wandering behaviour.
Checklists for each study were completed independently by two reviewers. For the effectiveness review, data extracted included details of participants, setting, methodology and results/relevant data; for the acceptability/ethics review, narrative and empirical data were extracted.
The results of two of the efficacy studies which used similar interventions, designs and outcome measures were pooled in a meta-analysis; results for other studies which reported standard deviations were presented in a forest plot. Owing to a lack of cost-effectiveness data, a modelling exercise could not be performed.
Four focus groups were carried out with relevant stakeholders (n = 19) including people with dementia and formal and lay carers to explore ethical and acceptability issues in greater depth. Transcripts were coded independently by two reviewers to develop a coding frame. Analysis was via a thematic framework approach.
Ten studies met the inclusion criteria (multi-sensory environment, three; music therapy, one; exercise, one; special care units, two; aromatherapy, two; behavioural intervention, one). There was no robust evidence to recommend any non-pharmacological intervention to reduce wandering in dementia. There was some evidence, albeit of poor quality, for the effectiveness of exercise and multi-sensory environment.
There were no relevant studies to determine the cost-effectiveness of the interventions.
Findings from the narrative review and focus groups were comparable. Exercise and distraction therapies were the most acceptable interventions and raised no ethical concerns. All other interventions were considered acceptable except for physical restraints, which were considered unacceptable. Considerable ethical concerns exist with the use of electronic tagging and tracking devices and physical barriers.
Existing literature ignores the perspectives of people with dementia. The small number of participants with dementia expressed caution regarding the use of unfamiliar technology. Balancing risk and risk assessment was an important theme for all carers in the management of wandering.
There is no robust evidence to make any reliable recommendations for clinical practice.
The authors recommend the following research:
The diversity of behaviours encompassed by the term wandering should be acknowledged, with future studies measuring explicit outcomes which reflect:
The views of people with dementia on the acceptability of non-pharmacological interventions to reduce wandering should be determined. This is particularly relevant for the use of assistive technologies in wandering. As the rapid development of relevant assistive technologies allows for a more diverse and sensitive range of electronic devices, research into users views of their acceptability and feasibility should precede expensive and complex quantitative studies to evaluate their effectiveness.
There is a need to explore in greater depth the process of risk assessment and management by carers for people with dementia who wander, in addition to evaluating the effectiveness and acceptability of specific interventions to promote safe wandering.
There is a need to explore with all relevant stakeholders the boundaries between walking, safe wandering and unsafe wandering. Such in-depth qualitative research would help identify mutually agreed significantconsequences/outcomes of wandering and provide better understanding of the different perspectives held by professional/lay carers and people with dementia, and may help facilitate a shift from the prevention of wandering to the promotion of safe walking.
Robinson L, Hutchings D, Corner L, Beyer F, Dickinson H, Vanoli A, et al. A systematic literature review of the effectiveness of non-pharmacological interventions to prevent wandering in dementia and evaluation of the ethical implications and acceptability of their use. Health Technol Assess 2006;10(26).
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The research reported in this monograph was commissioned by the HTA Programme as project number 03/16/04. The contractual start date was in March 2004. The draft report began editorial review in May 2005 and was accepted for publication in December 2005. As the funder, by devising a commissioning brief, the HTA Programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
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