Discrepancy between subjective and objective assessments of wandering behaviours in dementia as...

ORIGINAL ARTICLE

Discrepancy between subjective and objective assessments ofwandering behaviours in dementia as measured by the AlgaseWandering Scale and the Integrated Circuit tag monitoring system

So YAYAMA,1 Miyae YAMAKAWA,2 Shunji SUTO,3 Chieko GREINER,4 Kazue SHIGENOBU5 andKiyoko MAKIMOTO2

1Faculty of Nursing, Senri Kinran University,2Department of Clinical Nursing, Division ofHealth Sciences, Graduate School of Medicine,Osaka University, Osaka, 3Department of Medicaland Welfare Management, Seibi University, Kyoto,4The Japanese Red Cross College of Nursing, Tokyo,and 5Department of Psychiatry, Asakayama GeneralHospital, Osaka, Japan

Correspondence: Dr So Yayama PhD, Faculty ofNursing, Senri Kinran University, 5-25-1Fujishirodai, Suita, Osaka 565-0873, Japan. Email:[email protected]

Received 15 May 2012; revision received 19 August 2012;accepted 27 August 2012.

Abstract

Aim: Although wandering is one of the major research focuses of the behav-ioural psychological symptoms of dementia, assessment of wandering hasmostly relied on caregiver-administered questionnaires. The purpose of thisstudy was to compare staff-administered Algase Wandering Scale outcomeswith objective temporal and spatial movement indicators obtained from theIntegrated Circuit (IC) tag monitoring system.Methods: Patients with dementia were recruited from a dementia care unitin Osaka, Japan in 2007. Primary nurses administered the Algase WanderingScale, and the temporal and spatial movements of the subjects were moni-tored by the IC tag. Written informed consent was obtained from eachsubject’s proxies.Results: Nurses’ assessments of wandering were in agreement with the ICtag outcomes only during the day shift. Spatial movements assessed by thestaff did not reflect those measured by the IC tag.Conclusion: This objective measurement of wandering showed the limita-tions in the assessment of spatial and temporal movement by the staff.

Key words: Algase Wandering Scale, dementia,monitoring system, objective measurement,wandering behaviour.

INTRODUCTIONWandering is one of the most common, and likelythe most researched, behavioural and psychologicalsymptoms of dementia (BPSD). However, measure-ments of wandering still rely on caregiver-administered scales.1 The Neuropsychiatric Inventory(NPI) and the Cohen-Mansfield Agitation Inventory arescales commonly used to measure a wide array ofBPSD, one of which is wandering,2,3 but the AlgaseWandering Scale (AWS) is the only one that specifi-cally assesses wandering.4

A literature search identified two articles that vali-dated a staff-administered wandering scale through acomparison of objective measurements. One was theAWS and the other was the Circadian Sleep Inventoryfor Normal and Pathological States (CSINAPS). For thevalidation of the AWS, direct observation of dementiaresidents was one of the outcomes of interest,and cycle frequencies of spatial movement (random,

lapping, pacing, direct) were counted. Of these, onlyrandom movement was correlated with more than oneAWS subscale, namely, persistent walking, spatial dis-orientation, and eloping behaviours.5

In the other study, ActiGraph (Ambulatory Monitor-ing, Ardsley, NY, USA) equipment was used toexamine the association between caregiver-assessedCSINAPS and ActiGraph sleep indicators. In theCSINAPS study, the ActiGraph data were taken for2 weeks from 78 elderly subjects living in group carefacilities. Reports of sleep disturbances such as wan-dering at night were reflected in ActiGraph param-eters. However, the CSINAPS and ActiGraph variablescorrelated only modestly.6

Objective measurements of wandering have beenattempted through videotaped and direct observa-tion. In 1991, Martino-Saltzman et al. videotaped thewandering behaviour of 40 institutionalized elderlywith dementia for 30 days and identified four patterns

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doi:10.1111/psyg.12011 PSYCHOGERIATRICS 2013; 13: 80–87

80 © 2013 The AuthorsPsychogeriatrics © 2013 Japanese Psychogeriatric Society

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of spatial movement such as pacing and lapping.7

Coding of the movement seemed to be labour inten-sive, and this approach has not been replicated.

Algase et al. used direct observation to examinethe stability of wandering in 25 nursing home resi-dents with dementia for a 24-h period. In the days thatfollowed, each subject’s stability of wandering waschecked during two 2-h observations.8 A later studyby this team videotaped subjects, and the duration ofobservation was limited to 20 min per session.9 In thislater study, 181 nursing home residents with dementiawere monitored between 08:00 and 20:00, and upto 12 sessions were videotaped. They developed atypology of wandering, such as classic, moderate,and subclinical.

These previous studies could not measure the dis-tance moved and wandering according to the time ofday, and technology did not allow for simultaneousobservation of multiple samples. In recent years, tech-nology such as the Integrated Circuit (IC) tag monitor-ing system for measuring activity in dementia patientshas become available.

The IC tag monitoring system has been used todescribe the variations in distance moved and spatialmovements,10 to examine the side effects of medica-tion,11 and to compare staff hourly observationrecords with overnight IC tag data.12 However, the ICtag monitoring system has not been used to validateany scales used to measure wandering.

The aim of this study was to compare staff-administered AWS outcomes with objective temporaland spatial movement indicators obtained from the ICtag monitoring system.

METHODSSettingThis study was part of an IC tag monitoring projectperformed at a 60-bed dementia care unit inAsakayama General Hospital in Osaka, Japan,between November 2006 and March 2007. The studyunit was a closed system that consisted of 13 four-bed rooms and 8 private rooms as displayed inFigure 1. The unit admission criteria selected demen-tia patients with various BPSD and/or care burdenproblems. When the patient became stabilized, thepatient was discharged to a long-term care facility orto home. The unit has two common spaces used fordining and for occupational and recreational therapies(hereafter called the activity rooms).

The IC tag monitoring systemThe IC Tag monitoring system with Powertags (Matrix,Inc., Osaka, Japan) was used to evaluate wandering.Within the study unit, 15 antennae were placed overthe ceiling to receive signals from the IC tags (Fig. 1).An IC tag was attached to each patient’s shirt withadhesive tape so that it could be easily re-attachedafter a change of clothing. When a patient with an IC

Figure 1 Layout of the unit.

Bias in subjective wandering measurement

81© 2013 The AuthorsPsychogeriatrics © 2013 Japanese Psychogeriatric Society

tag moved under an antenna, the tag sent informationregarding tag identification, time and place, whichwas received by the antenna.13–16

Algase Wandering Scale (Version 2)A Japanese version of the AWS (J-AWS) consists offour subscales with 23 items and uses a 4-point Likertscale, with higher scores indicating more wanderingactivities. The five subscales are persistent walking,spatial disorientation, eloping behaviour, shadowing,and routinized walking.4 The J-AWS was developedby Greiner and its reliability has been established.17

Each patient’s primary nurse evaluated the patientusing the J-AWS after IC tag monitoring had begun.

Study subjectsEligibility criteria for patients in the study were asfollows: (i) dementia diagnosis; (ii) the ability to walkindependently; (iii) 3 consecutive days of IC tag moni-toring system before a J-AWS evaluation; and (iv) aJ-AWS evaluation.

Ethical considerationsThis research was approved by the Ethics Committeeof Osaka University, Graduate School of Medicine aswell as the Ethics Committee of Asakayama GeneralHospital. The study protocol and ethical consider-ations were explained to all the eligible patients andpatient proxies. The major components of the ethicalconsideration were as follows: (i) the study was vol-untary; (ii) patients could withdraw from the study atany time; and (iii) participation status would not affectthe subject’s treatment or care in any way. Writteninformed consent was obtained from each patient’sauthorized proxies, and monitoring was terminatedwhen the patient tried to remove the IC tag.

Diagnosis criteriaThe diagnosis was made by author K.S. For the dif-ferential diagnosis of Alzheimer’s disease, vasculardementia, frontotemporal dementia, dementia withLewy bodies, and dementia related to alcoholism, thecriteria of the DSM-IV-R were used.18

Data collectionPatient demographic data were obtained from medicalrecords. The Mini-Mental State Examination (MMSE)was used for cognitive assessment and evaluated by aclinical psychologist at the time of admission.19 The

Clinical Dementia Rating score was used to quantifyseverity of symptoms of dementia and evaluated byauthor K.S. shortly after admission.20

Comparing temporal movements measured byJ-AWS data with those measured by the IC tagmonitoring systemOf 23 J-AWS items, eight items could be comparedwith the temporal and spatial movement measured bythe monitoring system. Movements that could not beevaluated by the IC tag included ‘Resident gets lost’and ‘Resident cannot locate dining room withouthelp’; these were not included in the analysis.

Of the eight items compared, five involved tempo-ral movements and three involved spatial movements.Temporal movements covered four periods: (i)between waking up and breakfast; (ii) between break-fast and lunch; (iii) between lunch and dinner; and (iv)between dinner and bedtime. The correspondingtimes for the IC tag data were as follows: (i) 05:00–08:00; (ii) 08:30–11:30; (iii) 12:00–17:30; and (iv)18:00–21:00. The fifth item related to temporal move-ment was ‘During meals, resident tries to leave thetable or walks away’; the IC tag data of the followingperiods were classified as meal times: (i) 08:00–08:30;(ii) 11:30–12:00; and (iii) 17:30–18:00.

Three items pertained to spatial movements. ‘Resi-dent paces up and down’ was interpreted as movingback and forth between any two consecutive anten-nae.7 ‘Travels same route over and over’ was definedas lapping, where the patient consecutively movedaround the four corners of the unit, in either aclockwise or an anticlockwise direction.7 Consecutivemovements were defined as a minimum number (atleast three) of the same movement; this measure wasbased on our previous study.7 ‘Goes to same locationover and over on a daily basis’ was defined as fre-quency of detection by the monitoring system’santennae. However, if a patient was detected at oneplace and remained in that same place, it wascounted as one movement.

In addition, one item was ‘Resident is a wanderer’,which asked staff their subjective opinion on thesubject. The differences in the distance moved perday were tested among four responses ranging from‘Definitely not’ to ‘Yes, and it is a problem’. These fourresponses were the grouped into two categories:‘Non-wanderer’ (including ‘Definitely not’ and ‘Attimes’) and ‘Wanderer’ (both ‘Yes’ responses).

S. Yayama et al.


Data analysisDescriptive statistics were generated for all the vari-ables. The mean was used when the distribution wasnormal, and the median was used when the distribu-tion was skewed. Spearman’s correlation coefficientswere obtained in order to examine the associationbetween a J-AWS subscale and the distance movedper day and between a J-AWS subscale and theMMSE. In order to test the differences in the distancesmoved among the four responses to a J-AWS item,one-way ANOVA was used when the distribution wasnormal, and the Kruskal–Wallis test was used whenthe distribution was skewed. SPSS version 15.0 forWindows (IBM, Tokyo, Japan) was used for dataanalysis. P-values less than 5% were considered sta-tistically significant.

RESULTSPatients characteristicsThirty-six patients met the eligibility criteria. Sixpatients were monitored for less than 3 days prior toJ-AWS administration and were excluded from analy-sis. The median duration of monitoring was 7 days(range: 3–14 days; inter-quartile: 5 days), and themedian distance moved per day was 1337 m (range:89–13 542 m; interquartile: 1987 m). The demo-graphic data are displayed in Table 1. The majority ofthe subjects were elderly, and men accounted forslightly less than 50%. Nearly two-thirds of the sub-jects had Alzheimer’s disease with a moderate toadvanced stage of dementia (Table 1).

The means of seven J-AWS items ranged from1.9 1 1.1 for ‘During meals resident tries to leave thetable, or walks away’ to 2.8 1 1.1 for the item ‘Resi-dent is a wanderer’.

The median distance moved per day among the fourwandering statuses differed significantly (Kruskal–Wallis, P < 0.05). Those who were rated as ‘Wanderers’had a longer median distance moved per day thanthose who were rated ‘Non-wanderers’ (Fig. 2).

Distance moved per day was positively correlatedwith the total J-AWS score, and MMSE was negativelycorrelated with the total J-AWS score. ‘Persistentwalking’ and ‘eloping behaviour’ were associated withMMSE and the distance moved. Spatial disorientationwas only associated with MMSE, and ‘routinizedwalking’ was only associated with the distance movedper day (Table 2).

Comparing temporal movement measured byJ-AWS data and the IC tag monitoring systemThe median distance moved per period during thefour periods measured by J-AWS differed significantly

Table 1 Demographic and clinical characteristics of the subjects

VariablePercentage

(n = 30) Mean 1 SD

Age (years) – 67.6 1 13.1Sex

Men 46.7% –Women 53.3% –

Types of dementiaAlzheimer’s disease 63.3% –Vascular dementia 16.7% –Frontotemporal dementia 10.0% –Dementia related to alcoholism 6.7% –Dementia with Lewy bodies 3.3%

Mini-Mental State Examination score – 10.4 1 8.4Clinical Dementia Rating score

3 (severe) 33.3% –2 (moderate) 40.0% –1 (mild) 26.7% –

Figure 2 Box plot of the median distance moved per day accordingto the four responses to the AWS item, ‘Resident is a wanderer’.

Table 2 Spearman’s correlation coefficient between J-AWS sub-scale scores and the distance moved per day and Mini Mental StateExam (MMSE)

Correlation coefficientsAWS subscales Distance moved per day MMSE

Persistent walking 0.73* -0.52*Spatial disorientation 0.32 -0.63*Eloping behaviour 0.40* -0.62*Shadowing 0.34 -0.18Routinized walking 0.44* -0.26Total score 0.60* -0.63*

*P < 0.05.J-AWS, Algase Wandering Scale, Japanese version.



in the morning and afternoon (Kruskal–Wallis,P < 0.05), and a higher rate of wandering was associ-ated with a longer distance moved per period (Fig. 3).In contrast, this type of association was not apparentbefore breakfast, after dinner, and during meals,and statistical significance was not attained (Kruskal–Wallis, P > 0.05) (Fig. 3).

The proportion of subjects who walked during thenight (22:00–05:00), a period not covered by theJ-AWS scale, was 56.7%, and the median distancemoved during the night was 5.2 m (range: 0 m–878 m;interquartile: 33 m).

Four subjects were rated as pacing ‘more thanothers’, and of these subjects, two had a mediannumber of pacing incidents that was greater thanzero. Seven subjects were rated as lapping ‘more thanothers’; of these subjects, only one had a mediannumber of lapping incidents greater than zero. Asrepetitive pacing and lapping were rare, non-repetitivespatial movements were used to compare IC tag datawith corresponding AWS item scores.

When the median number of non-repetitive spatialmovements was compared with a J-AWS assess-ment, the median number of pacing incidents differedsignificantly among the four responses to a J-AWSpacing item (Kruskal–Wallis, P < 0.05). The mediannumber of lapping incidents did not differ significantly

among the four responses of a J-AWS lapping item(Kruskal–Wallis, P > 0.05). The number of non-repetitive pacing incidents was strongly associatedwith the distance moved per day (r = 0.81, P < 0.05),and it was the same for lapping (r = 0.80, P < 0.05).

The J-AWS item about habitual behaviour relatedto spatial movement was examined by plotting themedian frequency of antenna detections against thefour responses to the item ‘Goes to same locationover and over’. Of these four responses, the mediannumber of distributions for those rated as ‘Never’ and‘On a daily basis’ are displayed in Figure 4a and b,respectively. Of the six patients rated as ‘Never’, thehighest median number of detections was 60, and twoout of five subjects moved median distances of lessthan 1 km per day. Of those who were rated as‘Never’, only two exceeded 60 detections (Fig. 4a),and two out of eight subjects moved median dis-tances of less than 1 km per day (Fig. 4b). Field notestaken by the research assistants showed that theseless mobile subjects tended to spend most of the dayin the activity room.

DISCUSSIONThe current study found that nurses’ assessments ofthe temporal aspect of wandering reflected the dis-tance moved as measured by the IC tag monitoring

Figure 3 Median distance moved accord-ing to J-AWS item scored by period.*P < 0.05. †Responses for this item wereas follows: (i) never; (ii) on a few occasions;(iii) regularly but not daily; and (iv) on a dailybasis.

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system during the day shift hours; this did not occuroutside day shift hours and at mealtimes.

The major strength of our research is the around-the-clock monitoring of movement for more than7 consecutive days. Another study validating theJ-AWS used direct observations recorded by a barcode reader to code pattern and rhythm of ambula-tion.4 This paper did not provide a duration ofobservation, although another study by this teammentioned a 24-h period of direct observation.8 Thepaper also noted extensive error checking and clean-ing based on the field notes of data collectors, sug-gesting limitations in the use of direct observationto monitor wandering.5 Our monitoring system wasfully automated to record movements in the facilitywith high precision, eliminating interrater reliabilityproblems.

No other studies have compared professional car-egiver assessments of wandering with objective mea-surements. Only in one study of sleep-awake

disturbances in dementia patients were professionalcaregivers’ assessments compared with Actigraphicmeasurements.6 However, the scale included an itemon night-time wandering that was not defined in thepaper. The study subjects who were assessed aswandering at night had lower sleep efficiency thanthose assessed as not wandering at night, with theformer having a higher L5 (least active 5 h out of 24 h)values than the latter. Although these findings supportthe validity of caregiver assessment to some extent,the Actigraph was not developed specifically toassess ambulation itself.

Poor agreement on temporal movements betweenJ-AWS evaluations and IC tag measurements duringnon-day shift hours suggests the difficulty in assess-ing patient ambulation during the night shift, probablybecause of the minimal staff-to-patient ratio at night.Of note, the J-AWS does not have any item to evalu-ate night-time wandering. Night-time ambulation wascommon in our study as well as in Yamakawa et al.’s

Figure 4 (a) Median number of detectionsby 15 antennae for those who wereassessed as ‘never goes to same locationover and over’. (b) Median number ofdetections by 15 antennae for those whowere assessed as ‘goes to same locationover and over on a daily basis’. *Antennanumber locations are shown in Figure 1.



study conducted in 2008 and 2009 in the same studyunit, and in the latter, it was substantially underre-ported in the staff’s hourly observation sheet whencompared with the IC tag monitoring system data.12

Discrepancies between the subjective and objec-tive data on the spatial movements of pacing andlapping also occurred. There is a problem in evaluat-ing interventions to reduce wandering because theNPI is one of the most commonly used scales tomeasure wandering,21 and the NPI contains only oneitem on wandering, ‘pace or wheel around the facilitywith no reason’. (This belongs to the ‘Aberrant MotorBehaviour’ subcategory, which measures repetitivebehaviour.) In the study by Nakaoka et al., repetitivepacing and lapping spatial movements were onlyobserved in frontotemporal dementia patients,10

which suggests that pathological changes in the brainmay account for repetitive spatial movements. Objec-tive measurements of spatial movement seem to beworth pursuing.

Nurses’ evaluations of wandering may reflect theiroverall patient assessments including sleeping pat-terns and mental status. Yamakawa et al. reportedthat the agreement rates between staff’s hourly obser-vation records and the IC tag monitoring data at nightwere higher when the patient had certain conditionsor engaged in certain activities, such as alterations inmental status or taking afternoon naps.12 Their find-ings suggest that nurses set priorities for observationbased on patients’ conditions. In our sample, the leastmobile patient had a high rating for ‘Goes to the sameplace over and over’. Some patients with visible signsof BPSD were likely to get more attention from thestaff than those without, and this extra attention maylead to overestimations of patients’ movements.

Implications for clinical practiceThe J-AWS offers a rich description of wanderingbehaviours. However, compared with the NPI, it hasnot been frequently used to evaluate interventions toreduce wandering. A couple of reasons may explainits limited use. First, the clinical significance of theAWS has not been well described and the scale doesnot measure care burden. Second, wandering is onlyone BPSD, and in clinical settings, the staff needs toevaluate a wide array of BPSD. Therefore, a scale tomeasure a set of BPSD, such as the NPI, is morepragmatic to use than the AWS.

Although there is no consensus on the definition ofwandering, two aspects of wandering need to beassessed and documented in clinical practice: careburden-related behaviour and physical burden result-ing from excessive ambulation. Care burden-relatedbehaviours include seeking exits, eloping, boundarytransgression, and night-time wandering.1 Most ofthese behaviours are safety issues as well, and mul-tiple strategies are necessary to secure patient safety.

Physical burden occurs when patients excessivelywandering. In our sample, the median distancemoved per day exceeded 10 km in a few patients,and Miyoshi et al. described a weight loss problemin dementia patients who wandered excessively, asmeasured by the IC tag monitoring system.15 Patientswho appear to walk incessantly are in need of weightmonitoring and nutritional assessment.

Limitations and future research needsThe major limitation of this study was that the medianduration of IC tag monitoring was less than 2 weeks.Nevertheless, primary nurse evaluations of wanderingduring the daytime were in agreement with the dis-tance moved as measured by the IC tag monitoringsystem. The other limitation was the small sample sizefrom only one institution in Japan. In spite of theseproblems, our study finding of an association betweenJ-AWS subscales and the MMSE was in agreementwith the international study by Algase et al.,4 and theAWS subscales were associated with the distancemoved per day, giving validity to our findings.

The IC tag monitoring system is currently the onlysystem capable of monitoring patients’ temporal andspatial movement around the clock for an extendedperiod, and it is an excellent tool to monitor the effectsof medication on patient patterns of movement.8

However, there are limitations for clinical application.The IC tag needs to be attached to each patient’sshirt, and it needs to be reattached whenever the shirtis changed. A device that can be worn around thewrist, such as the Actigraph, was not well accepted byour study population. Development of a monitoringdevice that is acceptable to patients with dementia isnecessary to advance this research.

CONCLUSIONSThis study compared staff-assessed wanderingbehaviours in dementia patients with objective

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measurement outcomes from an IC tag monitoringsystem. Staff assessments of temporal movementswere in agreement with the IC tag measurement out-comes only during the dayshift hours, but not duringthe early mornings or late evenings. Our findingssuggest that staff assessment alone is insufficient forevaluating wandering behaviours.

ACKNOWLEDGMENTSThis study was supported by a Grant-in-Aid forScientific Research (Scientific Research B, no.17406032, 2005–07) from Japan’s Ministry of Educa-tion, Culture, Sports, Science and Technology. Theauthors would like to express their appreciation for thecooperation extended by the staff of AsakayamaGeneral Hospital.

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