Roundup: Where to Turn When Dementia Patients Wander

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.

Wandering is a troublesome—and common—behavior in dementia patients. Up to half of dementia patients wander.^1-4 Despite the numerous ways available to prevent wandering, these patients sometimes "elope" from their homes or nursing facilities. Twenty percent of people with dementia who leave their living situations in this dangerous way will die.^1,5 Some wandering appears goal-oriented, but wanderers' travel paths are often unrelated to their planned destination. Some wanderers elope with a buddy, and some successfully acquire transportation. Often, wanderers get lost.

Researchers recognize 4 specific types of wandering:

1. Direct travel is goal-directed, with either a real or imaginary purpose, like going home.
2. Lapping is wandering in circular patterns.
3. Pacing is back-and-forth movement in a confined area.
4. Random travel describes haphazard movement from one location to another; these patients often try doorknobs and exits.⁶

Wandering severity is a function of the patient's cognitive impairment, spatial disorientation, and behavioral disturbances.^3,4 Among people with dementia, aberrant behaviors and clothing that is at odds with the situation are common. For staff and visitors, the wanderer's appearance can be deceptive. The successful wanderer (one who evades containment) often looks like a visitor in a health care facility (perhaps carrying a purse or wearing a jacket or hat); these patients are helped by well-meaning individuals who open doors for them.

Sadly, wandering is often the reason families decide that a loved one must enter a long-term care facility or other strictly supervised setting. Falls, fractures, and serious or life-threatening complications are common outcomes for wanderers.⁷ After 24 hours, 46% of wanderers are found dead, usually from environmental stressors like exposure or drowning. Only 20% of those located after 72 hours are found alive.^8,9 Wanderers are also more likely to have sleep disturbances, be prescribed antipsychotics, lose weight, and be victims of abuse than nonwanderers.^10,11

Risk Factors

The best indication of a future problem with wandering is a past history of the same.¹² People close to patients with dementia must listen carefully for clues that suggest potential wandering behavior. Dementia patients, for example, may talk about leaving their place of residence or engaging in things they used to do (eg, "I need to go to work"), especially after a change in living arrangements. Wandering seems to increase when dementia patients are placed in unfamiliar environments, left alone, become more disoriented than usual, or verbalize about going somewhere.

Pharmacists should note that medication changes also seem to increase wandering behaviors.¹³ In addition, patients taking neuroleptic medications and experiencing akathisia (motor restlessness) seem to be more apt to wander.¹⁴ Dementia patients who have histories of or are being treated for depression, anxiety, or schizophrenia tend to wander more than others.^10,11

Prevention

Wandering is stressful and frightening for caregivers, and they often ask for medication to calm the patient's restlessness. It is, however, considered a nonaggressive behavior in most cases and is not considered a behavioral symptom that should be addressed with medication.¹⁵ The use of antipsychotic medications is inappropriate, unless the wandering causes a danger to the patient or others; they should be used only if the behavior is persistent, unrelated to preventable conditions, or impairs functional capacity.^3,5 Used under other conditions, behavior-altering medications are considered chemical restraints, and restraining patients physically often increases agitation or injury.⁴ Trials of antipsychotics alone or with divaproex indicate that these drugs do not improve nonaggressive behaviors like wandering.^11,15,16

In lieu of medication, caregivers can use other interventions. These must always include some physical environment modifications. Exits must be locked and sometimes disguised. Wanderers are notorious for following paths, so paths that are circular and lead back to the house or nursing unit are preferred. For obvious reasons, paths leading to docks or away from the home or nursing facility must be blocked.⁴ Marking doors (eg, to the bathroom) with large signs can reduce the need for the wanderer to search. Removing items that suggest travel, like hats and coats, is prudent, too.¹³ Childproof safety devices come in handy when a dementia patient is a wanderer.

Many nursing homes now offer specialized units for wanderers. They monitor patients electronically using bracelets, door alarms, and closed-circuit monitors. Some of these tools are available for use at home, too.

Safe Return, Compassionate Re-entry

Everyone who knows of and comes in contact with these patients must be told of their propensity to wander. Before it is needed, people close to the patient should develop a rescue plan in case the wanderer is successful. Several tendencies of wanderers can shed light on how they are apt to proceed (Table ^6,8,9,17).

Caregivers will need to contact first responders (police, fire, or other agencies) and always keep recent photographs of the patient for identification purposes. Caregivers should be prepared to search areas close to the patient's residence over again, even after the search area expands. Sometimes, it becomes necessary or helpful to notify the media, but only after the authorities have been notified and if the resident's life is in danger.

Conclusion

Not all wandering is considered problematic; for some patients, it is a harmless way to keep active and exercised if it occurs in a controlled setting. For those patients who wander to danger, however, it is a serious concern. Pharmacists should be prepared to counsel caregivers about medication and its relationship to wandering, either as an akasthisia-inducing cause of wandering or an ineffective cure. Many communities now train first responders to understand people with dementia and their wandering patterns better. If yours does, consider joining the team.

References

1. Koester RJ. Behavioral profile of possible Alzheimer's disease patients in Virginia search and rescue incidents. Wilderness and Environmental Medicine. 1995;6:34-43.
2. Algase DL. Wandering in Dementia. In Fitzpatrick JJ, ed. Annual Review of Nursing Research. New York: Springer, 1999.
3. Algase DL, Beattie ER, Bogue EL, Yao L. The Algase Wandering Scale: initial psychometrics of a new caregiver reporting tool. Am J Alzheimers Dis Other Demen. 2001;16:141-152.
4. Logsdon RG, Teri L, McCurry SM, Gibbons LE, Kukull WA, Larson EB. Wandering: a significant problem among community-residing individuals with Alzheimer's disease. J Gerontol B Psychol Sci Soc Sci. 1998;53:294-299.
5. Koester RJ. The lost Alzheimer's and related disorders search subject: new research and perspectives. Response 98 NASAR Proceedings. Chantilly, Virginia: National Association of Search and Rescue, 1998; 165-181.
6. Aud MA. Dangerous wandering: elopements of older adults with dementia from long-term care facilities. Am J Alzheimers Dis Other Demen. 2004;19:361-368.
7. Vieweg V, Blair CE, Tucker R, Lewis R. Factors precluding patients' discharge to the community. A Geropsychiatric hospital survey. Va Med Q. 1995;122:275-278.
8. dbS Productions. Alzheimer's Disease and Related Disorders Search and Rescue Research: Wandering Overview. www.dbs-sar.com/SAR_Research/alzheimer_research.htm. Accessed December 7, 2007.
9. dbS Productions. Alzheimer's Disease and Related Disorders Search and Rescue Research: Wandering Characteristics. www.dbs-sar.com/SAR_Research/wandering.htm. Accessed December 7, 2007.
10. Schonfeld L, King-Kallimanis B, Brown LM, et al. Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units. J Am Geriatr Soc. 2007;55:692-699.
11. L?vheim H, Sandman PO, Kallin K, Karlsson S, Gustafson Y. Relationship between antipsychotic drug use and behavioral and psychological symptoms of dementia in old people with cognitive impairment living in geriatric care. Int Psychogeriatr. 2006;18:713-726.
12. Warner ML. In Search of the Alzheimer's Wanderer: A Workbook to Protect Your Loved One. Ashland, Ohio: Purdue University Press, 2005.
13. dbS Productions. Alzheimer's Disease and Related Disorders Search and Rescue Research: Wandering Incident: Planning and Response. www.dbs-sar.com/SAR_Research/Wandering_Planning.htm. Accessed December 5, 2007.
14. Hussian RA. Severe Behavioral Problems. In: Teri L, Lewinsohn P, eds. Geropsychological Assessment and Treatment. New York: Springer, 1986, pp 121?43.
15. Forester B, Vanelli M, Hyde J, et al. Report on an open-label prospective study of divalproex sodium for the behavioral and psychological symptoms of dementia as monotherapy and in combination with second-generation antipsychotic medication. Am J Geriatr Pharmacother. 2007;5:209-217.
16. Gormley, N. and Howard, R. Should neuroleptics be used in the management of nursing home residents with dementia? Int J Geriatr Psychiatry.1999;14:509?511.
17. Koester R, Stooksbury D. Lost Alzheimer's Subjects-profiles and Statistics. www.dbs-sar.com/SAR_Research/Response.htm.