Roundup: Where to Turn When Dementia Patients Wander
Up to 50% of dementia patients wander, and pharmacists should be prepared to counsel caregivers about the appropriateness of medication and the importance of prevention.
Ms.Wick is a senior clinical researchpharmacist at the National CancerInstitute, National Institutes ofHealth, Bethesda, Maryland. Theviews expressed are those of theauthor and not those of any governmentagency.
Wandering is a troublesome—and common—behavior in dementiapatients. Up to half ofdementia patients wander.1-4 Despite thenumerous ways available to prevent wandering,these patients sometimes "elope"from their homes or nursing facilities.Twenty percent of people with dementiawho leave their living situations in thisdangerous way will die.1,5 Some wanderingappears goal-oriented, but wanderers'travel paths are often unrelated to theirplanned destination. Some wandererselope with a buddy, and some successfullyacquire transportation. Often, wanderersget lost.
Researchers recognize 4 specific typesof wandering:
- Direct travel is goal-directed, witheither a real or imaginary purpose,like going home.
- Lapping is wandering in circular patterns.
- Pacing is back-and-forth movement ina confined area.
- Random travel describes haphazardmovement from one locationto another; these patients often trydoorknobs and exits.6
Common Characteristics of Wanderers
- Wanderers will use their remainingmental and physical resources,sometimes successfully and sometimesnot
- They can be expected to react intheir usual way to change and willtake the path of least resistance.When elevations change, thepath of least resistance is usuallydownhill.
- Wanderers usually persevere untilthey become trapped, with 63%found in creeks, in drainage areas,or caught in briars and bushes;<1% respond to shouts or callsfrom rescuers
- Most are found within one-halfmile of their residence, 89% arefound within a mile, and they maybe fearful or regressing
- Wanderers may ignore or misunderstandsearchers' efforts.Searchers may walk close to thewanderer without seeing him orher, and then expand the search.
Adapted from reference 6, 8, 9, and 17.
Wandering severity is a function of thepatient's cognitive impairment, spatial disorientation,and behavioral disturbances.3,4Among people with dementia, aberrantbehaviors and clothing that is at oddswith the situation are common. For staffand visitors, the wanderer's appearancecan be deceptive. The successful wanderer(one who evades containment) oftenlooks like a visitor in a health care facility(perhaps carrying a purse or wearing ajacket or hat); these patients are helped bywell-meaning individuals who open doorsfor them.
Sadly, wandering is often the reasonfamilies decide that a loved one mustenter a long-term care facility or otherstrictly supervised setting. Falls, fractures,and serious or life-threatening complicationsare common outcomes for wanderers.7 After 24 hours, 46% of wanderers arefound dead, usually from environmentalstressors like exposure or drowning. Only20% of those located after 72 hours arefound alive.8,9 Wanderers are also morelikely to have sleep disturbances, be prescribedantipsychotics,lose weight, and bevictims of abuse than nonwanderers.10,11
The best indication of a future problemwith wandering is a past history ofthe same.12 People close to patients withdementia must listen carefully for cluesthat suggest potential wandering behavior.Dementia patients, for example, maytalk about leaving their place of residenceor engaging in things they used to do(eg, "I need to go to work"), especiallyafter a change in living arrangements.Wandering seems to increase whendementia patients are placed in unfamiliarenvironments, left alone, become moredisoriented than usual, or verbalize aboutgoing somewhere.
Pharmacists should note that medicationchanges also seem to increase wanderingbehaviors.13 In addition, patients takingneuroleptic medications and experiencingakathisia (motor restlessness) seem to bemore apt to wander.14 Dementia patientswho have histories of or are being treatedfor depression, anxiety, or schizophreniatend to wander more than others.10,11
Wandering is stressful and frighteningfor caregivers, and they often ask for medicationto calm the patient's restlessness.It is, however, considered a nonaggressivebehavior in most cases and is not considereda behavioral symptom that should beaddressed with medication.15 The use ofantipsychotic medications is inappropriate,unless the wandering causes a dangerto the patient or others; they shouldbe used only if the behavior is persistent,unrelated to preventable conditions,or impairs functional capacity.3,5 Usedunder other conditions, behavior-alteringmedications are considered chemicalrestraints, and restraining patients physicallyoften increases agitation or injury.4Trials of antipsychotics alone or with divaproex indicate that these drugs do notimprove nonaggressive behaviors likewandering.11,15,16
In lieu of medication, caregivers canuse other interventions. These mustalways include some physical environmentmodifications. Exits mustbe locked and sometimes disguised.Wanderers are notorious for followingpaths, so paths that are circular andlead back to the house or nursing unitare preferred. For obvious reasons,paths leading to docks or away fromthe home or nursing facility mustbe blocked.4 Marking doors (eg, tothe bathroom) with large signs canreduce the need for the wanderer to search. Removing items thatsuggest travel, like hats and coats, is prudent, too.13 Childproof safetydevices 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 useat home, too.
Safe Return, Compassionate Re-entry
Everyone who knows of and comes in contact with these patientsmust be told of their propensity to wander. Before it is needed,people close to the patient should develop a rescue plan in case thewanderer is successful. Several tendencies of wanderers can shedlight on how they are apt to proceed (Table 6,8,9,17).
Caregivers will need to contact first responders (police, fire, orother agencies) and always keep recent photographs of the patientfor identification purposes. Caregivers should be prepared to searchareas close to the patient's residence over again, even after thesearch area expands. Sometimes, it becomes necessary or helpful tonotify the media, but only after the authorities have been notified andif the resident's life is in danger.
Not all wandering is considered problematic; for some patients, itis a harmless way to keep active and exercised if it occurs in a controlledsetting. For those patients who wander to danger, however,it is a serious concern. Pharmacists should be prepared to counselcaregivers about medication and its relationship to wandering, eitheras an akasthisia-inducing cause of wandering or an ineffective cure.Many communities now train first responders to understand peoplewith dementia and their wandering patterns better. If yours does,consider joining the team.
Information to Obtain About Patients at Risk for Wandering
Caregivers who compile the information listed below will be more prepared to reduce patients' anxiety and discomfort by addressing patients by their preferred name and offering comforting reminders.
- What does the patient enjoy, and what causes anxiety?
- What names are used to address the patient?
- What topics does the patient enjoy discussing?
- Does the patient respond better to women or men?
- Do uniforms or any other traits frighten the patient?
- Who is the patient's best friend?
- Did the patient work or live in the area?
- If the patient recently lost a pet, what kind was it?
- What item does the patient always have on hand?
Adapted from reference 12.
- Koester RJ. Behavioral profile of possible Alzheimer's disease patients in Virginia search and rescue incidents. Wilderness and Environmental Medicine. 1995;6:34-43.
- Algase DL. Wandering in Dementia. In Fitzpatrick JJ, ed. Annual Review of Nursing Research. New York: Springer, 1999.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Warner ML. In Search of the Alzheimer's Wanderer: A Workbook to Protect Your Loved One. Ashland, Ohio: Purdue University Press, 2005.
- 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.
- Hussian RA. Severe Behavioral Problems. In: Teri L, Lewinsohn P, eds. Geropsychological Assessment and Treatment. New York: Springer, 1986, pp 121?43.
- 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.
- 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.
- Koester R, Stooksbury D. Lost Alzheimer's Subjects-profiles and Statistics. www.dbs-sar.com/SAR_Research/Response.htm.