Wandering (dementia)

Wandering occurs when a person suffering from dementia roams around and becomes lost or confused about their location. It is a common behavior that can cause great risk for the person, and is often the major priority (and concern) for caregivers. It is estimated to be the most common form of disruption from people with dementia within institutions.[1] Although it occurs in several types of dementia, wandering is especially common in people with Alzheimer's disease (AD). People with dementia often wander because they are stressed, looking for someone or something, attending to basic needs, engaging in past routines, or suffering from visual-spatial problems.[2] Other times, they may wander without aim at all.[3]

Elopement

Elopement, or unattended wandering that goes out of bounds, is a special concern for caregivers and search and rescue responders. Wandering (especially if combined with sundowning) can result in the person's being lost outdoors at night, dressed inappropriately, and unable to take many ordinarily routine steps to ensure his or her personal safety and security. This is a situation of great urgency, and the necessity of searching at night imposes added risks on the searchers.

In some countries the social costs of elopement, already significant, are increasing rapidly.[4] A search and rescue mission lasting more than a few hours is likely to expend many hundreds to thousands to tens of thousands of skilled worker hours and, per mission, those involving subjects with dementia typically expend significantly more resources than others.[4]

Assessment

Assessment of a person's risk of wandering is often neglected. A review of medical records of 83 people with dementia living in Los Angeles found that only 8% of the records included a wandering risk assessment.[5] Assessment can be performed by a social worker. In the United States, the Alzheimer's Association has developed a program called "Safe Return" that includes assessment tools. An assessment tool designed for use in nursing homes is the Revised Algase Wandering Scale-Nursing Home Version (RAWS-NH); this tool may be suitable for use in assisted living facilities.[6]

Prevention

The most common form of wandering prevention is for a caregiver to remain in the company of the person likely to wander, so the caregiver can either accompany them or prevent them from wandering when the situation occurs.

Other methods used to prevent wandering, or simply to reduce the risk of wandering out of bounds, include: drugs, physical restraints, physical barriers, 24-hour real-time surveillance, and tracking devices. All of these methods have ethical issues, and the use of physical restraints is widely considered to be inhumane.[7] Tracking devices of several kinds have been evaluated.[8][9]

Much of the literature on wandering concerns people who are residents of institutions. Studies on wandering from private residences are insufficient for comparison of prevention via drugs versus other methods.[10]

The risk of wandering can be reduced by several low-tech and minimally intrusive techniques, including: placing a visual barrier such as a curtain across a doorway or a small black area rug or a black throw rug in front of a door to mimic a hole thus discouraging elopement behaviors.[11]

Wandering can be due to a person searching for stimulation. If a wanderer does not purposefully attempt to escape the location where they are, a minimal barrier can deter wandering behaviour. However, some wanderers will look for a familiar route, place, or area from their past, while others will simply "explore."

Some cases of wanderers operating vehicles and driving either aimlessly or along a familiar route, road, or highway have been reported.

In response to wandering seniors, 25 states have adopted Silver Alert programs. Silver Alert is a program similar to AMBER Alert to notify the public of missing seniors with dementia and other cognitive disabilities.

Disasters

Any changes in routine can trigger wandering. Disaster scenarios are an example of a drastic change in routine that can lead to wandering and other catastrophic reactions. The overstimulation of activities, individuals and/or noise such as thunder and other stimuli such as lightning can trigger wandering behavior. To reduce the risk of wandering in these scenarios: Consider maintaining 1 vs. 1 contact with the individual, reassure them if they appear scared or upset, keep them engaged in activities, play music or put on a video they enjoy, proactively enroll them in dementia-related safety programs and make dementia specific disaster preparedness a priority (i.e. keeping incontinence products in your kit if the person with dementia has incontinence issues).

Technology

In other efforts to help keep residents safe, mitigate liability, and protect reputations, Long Term Care and Assisted Living Facilities may use radio frequency (RFID) products to protect their residents. A resident wears a wrist, pendant, or ankle transmitter. This RFID tag can be read by receiving antenna units, which are placed usually at door or hallway locations that are deemed likely routes of egress and need monitoring. The system will then either sound an alarm or briefly lock a door[12] when a door monitor reads a transmitter worn by a resident that is at risk for wandering. This helps prevent an elopement as staff can be notified by alarms at the door, pocket pagers, and email. A caregiver will be able to quickly find the person at risk and keep them safely inside. Smaller scale versions of this technology are also used in private residences.[13]

Newer versions of this equipment have become more advanced. The newest types of systems may have the ability to: identify a RFID tag by a specific resident and forward that name to the staff; give staff a last known location of the resident; show a photo of the resident at the staff station with a mapped out door location; report the frequency, times and severity of the incidents; and finally, integrate with other access control systems, HVAC, fire alarm equipment and phone equipment.

The reason this type of system seems to be preferable is that it helps monitor those at risk for wandering and elopements while not infringing on the freedom of other residents or visitors to a facility.

See also

References
  1. U.S. Congress, Office of Technology Assessment (1992). Special care units for people with Alzheimer's and other dementias: Consumer education, research, regulatory, and reimbursement issues. Washington DC: Government Printing Office. ISBN 978-1-4289-2817-6.
  2. Mayo Clinic Staff. (2020, August 07). Alzheimer's: Understand wandering and how to address it. Retrieved February 3, 2021, from https://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/alzheimers/art-20046222
  3. Strubel, D., & Corti, M. (n.d.). Wandering in dementia. Retrieved February 3, 2021, from https://www.alz.org/help-support/caregiving/stages-behaviors/wandering
  4. "Wandering and Alzheimer's overview". dbs-sar.com. Retrieved 2008-08-26.
  5. Cherry DL, Vickrey BG, Schwankovsky L, Heck E, Plauchm M, Yep R (August 2004). "Interventions to improve quality of care: the Kaiser Permanente-Alzheimer's Association Dementia Care Project" (PDF). Am J Manag Care. 10 (8): 553–60. PMID 15352531.
  6. Beattie ER, Song J, LaGore S (2005). "A comparison of wandering behavior in nursing homes and assisted living facilities". Res Theory Nurs Pract. 19 (2): 181–96. doi:10.1891/088971805780957323. PMID 16025697.
  7. Robinson L, Hutchings D, Corner L, Beyer F, Dickinson H, Vanoli A, Finch T, Hughes J, Ballard C, May C, Bond J (August 2006). "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. 10 (26): iii, ix–108. PMID 16849002.
  8. Miskelly F (September 2005). "Electronic tracking of patients with dementia and wandering using mobile phone technology". Age Ageing. 34 (5): 497–9. doi:10.1093/ageing/afi145. PMID 16107453.
  9. Miskelly F (May 2004). "A novel system of electronic tagging in patients with dementia and wandering". Age Ageing. 33 (3): 304–6. doi:10.1093/ageing/afh084. PMID 15082438.
  10. Hermans DG, Htay UH, McShane R (2007). Htay, U Hla (ed.). "Non-pharmacological interventions for wandering of people with dementia in the domestic setting" (PDF). Cochrane Database Syst Rev (1): CD005994. doi:10.1002/14651858.CD005994.pub2. PMC 6669244. PMID 17253573.CS1 maint: multiple names: authors list (link)
  11. Feliciano L, Vore J, LeBlanc LA, Baker JC (2004). "Decreasing entry into a restricted area using a visual barrier". J Appl Behav Anal. 37 (1): 107–10. doi:10.1901/jaba.2004.37-107. PMC 1284486. PMID 15154224.
  12. "Why residents wander and what you can do about it — Feature Article — Interview". Nursing Homes. 2003.
  13. http://www.ercim.org/publication/Ercim_News/enw28/leikas.html


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