Wandering (dementia)

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Wandering occurs when a person with 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 with visual-spatial problems. [2] Other times, they may wander without aim at all. [3]

Contents

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 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, may include sedative drugs, physical restraints, physical barriers, 24-hour real-time surveillance, or tracking devices. Of course, the ethics of these methods have been frequently called into question; the use of physical restraints, for example is widely considered to be inhumane. [7] Tracking devices of several kinds have been evaluated. [8] [9]

Much of the literature on wandering concerns institutional residents. 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. For example, placing a visual barrier such as a curtain or a black area rug across a doorway may 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 in the US have adopted Silver Alert programs. Silver Alert is 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, 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.

This type of system seems to be preferable because it helps monitor those at risk for wandering and elopement while not infringing on the freedom of other residents or visitors to a facility.

See also

Related Research Articles

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is the general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, caregivers, and on social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.

Delirium is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances, including changes in psychomotor activity, disrupted sleep-wake cycle, emotional disturbances, disturbances of consciousness, or, altered state of consciousness, as well as perceptual disturbances, although these features are not required for diagnosis.

<span class="mw-page-title-main">Dementia with Lewy bodies</span> Type of progressive dementia

Dementia with Lewy bodies (DLB) is a type of dementia characterized by changes in sleep, behavior, cognition, movement, and regulation of automatic bodily functions. Memory loss is not always an early symptom. The disease worsens over time and is usually diagnosed when cognitive impairment interferes with normal daily functioning. Together with Parkinson's disease dementia, DLB is one of the two Lewy body dementias. It is a common form of dementia, but the prevalence is not known accurately and many diagnoses are missed. The disease was first described by Kenji Kosaka in 1976.

<span class="mw-page-title-main">Geriatrics</span> Specialty that focuses on health care of elderly people

Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of the elderly. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient need and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently.

Elder abuse is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person." This definition has been adopted by the World Health Organization (WHO) from a definition put forward by Hourglass in the UK. Laws protecting the elderly from abuse are similar to and related to laws protecting dependent adults from abuse.

Cognitive disorders (CDs), also known as neurocognitive disorders (NCDs), are a category of mental health disorders that primarily affect cognitive abilities including learning, memory, perception, and problem-solving. Neurocognitive disorders include delirium, mild neurocognitive disorders, and major neurocognitive disorder. They are defined by deficits in cognitive ability that are acquired, typically represent decline, and may have an underlying brain pathology. The DSM-5 defines six key domains of cognitive function: executive function, learning and memory, perceptual-motor function, language, complex attention, and social cognition.

<span class="mw-page-title-main">Elderly care</span> Care serving the needs and requirements of senior citizens

Elderly care, or simply eldercare, serves the needs of old adults. It encompasses assisted living, adult daycare, long-term care, nursing homes, hospice care, and home care.

<span class="mw-page-title-main">Caregiver</span> Person helping another with activities of daily living

A caregiver, carer or support worker is a paid or unpaid person who helps an individual with activities of daily living. Caregivers who are members of a care recipient's family or social network, and who may have no specific professional training, are often described as informal caregivers. Caregivers most commonly assist with impairments related to old age, disability, a disease, or a mental disorder.

<span class="mw-page-title-main">Frailty syndrome</span> Weakness in elderly person

Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with ageing, and it has been recognized for centuries. It is a marker of a more widespread syndrome of frailty, with associated weakness, slowing, decreased energy, lower activity, and, when severe, unintended weight loss. As a frequent clinical syndrome in the elderly, various health risks are linked to health deterioration and frailty in older age, such as falls, disability, hospitalization, and mortality. Generally, frailty refers to older adults who lose independence. It also links to the experiences of losing dignity due to social and emotional isolation risk. Frailty has been identified as a risk factor for the development of dementia.

Psychological therapies for dementia are starting to gain some momentum. Improved clinical assessment in early stages of Alzheimer's disease and other forms of dementia, increased cognitive stimulation of the elderly, and the prescription of drugs to slow cognitive decline have resulted in increased detection in the early stages. Although the opinions of the medical community are still apprehensive to support cognitive therapies in dementia patients, recent international studies have started to create optimism.

As populations age, caring for people with dementia has become more common. Elderly caregiving may consist of formal care and informal care. Formal care involves the services of community and medical partners, while informal care involves the support of family, friends, and local communities. In most mild-to-medium cases of dementia, the caregiver is a spouse or an adult child. Over a period of time, more professional care in the form of nursing and other supportive care may be required medically, whether at home or in a long-term care facility. There is evidence to show that case management can improve care for individuals with dementia and the experience of their caregivers. Furthermore, case management may reduce overall costs and institutional care in the medium term. Millions of people living in the United States take care of a friend or family member with Alzheimer’s disease or a related dementia.

Simulated presence therapy (SPT) is an emotion-oriented non-pharmacological intervention for people with dementia developed by P. Woods and J. Ashley in 1995. SPT was created as part of a study conducted in a nursing home where 17 individuals with the disease listened to a recording of a caregiver over a stereo. The study was originally conducted in order to combat one of the side effects of dementia such as disturbances of behavior which are called behavioral and psychological symptoms (BPSD) associated with dementia. This therapy is based on psychological attachment theories and is normally carried out by playing a recording with voices of the closest relatives of the patient in an attempt to treat BPSD in addition to reducing anxiety, decreasing challenging behavior, social isolation, or verbal aggression.

Family caregivers are “relatives, friends, or neighbors who provide assistance related to an underlying physical or mental disability for at-home care delivery and assist in the activities of daily living (ADLs) who are unpaid and have no formal training to provide those services.”

<span class="mw-page-title-main">Alzheimer's disease</span> Progressive neurodegenerative disease

Alzheimer's disease (AD) is a neurodegenerative disease that usually starts slowly and progressively worsens, and is the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, self-neglect, and behavioral issues. As a person's condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Although the speed of progression can vary, the typical life expectancy following diagnosis is three to nine years.

Sundowning, or sundown syndrome, is a neurological phenomenon associated with increased confusion and restlessness in people with delirium or some form of dementia. It is most commonly associated with Alzheimer's disease but also found in those with other forms of dementia. The term "sundowning" was coined by nurse Lois K. Evans in 1987 due to the timing of the person's increased confusion beginning in the late afternoon and early evening. For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long term adverse outcomes. Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia and seems to subside with the progression of the person's dementia. People are generally able to understand that this behavioral pattern is abnormal. Research shows that 20–45% of people with Alzheimer's will experience some variation of sundowning confusion. However, despite lack of an official diagnosis of sundown syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there is currently a wide range of reported prevalence.

Caregiver syndrome or caregiver stress is a condition that strongly manifests exhaustion, anger, rage, or guilt resulting from unrelieved caring for a chronically ill patient. This condition is not listed in the United States' Diagnostic and Statistical Manual of Mental Disorders, although the term is often used by many healthcare professionals in that country. The equivalent used in many other countries, the ICD-11, does include the condition.

The Institute of Gerontology (IOG) at Wayne State University conducts research on the behavioral and social aspects of aging. Located in Detroit, Michigan, the Institute has a strong focus on urban issues, especially disability, mobility and transportation, financial challenges, and disparities in health between ethnic groups. Faculty at the Institute are jointly appointed with a home department in a complementary discipline, such as economics, physical therapy or nursing. The Institute also maintains a Lifespan Cognitive Neuroscience of Aging laboratory currently profiling brain changes in normal aging through traditional testing and magnetic resonance imaging (MRI) of participants brain structure and function.

For patients with Alzheimer's disease, music therapy provides a beneficial interaction between a patient and an individualized musical regimen and has been shown to increase cognition and slow the deterioration of memory loss. Music therapy is a clinical and evidence-based intervention that involves music in some capacity and includes both a participant and a music therapist who have completed an accredited music therapy program.

Caregiver burden is the stress which is perceived by caregivers due to the home care situation. The subjective burden is considered to be one of the most important predictors of negative outcomes from the home care situation.

Jiska Cohen-Mansfield is the Igor Orenstein Chair for the Study of Geriatrics at Tel Aviv University Medical School and a professor at the Department of Health Promotion at the School of Public Health in the Sackler Medical Faculty at Tel Aviv University. She is the director of the Minerva Center for Interdisciplinary Study of End of Life at Tel-Aviv University.

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. 1 2 "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 Technology Assessment . 10 (26): iii, ix–108. doi: 10.3310/hta10260 . 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. 2010 (1): CD005994. doi:10.1002/14651858.CD005994.pub2. PMC   6669244 . PMID   17253573.{{cite journal}}: 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. ↑ "Security Alarm System supports Independent Living of Demented Persons".


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