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Wandering is the second most frequently reported behavioral problem in dementia long term care: sundowning is the first (Canevelli et al, 2016). The peak incidence of ambulation in nursing homes is between 5 pm and 7 pm, which is also when sundowning most often occurs (Martino-Saltzman et al, 1991).  Wandering may be more frequent in AD than in VaD (26% v. 18%) and even more prevalent in LBD, but no studies have been done to confirm these results (Cooper and Mungas, 1993).  Wandering does not differ in frequency of occurrence by gender or age, but men seem to pace more than women (Keily et al, 2000).  Wandering occurs more in the later stages of dementia and those taking antipsychotic medications have a greater chance of wandering than those who do not.

 

What causes wandering? One debate concerns whether wandering is purposeful or aimless behavior.  Some researchers believe the IWD who wanders may feel threatened and search for something as a result (Colthorp et al, 1996) or the behavior may reduce anxiety or relieve discomfort (Kiely et al, 2000). Some posit that wandering is agitation expressed in a nonaggressive way (Algase et al, 2008).    It is thought that wanderers have a higher reaction to stress: perhaps internal discomfort combined with external demands or stimuli exceed their stress tolerance threshold. Others hypothesize that those who wander were more active in their earlier lives and may actually be expressing positive emotions.  Happiness and pleasant emotions were linked more often with wandering than emotions of anger or sadness in a 2014 study (Cipriani et al, 2014). Wandering may not be a modifiable behavior in some individuals. 

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Medical explanations for wandering are equally as varied as possible causes.  Some scientists believe those who wander have a decreased blood flow in the left temporal parietal region (Meguro et al, 1996) and decreased frontotemporal glucose utilizations as shown on PET scans (Rolland et al, 2005).  These individuals may have spatial perception and memory issues or impairment in their visual attention and optic flow, which provides information about backward and forward self-motion. Like those who exhibit sundowning, wanderers also tend to have sleep disturbances.  If an IWD wanders, it is important to look for patterns including the time of day, perceived destination, and precipitating events.  Wandering can also occur as a side effect of medication, so this should be ruled out as a possible cause.  One useful tool in analyzing wandering behavior and its antecedents is the Algase Wandering Scale (Algase et al, 2001). 

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To date, there are no randomized controlled trials to recommend either non-pharmacological or pharmacological treatments for wandering.  Some studies have found the following to be helpful.

• Regularly schedule exercise, especially to music. This can help minimize restlessness.

• Provide a safe area for pacing/wandering such as a fenced yard or a clear path within the home.  It may also be beneficial to walk/pace with the wanderer.

• Watch for behaviors that may precipitate wandering such as pacing, disorientation in locating rooms in the home, nervousness in crowded areas, talk about going to work/shopping, etc.  Put a stop sign, curtain, streamers, or other sign to mask the door or indicate it is not to be used. 

• Plan activities at the time wandering is most likely to occur. 

• Provide reassurance if the IWD wants to “go home” or to “work”.  Tell them they are staying home, don’t have to go to work, are safe, and can “go home” in the morning/after a good night’s rest, etc.  If the IWD no longer drives, keep car keys hidden. 

• If wandering occurs at night, lower the bed to about a foot off the floor and place a mat next to it.  It will be difficult to leave the bed but safe to do so with the cushioned mat beside it. Likewise, a black door mat or painted space on the doorstep may discourage crossing as it may appear to be impassable (due to changed visual perception).

• Place locks either high or low on doors and/or include a warning sound or signal such as a bell as an alert when the door is opened.  Childproof covers to doorknobs can be used.

• Put coats, umbrellas, purse, etc. out of view.  Many individuals will not go out if they do not have certain items.

• Avoid noise or crowds that contribute to disorientation or overstimulation.

• Develop a plan in case wandering occurs. 

The Alzheimer’s Association has a program for missing persons with dementia called MedicAlert + Alzheimer’s Association Safe Return.  As of this writing, their contact number is 1.800.625.3780. Your loved one can be registered; first responders check the registry when a missing person with dementia is located.  One does not need to be enrolled to file a missing person report.  Other tips to prepare include having a recent photo and medical information to give police, list of places the IWD might wander to, list of neighbors and their phone numbers to contact if the person is sighted alone, and identification jewelry.  The Alzheimer’s Association suggests searching your immediate area no longer than 15 minutes before contacting authorities.  Some communities have nonprofit organizations designed to help family members quickly locate those who wander.  An example is Project Lifesaver in Suffolk County, NY.  This organization provides radio transmitters that triangulate the location of the wanderer.  GPS might also work in some instances.  For more information, see projectlifesaver.org (Watts, Dec/Jan 2019). 

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Sources:

Algase DL, Antonakos C, Yao L, Beattie ER, Hong GR, Beel-Bates CA.  Are wandering and physically nonaggressive agitation equivalent? Am    J Geriatr Psychiatry 2008;16;293-299.

 

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 May-Jun;16(3):141-    152.

Canevelli M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, Bruno G.  Sundowning in dementia: clinical relevance,     pathophysiological determinants, and therapeutic       approaches.  Front Med. 2016;3(73):1-7.

 

Cipriani G, Lucetti C, Nuti A, Danti S.  Wandering and dementia.  Psychogeriatrics, 2014;14:135-142.

Colombo M, Vitali S, Cairati M, Perelli-Cippo R, Bessi O, Gioia P, Guaita A.  Wanderers:  Features, findings, issues.  Arch Gerontol Geriatr 2001(7):99-106.

Coltharp W Jr, Richie MF, Kaas MJ.  Wandering.  J Gerontol Nurs 1996;22:5-10.

 

Cooper JK, Mungas D. Risk factor and behavioral differences between vascular and Alzheimer’s dementias:  the pathway to end-stage disease.  J Geriatr Psychiatry Neurol 1993;6:29-33 as cited     in Cipriani et al, 2014.

 

Kiely D, Morris J, Algase D.  Resident characteristics associated with wandering in nursing homes.  International Journal of Geriatric Psychiatry 2000;15(11).

 

Martino-Saltzman D, Blasch BB, Morris RD, McNeal LW.  Travel behavior of nursing home residents perceived as wanderers and nonwanderers. Gerontologist 1991; 31L666-672. 

 

Meguro K, Yamaguchi S, Yamakazi H, Itoh M, Yamaguchi T, Matsui H, Sasaki H.  Cortical glucose metabolism in psychiatric wandering patients with vascular dementia.  Psychiatry Res 1996; 67:71- 80.

 

Rolland Y, Payoux P, Lauwers-Cances V, Voisin T, Esquerre JP, Vellas B.  A SPECT study of wandering behavior in Alzheimer’s disease.  Int J Geriatr Psychiatry 2005; 20:816-820.

Watts, S. Rescuing loved ones who wander.  Brain & Life, 2019;December/January:6-7.