Alzheimer's Disease: Understanding Wandering Behavior
Wandering affects all dementia patients but is more prevalent with people with Alzheimer’s disease1,2. The patient may simply be wandering aimlessly or trying to achieve an objective such as finding a bathroom or home. This has led to the two classifications of wandering – Wandering aimlessly and goal-oriented wandering. In either case, the patient could wander into dangerous situations such as crime infested neighborhoods, high traffic areas and bad environmental conditions.
Another term that you may hear used with wandering is “Critical wandering.” Both wandering and critical wandering mean the same thing, referring to any person with dementia who wanders away from their caregiver or controlled environment such as a facility or home. Wandering may occur by walking, driving or other means, and it can also happen within a controlled environment. When a dementia patient wanders from a home or facility, this is referred to as elopement. In many cases, the patient simply wanders from a home or facility at night, leaving their safe confines for conditions that could be hazardous to their health.
Understanding Wandering
Wandering causes worry and for both caregivers, loved ones and certainly for the patient. Often the patient is highly stressed, trying to reach the destination they are trying to get to. This is therefore a time when patience and the use of psychological skills can help in calming the patient and weaning them of the need for a particular trigger for wandering.
Many factors can contribute to wandering in Alzheimer’s patients. Perhaps the most significant is the severity of the patient’s dementia. Unfortunately, the more severe the dementia, the more difficult it becomes to identify the causes, since communication continues to decline. Following are some common causes of dementia-related wandering in people with Alzheimer’s.
•Memory loss. Patients who cannot remember their destination may wander as a result. Wandering may also occur when the person attempts to reach a destination that is part of his or her past routine, such as going to work or meeting a friend.
•Physical needs. Toileting and other basic physical needs may prompt wandering.
•Social needs. A decline in language skills may prompt wandering in a person who simply needs social interaction.
•Insomnia. Increased mental fatigue due to lack of sleep can contribute to confusion and disorientation, resulting in wandering.
•Side effects from medication. Many drugs used to treat common conditions in the elderly may have side effects such as uninhibited behavior and restlessness, which can result in wandering.
•Disorientation. Confusion regarding time, place and identity is common in Alzheimer’s patients. Combined with memory loss and an inability to recognize familiar people and environments, the patient may wander out of fear, in an effort to reach a more familiar, comforting place.
Not only is there the potential for getting lost, but a person with Alzheimer’s is also unable to distinguish safe situations from dangerous ones.
Using Restraints to Curb Unsafe Wandering Behavior
In an attempt to prevent the patient from wandering, one might be tempted to use some form of restraint on the patient. This procedure is seen as ineffective by most experts. According to the Alzheimer’s Association, physical restraints have not shown a reduced incidence of “successful exit seeking” and they have not been shown to enhance the safety of wanderers. Rather, restraint use is associated with an increased risk of injury to Alzheimer’s wandering patients3. It is far better to try to determine the underlying causes for the wandering behavior, address those needs, and provide a safe environment for the Alzheimer’s disease patient to move about, avoiding any kind of restraints.
Sometimes, agitation or acting out could also be present. In that case, the use of restraint may become necessary. Studies conducted by the Alzheimer’s Association show that confused or cognitively impaired patients are the most frequently restrained(3). The use of restraint on any patient should always be communicated to the designated contacts for the patient. There are very few things as disturbing to walk into a situation in which your loved one is being restrained without prior notification. Communications with the contacts should include the process being used including medications.
Managing Wandering Behavior
Determining the reasons for the Alzheimer’s wandering behavior can help caregivers understand what the patient’s motivation is—for example, pain, physical discomfort or simply a need to move. Sometimes wandering may be triggered by an urge to return to a safe, familiar and secure environment (such as the person’s home) or former place of work, and it is not an attempt to actually “escape.” Once outside of a controlled setting, however, injuries, fatigue, other injury exacerbating situations such as falls and even death can occur.
We can learn much from patients through observation and understanding their history. An Alzheimer’s disease patient who constantly sorts or rearranges books or other objects, for example, is sharing clues from a former life. Perhaps this person used to work in inventory or in the post office. Patient care for this individual would include suitable activities that safely fulfill the desire to sort things. Does the Alzheimer’s wandering behavior satisfy a need to explore, socialize, seek out someone or something, or is it simply a manifestation of boredom and lack of stimulation? The answers may lie in learning what the patient did prior to the onset of the disease.
Simply put, the first step in managing wandering behavior in Alzheimer’s patients is to determine the unmet needs that are triggering the “wandering.” In dealing with the patients, you have to remain calm. People with dementia can read body language and facial expressions, so remaining calm will help reduce the wanderer’s stress as well. Approach slowly and speak softly. Establish what the wanderer is doing. Ask specific, answerable questions. For goal-directed wandering, some strategies include:
•Validation. What does the wanderer’s emotional state appear to be? Establish a rapport by validating his or her feelings with positive, open statements such as, “You look worried.” Offer to help.
•Distraction. Focus the wanderer’s attention on something more positive. Try establishing a common goal, such as searching for something together, steering the person toward that goal.
•Redirection. Once you have the wanderer’s attention, redirect it in a reassuring manner. For example: “I’m sorry you’re upset. Let’s sit down for a cup of coffee.”
After the situation has been controlled, it may be possible to redirect the wanderer’s attention once again to a calming activity such as listening to music, looking at photos or working on a puzzle.
The environment can also be made safer for the Alzheimer’s patient. Patients can be lost in their own front yards, so it is important not to leave them unattended outside. In situations where there are several people present in the home, make sure that one per¬son is clearly responsible for knowing where the Alzheimer’s patient is. Some families have members take turns with this responsibility. Patients should wear Medic-alert bracelets with their addresses on them in case they do get lost some¬where, and caregivers and/or families should keep recent photos of patients on hand in case the police must be called in to help search. To prevent someone from leaving at night when caregivers are not watching, install a deadbolt lock on the main door of the house, or add a lock to the door in a place a patient might not think to look, such as near the floor.
If wandering occurs at a specific time of day, it may be reduced by getting the patient involved in a strenuous activity such as a long walk, immediately before that time. If wandering coincides with a particular event each day, such as mealtime or the arrival of a particular person, caregivers should try to make that event less stressful in case the wandering represents an effort to escape the situation. If wandering occurs at night, more exercise during the day may help the person to sleep through the night. Since wandering may also represent a search for the bathroom, caregivers should ask patients if they need to use the bathroom and watch for signs that they need to use the bathroom.
References
- Alzheimer’s Association, Key clinical issues in dementia care. As seen in National Hospice and Palliative Care Organization, Caring for Person with Alzheimer’s and other dementias: guidelines for hospice providers
, pg 5, Accessed December 16, 2008
- Tilly, J, Reed P, Eds. Chicago: Alzheimer’s Association , Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Home—Phase 2: Resident Wandering, pgs 18-21, 2006.
- Tilly, J, Reed, P, Falls, wandering, and physical restraints: Interventions for residents with dementia in assisted living and nursing homes, pgs 3-9, Retrieved November 25, 2008,
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