Problems with Wandering – review

· stress
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Problems with Wandering

Practical suggestions for understanding problem behaviors

POSSIBLE CAUSES

Physiological or medical causes:

Direct result of physical changes in the brain.

Inability to identify or express hunger.

Reaction to sedatives, tranquilizers, or the interaction of medications.

Physical discomfort due to pain, infection, constipation, bruises.

Seizures resulting in aimless, confused wandering.

Need to use bathroom.

Desire to exercise.

Dehydration contributing to confusion, wandering.

Stress.

Temperature uncomfortable – to hot or cold.

Can’t make sense of environment.

Sensory overload – too many people or activities, excessive noise.

Sensory deprivation – too quiet, boredom.

Poor lighting, resulting in shadows which are misinterpreted or frightening. Sometimes people make be looking for light because they are frightened.

Feels closed in, trapped.

Friend or family member out of sight.

Desire to leave triggered by seeing outdoor clothing such as coat, hats, boots, etc.

Acting out once regular routine, such as leaving for workplace.

Lost. Sometimes people with dementia suddenly begin losing their way to familiar places and become lost.

Inability to recognize new unfamiliar surroundings, e.g., person recently begun attending day care program.

Feels tension in environment.

OTHER CAUSES

Task too difficult

Perceives activity as too childlike.

Feels useless, helpless while watching others do task.

Inability to follow through on task.

Bored with activity or lace of activity.

Clothing too tight or uncomfortable.

Caregiver’s anger, tension, impatience sensed by person.

Touching by caregiver frightening or misinterpreted.

Caregiver speaking too quickly.

Directions from caregiver not understood, not simply stated

Searching from home or people from the past.

NIGHTTIME WANDERING

Inability to separate dreams from reality.

Inactivity; too much sleep during daytime.

Adverse reactions to tranquilizers.

Inability to differentiate day and night.

Disorientation to time. When person wakes up he/she thinks it is time to get up.

COPING STRATEGIES

Have a through medical evaluation, particularly if wandering begins suddenly. (Very often it will be a urinary tract infection)

Consider possible physical causes such as illness, fever, hunger, pain, swelling, etc.

Allow person to wander if environment is safe and secure.

Place familiar objects, furniture, and pictures in surroundings.

Help direct person with clearly labeled rooms. For example door decorations or name plaques may be useful for finding bedroom; a picture of a toilet or a brightly colored door may help person locate bathroom.

Decrease noise levels and number of people interacting with wanderer at one time.

Go for a walk around neighborhood, in a mall, around home. Walking or other exercise often reduces a agitation that leads to wandering, and also helps person to sleep better.

Remove items that may trigger desire to go out: shoes, coat purse, coat rack, etc.

Take a drive in the car. Make sure person with dementia is safely buckled in and doors are locked. Never leave a person with dementia unattended in a car. The person may become frightened about being alone, could wander away, release emergency brake or fiddle with gear shifts.

Distract with conversation, food, drink or activity.

Try to involve person in household activities, such as folding laundry, washing dishes, which will help him/her feel useful.

Limit activities to 20-30 minutes or less, depending on level of impairment.

Consider past skills and interests when presenting activities. Is it possible to adapt activity to encourage participation? Is it possible for the wanderer to do one type of activity?

Make sure the person isn’t wandering because he/she needs to use the bathroom. Look for signals such as fidgeting with clothes. At night be sure the bathroom or a commode is easily accessible.

Improve lighting throughout environment, especially, at night. Older people need about three times as much light to see properly as younger people.

Try placing a large, digital clock by the bed to orient person to time.

Try these communication techniques with wanderers:

Reassure person frequently about where he/she is and why.

Speak in calm, normal tone of voice.

Try written reassurances for mildly impaired person ,such as “Liz will be here at 3:00 o’clock to pick you up.”

Try not to confront or argue with the person.

Limit number of people to redirect wanderer. If more than one person is needed for safety, second person can remain out of sight, or in a background behind other caregivers.

Increase  the wanderer’s trust by humoring and cajoling.

Allow the person to verbalize feelings without arguing.

Alleviate fears – “Your family knows where you are.”

Approach wander in a casual non-threatening manner. It is best to approach wanderer from the front slowly and calmly. Fall into step beside person and walk a short distance with the person before gently guiding him/her back to activity, event or location.

Give wanderer verbal identification of person, place and time. Large numeral clocks may help orient to time.

KEEP THE WANDERER SAFE

Place night lights throughout the house.

Try locks on doors that are out of sight or reach. Install slide bolts on either top or bottom of outside door.

Use dead bolt locks. Models are available that require a key for exit or entrance. It is important to think about exiting in an emergency if key locks are being considered.

Try child proof door knob covers that prevent potential wanderer from turning door knob. Covers are available at toy stores or medical supply stores. May be inadvisable for caregiver who have arthritic hands.

Place warning bells above door. Bells that jingle when door is opened will signal caregiver.

Try monitoring devices, available in a wide price range, which alter caregivers that exit door has been opened.

Order a “toddler monitor,” available through children’s stores and catalogs. A small device attached to a person’s clothing will set off a beeper when person goes outside of a 25-50 foot range.

Make house accident proof. Keep medications, toxic substances such as cleaning supplies, sharp objects, alcohol, and matches locked in cupboards or closets. Put locks on outside gates. Fenced in back yards allow people to wander safely.’

Use a safety gate across doors and at top or bottom of stairs. This may help keep the wanderer in a limited area where he/she can explore safely.

Consider using a bean bag chair for sitting and resting. This may be helpful because they are comfortable yet difficult to get out of. Person may need assistance in sitting down and getting out of chair.

Provide the wanderer with some type of I.D.: Medic-Alert bracelet (available at many pharmacies), I.D. labels sewn in clothes, emergency cards in wallet, purse or pocket. I.D. should have person’s name, address and phone number and the statement “memory impaired person.”  Better yet, use Alzheimer’s Association “Safe Return” program.

Have a current picture of person available, in case he/she become lost. A videotape of person may also be helpful.

Alert neighbors and police that a memory impaired person lives at residence. Keep a list of important phone numbers, e.g., neighbors, police, physician and family members.

Notify police about circumstances in caring for someone with dementia. They might want to keep a picture of person in file and perhaps fingerprints. These may be helpful if person has wandered away.

Use brightly colored outdoor clothing such as jacket, coat, pants. Reflectors sewn onto sleeves or pant legs may be helpful to police involved in searching for the persons.

This may sound weird if you are a city person. But in rural settings have an unwashed piece of clothing available for tracking dogs. If person has been missing a long time, this clothing may be helpful to police involved in the search.

Be aware that often the police do not consider someone a missing person until missing 24 hours. You must convince police that 24 hours can be life threatening to a person with dementia.

For caregivers at home, there are some physical restraints that can be used to keep the person in a bed or chair as A LAST RESULT. While it may be distressing for caregivers to restrain the person, there may be no other way to prevent injury. Restraints may also be helpful for the caregiver to use while in the bathroom, cooking, etc. A poesy (harness or vest with ties) is one device which may be useful. Geriatric chairs keep the person in one place and have a tray for eating or doing activities. It is important that the person does get exercise regularly.

Keep walker or cane, if used, in same place at all time.

KEEPING THE WANDERER COMFORTABLE AND HEALTHY

Weigh weekly to make sure the person is not losing too much weight. Loss of five pounds in six weeks, for example, is of concern.

Provide comfortable clothing such as jogging suits and tennis shoes.

If the person wanders a great deal, try to get him/her to rest for a half hour every few hours, with feet raised to prevent swelling.

Give frequent drinks of water or juice to prevent dehydration. The person with dementia will often forget to drink or not recognize thirst. Dehydration can be dangerous and may increase confusion.

Check feet often for swelling or blisters. Elevate feet when swelling occurs.

IN LONG TERM CARE SETTINGS

Provide opportunities for exercise, particularly when people are waiting for a meal or activity. Exercise might also include singing, rhythmic movements, dancing, etc.

With help from families, develop a social/medical history that includes information on the person’s style of coping with change and stress, patterns of physical exercise, and lifetime habits both at work and at home. This information may be helpful in determining whether the wandering is related to previous lifestyles.

Develop areas indoors and outdoors where people can explore and wander independently.

Reduce amount of noise, and confusion in the environment. For example, change of shifts, loud speakers, music, noises from housekeeping activity, delivery of food or supplies are all potentially stressful situations.

In many States, it is illegal but consider using physical restraints such as belts, geriatric wheelchairs, half door, for only brief periods of time and only as A LAST RESORT. Often times restraints add to the amount of stress and tension the person may be experiencing.

Reinforce where bathrooms and other public areas are by having rooms clearly labeled, painted bright colors, or marked with lights or awning.

Carefully monitor all medications, especially if antidepressants or anti-anxiety drugs have recently been changed or introduced.

Try a yellow strip of plastic (symbolizing caution) that is Velcroed across doors to prevent wanders from entering. The strip is easy to get through in case of an emergency, allow patients to keep doors open to see and hear what is happening inside or outside their rooms.

Have a plan of action in place, in case someone wanders away from facility.

Camouflage doors by painting exit doors same colors as walls.

Cover doors with curtains or movable screens.

A large NO! on doors may discourage wanderer from entering, exiting.

Place a full length mirror on exit doors. Some people will turn around when they see the image, not recognizing themselves.

Be aware that after a move into a nursing home, it is not uncommon for a person to become disoriented when awakened in the middle of the night. Often patients are searching for a familiar person, place or possession. Reassure with a calm voice. Listen to what feeling is being expressed. Distracting with food, drink or activity may be helpful. Walking with person to the bathroom may serve as a distraction as well as promote sleep.

OTHER CONSIDERATIONS

A written diary or log may be helpful to understand what leads to wandering. Write down your observations about wandering for several days. Is the person tryiung to find a room? What was going on before wandering started? What time of day is it? Consider how medications, mealtime, weather, bath time, other people relate to wandering.

Wandering maya be due to the person searching for a part of life lost to the disease or for a person, place or object from the past. Reminiscing about things from the past may be comforting. Photo albums, travel books, etc., may be helpful ways to reminisce.

For some people with demetia, wandering is a coping mechanism to relieve stess and tension. Trying to stop the wandering may increase agitation and cause anger and frustration.

Anticipating an event such as a visit to or from relatives may contribute to wandering. Consider if person should be advised of plans ahead of time and if so, what amount of time is necessay withou couasing anxiety or restlessness.

Wandering may occur when a change of location is anticipated. In event of relocation, slowly introduce person to idea. Visit new location several times prior to move to help orient person to new surroundings. Involve person in actual move, if possible. When in new environment such as day care center, hospital  or long term care setting, stay with person to reassure him/her about new suroundings.

Medications may be helpful in controlling agitation that leads to wandering. Again, this should be A LAST RESORT as these medications do have side effects. Also,k it is important to know  that for some people these medications may increase restlessness.

A person who wanders at the same time every day may be returning to a former schedule or routine. For example, a person may be trying to get back to work after lunch. Think of ways to accommmodate this, such as going for a walk or drive, or distractions.  (A good example is Ronald Regan, when he got worse, they had an office and everyday he would get dressed up and take to hiss “office”).

Good Luck. Remember: Observe, Predict, Anticipate

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