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Aimless Excursions: Wandering in the Elderly

Article  in  The Consultant pharmacist: the journal of the American Society of Consultant Pharmacists · September 2006
DOI: 10.4140/TCP.n.2006.608 · Source: PubMed

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 Aimless Excursions:
Wandering in the Elderly
One in five people with dementia wander. Long-term care facilities must tions, maintain a home-like environ-
deal with wandering while simultaneously protecting residents, complying ment, and respect residents’ rights.”
with life-safety codes, maintaining a home-like environment, and respecting Considerable research is now devoted
resident rights. Wanderers tend to be physically healthier than those to this topic.
who do not wander, but more behaviorally disturbed. Experts indicate
that 72% of patients who elope will attempt to elope again. Strategies What Kind of Wandering?
like using commercial security systems, landscaping to direct wanderers’ Until recently, most studies exam-
attention back to the facility, keeping resident albums with recent pictures ined wandering in the context of
and facts about the resident, and having a research-based policy help elopement (abscondence from
prevent serious outcomes. the facility), each study employing
unique definitions and criteria. Now,
Key words: Alarm system, Dementia, Elderly, Hypothermia, Long-term care, researchers recognize four specific
Wandering. types of wandering:
! Direct travel or goal-directed
wandering, which has a real or imag-
inary purpose, such as going home
! Random travel describes haphaz-
ard movement from one location to
another
! Pacing is back-and-forth move-
ment in a confined area
! Lapping is wandering in circular
patterns4
Although no one specifically tracks resident wandering as a source of All wandering behaviors occur
patients with dementia who wander, mild or severe job-related stress.3 with significant frequency.
studies have found that one in five Carol Moseley, Director of Quality Distinction between wandering
people with dementia who wander Assurance for Northport Manage- types has implications for preven-
off will die as a result of their wan- ment in Tuscaloosa, Alabama, says, tion. For example, unlike lappers,
dering.1,2 Long-term care residents “Long-term care facilities try to patients who wander randomly
may wander within the facility and do four things simultaneously.They often fidget with doorknobs and
leave it despite the facility’s efforts try to protect residents, comply egress devices.
to contain them. Staff places wan- with life-safety codes [regulations
dering high on the list of problemat- establishing minimum building safe- Prevalence
ic daily behaviors, and surveys ty requirements] that don’t always Wandering’s real prevalence is
report up to 50% of staff identify allow more restrictive interven- unclear, partly because studies have

608 THE CONSULTANT PHARMACIST AUGUST 2006 VOL. 21. NO. 8

Jeannette Y. Wick
Guido R. Zanni

analyzed different populations or

combined community-dwelling and
long-term care residents. Among
institutionalized adults, prevalence
seems to range from 13% to 22%,
and among dementia patients specif-
ically, it approximates 31%.2 Among
all ambulatory institutionalized
and community-dwelling patients
with dementia, prevalence may be
as high as 50%.5
Prevalence is unaffected by
gender, race, or living situation,
although residents who look like
they are visitors (residents who Prevalence is unaffected by gender, race,
carry a purse or like to wear a
jacket or hat) may elope with
the assistance of well-meaning or living situation, although residents
visitors who open doors for them.
Wandering is a function of the who look like they are visitors
severity of cognitive impairment,
spatial disorientation, or behavioral
disturbances.5,6 In mildly demented
(residents who carry a purse or like to
patients, up to 18% wander.The
proportion increases to 24% among wear a jacket or hat) may elope with
moderately demented patients and
50% among severely demented
patients.3 Up to 65% of all dementia
the assistance of well-meaning visitors
patients will wander at least once.6
Wanderers consistently score poorly who open doors for them.

Jeannette Y. Wick, RPh, MBA, FASCP, is a

senior clinical research pharmacist, National
Cancer Institute, National Institutes of Health,
Bethesda, Maryland. Guido R. Zanni, PhD,
is a psychologist and health systems consultant,
Alexandria,Virginia.

Views expressed in this article are those of the

authors and not those of any government agency.

© 2006 American Society of Consultant

Pharmacists, Inc. All rights reserved.

VOL. 21. NO. 8 AUGUST 2006 THE CONSULTANT PHARMACIST 609

 Aimless Excursions: Wandering in the Elderly
Elopement Profile of Typical Wanderers
Studies have found that people with dementia who wander
share many characteristics. These can be used to implement
preventive strategies and safety programs.
! Elopements within 48 hours of admission: 45%
! Alzheimer’s patients who elope from a secure facility: 1%
! Elopers with previous history of wandering: ~72%
! Least likely time for elopement: midnight to 7 a.m.
! Proportion of patients who will respond to shouts or
call for help: 1%
! Travel patterns: path of least resistance (e.g., through
unlocked doors, downhill)
! Proportion of cases in which clues are found: 14%
! Average distance from residence where found: 0.5 mile
! Proportion of wanderers found within 1 mile: 89%
! Proportion of wanderers found in creeks, drainage areas,
or caught in briars and bushes: 63%
Source: References 4, 6, 11-13.
610 THE CONSULTANT PHARMACIST AUGUST 2006 VOL. 21. NO. 8
on global measures of cognition
(memory, language, attention, and
concentration).3
Although wanderers are physically
healthier than nonwanderers, they
are more behaviorally disturbed.
They often wake others, cry, remain
restless, and make worrisome ges-
tures.6 Wandering and environmen-
tal stimulation are also linked; in
unstructured environments, patients
with mild cognitive impairment
are more apt to wander than those
involved in structured activites.6
An observational study found two-
thirds of nursing home patients
who suffer from moderate dementia
spent unstructured time walking.7
Outcome
Wandering is associated with falls,
fractures, and reduced survival of
up to three years.8 Wandering
approximately doubles the risk of
fracture in residents of nursing
homes9 and often dictates placement
to restrictive environments.10
A resident’s unauthorized and
dangerous departure from the facili-
ty is every caregiver’s fear. Statistics
on elopement are skewed by under-
reporting.Wandering results in
elopement when the resident:
! Does not intend to leave, but is
spatially disoriented and wanders
away, searching for familiar cues
! Wanders haphazardly and ends
up outside the unit
! Intentionally leaves the unit with
direct travel in mind
While the latter appears goal-
oriented, the wanderer’s travel path
is often discordant with the intended
destination.The accompanying side-
bar lists elopement facts, highlighting
a profile every caregiver needs to
know. Clinicians should note that
some wanderers elope with a friend,
and they may secure a vehicle of
some sort. Often, they get lost.
Outcome correlates closely with
the length of time the patient has
wandered; 24 hours appears to be
critical. Statistics are sobering: of
wanderers located after 24 hours,
46% are found dead. Only 20% of
those located after 72 hours are
found alive.12,13 In most instances,
patients die from environmental
stressors (hypothermia, drowning),
not wandering-related injuries or
comorbid diseases.
Facility factors also contribute to
elopement. A recent study associated
elopement with:
VOL. 21. NO. 8 AUGUST 2006 THE CONSULTANT PHARMACIST
! Lack of effective precautions
for residents who voiced a desire to
leave or had an elopement history
! Ineffective use of alarm systems
or other devices alerting staff to
potential elopement
! Poor resident monitoring
4
The latter is particularly signifi-
cant. An analysis4 found that in 53%
of cases, staff were ignorant of the
elopement until contacted by out-
siders who found the patient. In
611
 Aimless Excursions: Wandering in the Elderly
Table 1. Wandering Triggers
Residents are more likely to wander when:
! Placed in unfamiliar environment
! Adapting to a recent medication change
! Left alone
! Experiencing a schedule or routine change
! Spatially disoriented to familiar cues (e.g., dining room)
! Verbally desiring to engage in a past practice (e.g., visit a relative)
Source: Reference 14.
some instances the patient was
nearby or gone only minutes; never-
theless, it is a disturbing finding.The
same study found four major trends
associated with ineffective alarm
systems: residents interfered with
the alarm; the alarm was inaudible
to staff; staff ignored the alarm,
believing they knew who just left
the unit; or the alarm was turned
off or malfunctioned.
Resident Risk
Mark L.Warner, an architect and
gerontologist, has made a career of
trying to understand the machina-
tions of the mind when people with
dementia wander. He has reviewed
police reports, newspaper articles,
and case reports that describe
wanderers who found themselves
in predicaments incomprehensible
to their decaying minds. He has
tried to identify clues that did or
might prevent wanderers from
falling or succumbing to the ele-
612 THE CONSULTANT PHARMACIST AUGUST 2006 VOL. 21. NO. 8
ments. He says, “Caregivers and
families need to know that 72%
of patients who elope once will
attempt to do it again.” Moseley
elaborates, “The most important
factor is getting accurate informa-
tion during the admissions process.
Sometimes families are reluctant to
give accurate information, but it’s
essential to know if the resident has
a history of wandering or elope-
ment.” Staff must take any state-
ment indicating a desire to leave the
facility or engage in retired past
practices (e.g., “I need to go back to
work”) seriously, especially during
the first few days after admission.
Several triggers (see Table 1) are
associated with individual wander-
ing and should be addressed pre-
emptively, with close monitoring.
Prevention
Historically, clinicians often used
physical restraints to prevent wan-
dering.Today, regulations prohibit
restraints for their dehumanizing
features and propensity to increase
patient agitation and/or injury risk.6
Antipsychotic medication is not
considered an appropriate interven-
tion for wandering. Antipsychotics
can only be considered by the treat-
ment team in individuals with
dementia who wander if:
! The behavior is persistent
! It is not caused by preventable
reasons
! The behavior is causing resi-
dents to present a danger to them-
selves or others and is not being
adequately managed
! If they continuously scream,
yell, or pace and these behaviors
cause an impairment in functional
capacity
Wandering that does not cause
a danger to residents or others
is never an indication for an
antipsychotic.1,5
Most programs typically employ
one or more strategies:
! Physical environment modifica-
tion (e.g., disguising exits, circular
pathways in the unit)6
! Creating program units
specifically for wanderers
! Monitoring patients and
environment electronically with
bracelets, door alarms, and closed
circuit monitors
Because spatial disorientation
correlates strongly with wandering,
environmental cues are critical.The
wanderer’s response to directional
cues is often impaired.When they
see a dock, it looks like a path—

that it has an abrupt end does not
register. Place large signs on bath-
room doors to avoid searching for
toilets. Railings are good directional
cues. Use pictures on resident doors
and above each resident’s bed. If pos-
sible, eliminate items suggesting
travel, like coats and hats. Some
facilities design walking paths with
interesting object and spatial cues for
safe wandering.14 Units without alarm
systems need childproof doorknob
covers or other safety devices, and
one staff member should be respon-
sible for resident surveillance and
accountability.
Policy on Wandering
Most facilities consider their policies
proprietary and are unwilling to
share them, but several did provide
copies for this article. Effective pre-
vention and training involves all staff,
including dietary workers, beauti-
cians or barbers, housekeeping per-
sonnel, and facility staff. All staff
should rehearse the rescue plan to
be invoked once elopement occurs,
using drills or mock elopements
at least annually, and if possible,
more often.
According to Warner, whose book,
In Search of the Alzheimer’s Wanderer,
was published by Purdue University
Press in September 2005, “It is
incredible how many clues wander-
ers leave, and how often caregivers
and loved ones omit important clues
when briefing first responders.” He
cites two examples. In the first, the
wanderer was a hoarder of blue
Aimless Excursions: Wandering in the Elderly
sugar packets. Knowing that prompt- who coordinates a search of the inte-
ed first responders to successfully rior of the home for 15 to 30 min-
intensify their search when they utes. Stage 2 (a search of the grounds
found a stray packet by a lake. and a call for additional help) might
The second is an example of how begin at 15 to 30 minutes, or sooner
stress can cause family to omit if clues indicate that the resident has
important information when briefing left. After 15 minutes, Stage 3 would
authorities. He tells of
an elderly woman who
called the ambulance
because her sister had
a heart attack. Stress
was a factor in her
inability to tell respon-
ders her sister’s name,
thus impeding the
search. Long-term
care staff should docu-
ment the answers to
questions described in
Table 2 and have them
ready for first respon-
ders. In anticipation of
a successful outcome,
searchers should
assemble a box of
photos or belongings
Statistics are sobering: of
that the resident will
recognize and enjoy. wanderers located after 24
Define search and
rescue processes in
stages or phases, indi-
hours, 46% are found dead.
cating who will be
involved, the exact Only 20% of those located after
areas to be searched,
and a reasonable time 72 hours are found alive.
frame that the stage or
phase will last. Stage
1, for example, may
involve notifying the
director of nursing
VOL. 21. NO. 8 AUGUST 2006 THE CONSULTANT PHARMACIST 615
 Aimless Excursions: Wandering in the Elderly

Table 2. Facts to Know About a Resident Who May Elope can walk right past them and then
expand the search.”
! What does the resident enjoy, and what upsets him? Family members may be angry if
! What names do the resident’s loved one use to address him? they are not notified immediately,
but the patient’s whereabouts
! What topics does the resident enjoy discussing?
and welfare must be the primary
! Does the resident respond better to women or men? Do uniforms concern. Long-term care manage-
or any other traits frighten the resident? ment coordinates searching with
! Who is the resident’s best friend?
first responders (police, fire, or
other agencies); maintaining recent
! Did the resident work or live in the area? photographs of all residents helps
! If the resident recently lost a pet, what kind was it? searchers unfamiliar with the resi-
dent identify him or her. Engaging
! If the resident lost a relative, what was their relationship?
law enforcement personnel is not
! What item does the resident always have in his possession? permission for long-term care
staff to stop searching.They must
re-search areas close to the facility
while the search expands.
n Elopement policies must also
indicate when and how to involve
Table 3. Who Should Be involve notifying local police and a the media. A flurry of premature
Notified if a Resident Elopes? chain of other internal and external coverage is unnecessary, but if the
notifications (see Table 3). authorities have been notified and
! Facility director or administrator Searchers should remember the resident’s life is in danger, the
! Medical director (in a nursing home) that the wanderers will use their media can be an ally that increases
remaining resources, (vision, smell, the likelihood of success.The
! Police
money), sometimes successfully elopement policy should indicate
! Physician and sometimes not.They will who will call the media and how
! Family member/responsible party
react in the usual way to change, they will present the information.
so when the elevation changes, A good policy:
! Executive director they will take the path of least ! Is facility- and locale-specific,

! State agencies resistance, usually downhill. especially with regard to maps

Patients are likely to continue until
! News media
they become trapped, and fewer
than 1% respond to shouts or call
for help.13 “Wanderers are usually
found within one mile of their PLS
(point last seen),” says Warner,
“They are often fearful or regress-
ing, and may not recognize or
understand others’ effort. Searchers
! Is consistent with other facility
policies in format and style
! Uses clear, explicit, and under-
standable language
! Clarifies and assigns expecta-
tions and responsibilities for all staff
members
! Has information indicating
when the policy was last revised

616 THE CONSULTANT PHARMACIST AUGUST 2006 VOL. 21. NO. 8

 ! Includes few superfluous details
that may change with time
! Indicates where more informa-
tion can be found
! Uses simple visual flow charts
when possible
Policies should not be constrained
by history. “We always search in
concentric circles, or from east to
west,” may need to be replaced
with, “Work from higher to lower
ground.”
Return and Re-Entry
If the resident is found and returned,
certain steps are essential. First-aid
or emergency treatment is the
priority. Again, using the answers to
questions in Table 2 will reduce the
resident’s anxiety and discomfort.
Staff should meet with all involved
in the elopement and search and
then debrief.Try to find out how
the resident eloped, and why.
Implement changes into policy and
practice. “Staff feel traumatized
and responsible when a resident
elopes, and they retrace the event
informally and formally.We use
that information to make changes
at either the organization level or
the specific facility,” says Moseley.
For example, she says, “At facilities
where the nursing staff can’t see the
front door, we’ve installed surveil-
lance cameras. And, if a resident
elopes more than once, we imple-
ment an additional intervention
each time.We do not simply review
what was in place and continue with
the same plan.”
End Note References
Warner indicates that three key 1. Koester RJ.The lost Alzheimer’s and related
disorders search subject: new research and per-
steps can help long-term care facili- spectives. Response 1998 NASAR Proceedings.
ties reduce the likelihood of future National Association of Search and Rescue;
elopements. First, facilities need Chantilly,VA, p.165-81.
2. Koester RJ. Behavioral profile of possible
commercial alarm systems. Most Alzheimer’s disease patients in Virginia search and
facilities that provide care to people rescue incidents.Wilderness and Environmental
with dementia use one Medicine 1995;6:34-43.
of the several available
alarm systems.
Second, and he notes
this is rarely done,
facilities should incor-
porate back-up strate-
gies that limit how
far one can wander
once outside the door.
Paths do not always
have to lead to gates;
they can meander back
to the building. Or,
secondary gates may
have gravity latches
that require multiple
simultaneous actions
to open.
Third, facilities
“Caregivers and families need
should always be
ready to provide first to know that 72% of patients
responders with
patient-specific clues. who elope once will attempt to
Many communities
now train their first
responders to under- do it again.”
stand what is known
about people with
dementia and their
wandering patterns.
If yours does not,
it may be time to
consider it.
VOL. 21. NO. 8 AUGUST 2006 THE CONSULTANT PHARMACIST 617
 Aimless Excursions: Wandering in the Elderly

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Although wanderers are physically

healthier than nonwanders, they

are more behaviorally disturbed.

618 THE CONSULTANT PHARMACIST AUGUST 2006 VOL. 21. NO. 8

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