In January 2012, ECRI Institute released a Risk Analysis about hazardous wandering and elopement by people with dementia in long-term care facilities. In the article, the independent nonprofit discusses things facilities can do to support "safe wandering" as an intervention for elopement-and reduce the risk of unsafe behavior.
Wandering may represent "a behavioral expression of a basic human need and support the individual's independence and sense of control," according to the Alzheimer's Association. Though researchers don't know for sure why people with dementia wander, it is often preferable to support safe wandering than to try to stop it altogether. The benefits of supporting safe wandering can be ample.
"It seems that the need to locomote feels very real to people who wander. Trying to stop people from wandering not only might not work, it could be dangerous," said Josi Wergin, ELS, healthcare writer for ECRI Institute and editor of Continuing Care Risk Management.
Safe vs. Unsafe Wandering
People who wander unsafely may face a higher risk of injury, such as fall-related injuries, burns, fractures, lacerations or poisoning. They may elope, get lost or become trapped in unsafe areas (e.g., a freezer, a maintenance closet, a tool shed). In addition, they may be at higher risk of dehydration and malnutrition as well as fatigue and sleep disruption. People with dementia who elope are at risk for injuries, dehydration or malnutrition, exposure, medical complications, drowning or being hit by a car.
"It's also important to consider the impact of wandering on others," said Wergin. "Wandering can lead to caregiver stress, which could lead to inappropriate restraint use. Long-term care residents who wander may infringe on the rights of other residents, such as by wandering into others' rooms or personal space or interrupting their activities, potentially leading to fights."
Alternatively, those who are allowed to wander safely may benefit from stimulation and social interaction; improvement of mood; maintenance of mobility, conditioning, strength, circulation and function; and prevention of problems associated with immobility (e.g., pressure ulcers, orthostatic hypertension, urinary tract infection, pneumonia, constipation).
Because it's autonomous, wandering may also support the individual's independence and sense of control, said Wergin.
Applying Individualized Interventions
Promoting safe wandering is only part of the equation, believes Wergin. Individualized assessment and interventions are other critical components that help staff determine whether a resident is likely to wander and can help identify triggers, patterns, and frequency of wandering and elopement attempts.1
"Chronic or acute health problems (e.g., urinary tract infection, constipation), pain, depression, anxiety, incontinence and other issues may contribute to wandering, so it's important to evaluate for those factors as well," she noted. "Staff can then work to find interventions that work for that individual."
Some examples include exercise programs, air mat therapy, activities that used to be performed (such as simulated chores or previous job duties), lifestyle activities (such as gardening), music therapy, and visits from family and friends.
Most likely, individualized interventions aren't going to stop wandering entirely, acknowledged Wergin.
So, it's also important to have a safe environment for wandering, including both spaces that encourage activity and spaces that encourage rest. Regardless of whether the person is wandering safely or engaging in individualized activities, supervision is critical.
"The supervision plan can be tailored to the wandering patterns and triggers of the individual. For example, if a long-term care resident's wandering tends to peak at the afternoon shift change, that might be a good time to increase supervision for that resident," she said.
Managing Wandering & Elopement
Katherine Owens, CMIS, Director of Marketing at Arden Courts of Fair Oaks, a Memory Care community in Fairfax, VA, understands that people with memory impairment can wander for myriad reasons. One such motive may come in the form of anxiety, e.g, a person might start looking for a place, person or object they cannot find.
"In a specific case at Arden Courts, one of our residents was wandering looking for her car when, in fact, it had been years since she had driven," recalled Owens.
Others might be wandering as a result of 'sundowning,' which is a syndrome that typically occurs in those affected by dementia during the late afternoon/early evening hours of the day. Some may wander out of boredom simply because they are not being stimulated enough on many different levels.
"One of the things we try to do in our Memory Care community is look for trends in one's wandering to narrow down underlying reasons for what might be triggering the occurrences," explained Owens. "If it's something that compromises the safety of our residents, then of course we want to eliminate the source of the issue."
Though this largely depends on each individual's needs, Owens recommends putting in place environmental precautions to support the safety of those who wander. This includes assessing whether or not the individual is at risk for falling and having the equipment necessary to prevent injury, alarm systems, 24/7 caregiver support and supervision, and programs like Medic Alert Safe Return or Project Lifesaver.
Owens is also a proponent of validation therapy as a way to manage wandering.
"This is where one might exit-seek to 'go home,' and 'home' might be at the farm back in Kansas 50 years ago. We validate where they are in their own mind, not by arguing with them, but instead we might say, 'We'll head back to the farm in a little while, but first I thought you could come and help me with something.' Not only does this reaffirm their thought process, it also redirects their original mindset and offers a temporary solution that empowers them to 'help' with something," she said.
Maintaining Safe Independence
As long as residents are not at any serious risk for falling, are wandering in a safe and secure environment, and any possibility of anxiety, pain or discomfort is eliminated as a cause for the wandering, Owens said she does not see any taxing reason to try and stop their wandering.
"Wandering in a safe and secure environment can allow for both physical and social stimulation. Just a small amount of walking can go a long way to help keep our residents stronger, which increases their chance of ambulating independently for much longer," she said.
The outdoor space and overall design of Arden Courts allows residents to feel as though they are not confined. A secure walking path complete with a "backyard" and two courtyards totals about three quarters of a mile that residents have access to during the day, allowing them to wander as they please.
"Families and friends of loved ones with dementia are thrilled that our design allows our residents to maintain as much independence as possible, for as long as possible while keeping their safety at bay. The daily routine and programming is also very healthy for our residents," said Owens. "Each of these factors plays a role in eliminating the risk of any negativity that might lead to wandering for the wrong reasons."
1. Futrell M., Melillo K.D., (2008, July). Remington R. Wandering. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation Dissemination Core; 51 p.
Beth Puliti is a frequent contributor to ADVANCE.