Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0115Phenomenology of WanderingA. Habib and G. T. GrossbergSt Louis University, MO, USAWith current increases in the elderly population, dementia and itsrelated behavioral disturbances are receiving much more attention.Wandering is one of the common, often treatment-resistantbehavioral concomitants of progressive dementia. Most researchon wandering has focused on nursing home- or dementia clinicbasedsamples. In these samples, wandering occurs in up to 65%of patients at some point in the disease process 1–7 .Table 115.1Why patients wanderTrying to find ‘‘home’’Trying to find bathroomAre hungryAre in painAcute medical or environmental trigger, stress, or lossDrug side effect or withdrawalAre boredDEFINITION AND PHENOMENOLOGYThere has been much debate about the appropriate definition ofwandering, as well as its phenomenology. A major difficulty inwandering research has been the lack of a uniform definition andof reliable assessment instruments. Wandering was initiallydefined as ‘‘aimless movement’’ 8,9 . More recent definitions haveviewed wandering not only as aimless, but also as havingpurposeful intent 10,11 . Wandering has further been classified, onthe basis of phenomenology, as benign or problematic 8 . A benignwanderer is a patient who roams aimlessly and is easilyredirectable, whereas a problem wanderer is one who is disruptiveto family, staff or other residents and includes the individual whois resistant to redirection. Attempts have made to quantifywandering behavior into two broad categories, continuous andsporadic. ‘‘Continuous wanderers’’ are defined as ambulatingmore than 50% of their wakeful time, while ‘‘sporadic wanderers’’move about for less than half of their wakeful time.A common theme that is consistently supported in the literatureis that wandering is primarily influenced by a continuity ofbehaviors from earlier premorbid times 12 . Recent research 13 hasalso focused on the relationship of premorbid personality andwandering. Overall, wandering is viewed as having a beneficialeffect for the wanderer by fulfilling a particular need. De Leon etal. 18 showed that wanderers had poorer parietal lobe functioningthan subjects with similar degrees of cognitive impairment.However, in a multisite, random sample of 163 ambulatory,cognitively impaired subjects, wanderers showed significantlygreater impairment in basic skills (orientation, memory andconcentration) and in the higher-order skills of language, abstractthinking, judgement and spatial skills 14 . In Monsour and Robb’s 12sample of wanderers, 36/44 subjects had dementia or Alzheimer’sdisease; eight had cerebral vascular accidents or arteriosclerosis.Although wanderers may have more cognitive decline, they oftenexhibit an intact social facade, which masks their deficits 15 . Snyderet al. also identifies that wanderers had a higher number ofpsychosocial needs than non-wanderers on the Human DevelopmentInventory (HDI).Triggers of WanderingTable 115.1 lists some common reasons why patients wander.They may be trying to find ‘‘home’’ or their room, whereas someare merely driven by the urge to void and are trying to find abathroom. Some patients may be scavenging for food becausethey are hungry. Wandering behavior may be due to pain, e.g.arthritis or other painful medical states, which the patient cannotcommunicate. If the wandering behavior is of abrupt onset, oneneeds to ask if an acute stress or loss, whether a medical (e.g. aninfection) or environmental (e.g. death of a roommate or familymember) factor has triggered the wandering behavior. At times,wandering may be due to boredom.TREATMENTTable 115.2 highlights general treatment approaches to wanderingbehavior. The management of wandering behavior can beclassified into three groups according to the potential etiologyof the wandering behavior: (a) medical; (b) psychosocial; and(c) environmental.The most important cause of wandering to exclude is an acuteor chronic underlying medical problem, for example, an abruptarrhythmia. Also, could the need to be on the move be a side effectof medications? Akathisia with neuroleptics or agitation withTable 115.2Treatment of wandering: general approachesEliminate physical/chemical restraintsWander-safe indoor and outdoor areasEliminate distracting light and noise from environmentUse of electronic elopement prevention devices and patient identificationbraceletsProper staffingStaff education and trainingPhilosophy of rehabilitationPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd