Transcript Interventions to Manage Wandering

Wandering & Dementia
What Every SAR Participant
Should Know!
Presented by: Teepa Snow, MS, OTR/L, FAOTA
Dementia Care & Training Specialist
Four Cases…
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Case One – Anita
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Case Two – Frank
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Case Three – Mary
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Case Four – Glenn
Definitions…
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Critical wanderer – anyone with dementia who
leaves and wanders away from a supervised care
situation, a controlled environment, or cannot be
located
At-Risk Wanderer – anyone who has a history of or
current behavior of getting lost, dementia, dislike for
current situation, med change, pacing, disorientation,
disturbed wake/sleep cycle, ‘delusional thinking’,
desire to leave or get somewhere, exit seeking…
– Escape – planned and purposeful secret leaving
– Elopement – leaving a location to get out and go
– Goal directed wandering – movement attributed to some
goal – not trying escape so much as do something
– Random wandering – movement appears to be random
and without purpose- following, seeing and going…
Statistics on Wandering
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Over 127,000 people with dementia are
critical wanderers each year in the US…
With increasing number of people with
dementia expected – the number may
grow to 500,000 by 2040!
The only group more likely to wander
are children!
Typical Behaviors with Dementia
that Affect a Search & Rescue
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Go till ‘stuck’
Don’t ‘turn around’
Going to ‘past places,
times, events’
Found in creek, drains,
briars or brush (63%)
Leaves quietly
Other medical
problems affect safe
mobility
History of wandering
(72%)
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Cross or leave roadways
(67%)
Found within a mile of initial
location (89%)
Found within short distance to
the road (50%)
Going to a ‘familiar place’
Will not leave clues or trail
Will not call out for help (95%)
Will not respond to calls (95%)
Affected by the environment
What is it NOT…
NORMAL Aging
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Slower to think
Slower to do
Hesitates more
More likely to ‘look before
you leap’
Know the person but not
the name
Pause to find words
Reminded of the past
For you, its worse…
NOT Normal Aging
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Can’t think the same
Can’t do like before
Can’t get started
Can’t seem to move on
Doesn’t think it out at all
Can’t place the person
Words won’t come – even
later
Confused about past
versus now
For you it’s DIFFERENT
What Could It Be?
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Another medical condition
Medication side-effect
Hearing loss or vision loss
Depression
Acute illness
Severe but unrecognized pain
Other things…
Could It Just Be Forgetfulness
or Getting Old?
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There is a difference
At first it may be hard to tell
Then you start to notice patterns
One of these things start to show…
– Memory
– Word finding
- Problem solving
- Behavior
Cognitive Changes with Aging
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Normal changes = more forgetful & slower to learn
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MCI – Mild Cognitive Impairment =
– Immediate recall, word finding, or complex problem
solving problems (½ of these folks will develop dementia
in 5 yrs)
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Dementia = Chronic thinking problems in > 2 areas
Delirium =Rapid changes in thinking & alertness
(seek medical help immediately )
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Depression = chronic unless treated, poor quality , I
“don’t know”, “I just can’t” responses, no pleasure
can look like agitation & confusion
DEMENTIA
Alzheimer’s
Disease
•Early - Young Onset
•Normal Onset
Vascular
Dementias
(Multi-infarct)
Lewy Body
Dementia
FrontoTemporal
Lobe
Dementias
Other Dementias
•Genetic syndromes
•Metabolic pxs
•ETOH related
•Drugs/toxin exposure
•White matter diseases
•Mass effects
•Depression(?) or Other
Mental conditions
•Infections – BBB cross
•Parkinson’s
Alzheimer’s
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New info lost
Recent memory worse
Problems finding words
Mis-speaks
More impulsive or indecisive
Gets lost
Notice changes over 6 months – 1 year
Two forms of Alzheimer’s
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Young Onset (30-65)
– Anyone with Down’s Syndrome (35-55+)
• Early symptoms different
– Less language, attention, self-care, emotional control
– More self-stim, seizures, behavior pxs
– Younger people – in families & NOT
• Added symptoms:
– Problems at work, in relationships, with law
enforcement, with money, with drinking
– Faster progression (2-5 years)
– Mostly MISSED as a dx
Most Common Alzheimer’s
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Normal Onset – after age 65
– At 65 about 5-10% have it
– At 85 about 45-50% have it
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Gradual onset (8-12 years in duration)
Progression Pattern Predictable
ONLY 20% of early stage is diagnosed
Vascular Dementia
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Sudden changes
Picture varies by person
Can have bounce back & bad days
Judgment and behavior ‘not the same’
Spotty losses
Emotional & energy shifts
Lewy Body Dementia
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Movement problems - Falls
Visual Hallucinations
Fine motor problems – hands & swallowing
Episodes of rigidity & syncopy
Insomnia & Nightmares
Fluctuations in abilities
Drug responses can be extreme & strange
Fronto-Temporal Dementias
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Many types (includes Pick’s)
Frontal – impulse and behavior control loss
– Says unexpected, rude, mean, odd things to
others
– Dis-inhibited – food, drink, sex, emotions,
actions
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Temporal – language loss
– Can’t speak or get words out
– Can’t understand what is said, sound fluent –
nonsense words
The person’s brain is dying
More In-depth Information
for training & building skills
Why Do They Leave?
TRIGGERS
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Placed in unfamiliar environment (2028%)
Saw coat – decided to go (13-27%)
Argument – got angry (23-47%)
Change in routine or schedule (23-27%)
Spent the day away (23%)
Change in medication (21%)
Left alone in a vehicle (18%)
How common is dementia?
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Estimates – over 70% of people in care
facilities have some degree of dementia
The rates go up dramatically between
ages 65-85 – from 5% to 50%
Early on you can ‘miss’ the signs
There are over 70-80 different types
and causes of dementia
SO… What is Dementia?
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It is NOT part of normal aging! It is a
disease!
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It is more than just forgetfulness - which
is part of normal aging
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It makes independent life impossible
Cognitive Changes with Aging
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Normal changes = more forgetful & slower to learn
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MCI – Mild Cognitive Impairment =1 problem only
– Immediate recall, word finding & complex problem solving
problems (½ of these folks will develop dementia in 5 yrs)
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Dementia = Chronic thinking problems in > 2 areas
Delirium =Rapid changes in thinking & alertness
(seek medical help immediately )
Depression = chronic unless treated, poor quality , I “don’t
know”, “I just can’t” responses, no pleasure
can look like agitation & confusion
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PET and Aging
PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain
ADEAR, 2003
Positron Emission Tomography (PET)
Alzheimer’s Disease Progression vs. Normal Brains
Normal
Early
Late
Alzheimer’s Alzheimer’s
Child
Building
Skills & Knowledge
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Understand dementia & its progression
Know how symptoms affect behavior
Describe needs connected to behavior
Optimize interaction skills
Understanding Dementia Brain Failure
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memory loss
language loss
impulse control loss
emotional control loss
circadian rhythm loss
self-care skill loss
How do these losses relate
to some AT-RISK wandering
behaviors?
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Eloping - escaping
– following cues
– wanting to leave
– going somewhere
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Exploring the environment &
objects
– Pushing/opening doors or
windows
– Following people
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Persistent ‘going’
– inability to terminate
– not able to do anything else
– Discomfort
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Can’t do things on their own
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Lost and ‘Looking’
– can’t find places
– looking for familiar
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Invading space
– automatic actions
– following interests & habits
– no awareness of ‘personal
space’
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Shadowing
– looking for help
– Comfort
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Resisting care – getting mad
Night time wakefulness
Factors to Assess…
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Level of dementia
Personal history
Health history
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Caregiver approach
& assist
Environment
Schedule & flow of
the day
For ALL individuals with
dementia...
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There is always the possibility of a FIRST
TIME…
PACING is an indication of growing distress
Dementia does NOT equal stupid
Things typically get worse as the day goes
on… by late afternoon/early evening… or at
night…’Sun-downing’
Each person is an individual… know them!
Progression & Typical AT-RISK
Wandering Behaviors
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Early
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Way-finding problems
Need to get ‘home’, to ‘work, to ‘familiar’
Can’t remember new info on location
Not aware of impairments
Gets frustrated with limits set by others
May still drive or Can get independent transport
Poor time awareness
Look for ‘signs’ – not diagnosed - BEHAVIORS
• Meds – Aricept, Excelon, Razadyne, Namanda, Haldol,
Seraquel, Respirodol, Ativan, Geodon, Abilify, Zyprexa
Progression & Typical AT-RISK
Wandering Behaviors
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Middle
– Goes to old situations and activities
– Gets stuck on ‘important things to do’
– Can still think and watch caregivers for
inattention or information
– Fluctuates in ability during 24 hrs
– Wake-sleep disturbances
– Will agree with caregivers – won’t
remember it or mean it
Progression & Typical AT-RISK
Wandering Behaviors
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Late
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Follows/shadows caregivers
Can’t verbally communicate
Fears ‘chasing’
Can’t communicate needs or wants
Follows visual cues – doors/cars/windows
No self-protection
Doesn’t turn around
Worsening mobility skills
No day-night or seasonal awareness
Can’t meet own needs (food/drink/care)
What Can & Does the
Diamond - Earliest
Person Do?
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Seeks authority figures for help
Follows simple directional signs
Follows prompted schedules
Follows familiar routes to get around
Looks for places, people, activities that are
desired BUT gets lost easily
Becomes easily frustrated when things don’t go
well or others won’t ‘behave right’
Will look and sound ‘normal’ most of the time
What Can & Does the
Emerald – Early/Moderate
Person Do?
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Asks questions over and over
Picks up on visual information more than verbal
Elopes - Goes back to old work & home habits
Elopes – To get away from current rules/situation
Has some problems with hygiene, personal care, care of others
or pets, can’t be alone
Becomes upset if unable to figure out what should or needs to be
done
What Can & Does the
Amber – Moderate-Severe
Person Do?
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Needs step-by-step guidance & help for care
Follows demonstrations and hand-under-hand guidance after a
few repetitions, uses utensils (not always well)
Likes to handle, manipulate, touch, gather, place things
Will not respect others’ space or belongings
Goes to places or activities that are interesting visually, tactilely,
auditorily
Leaves places or activities that are TOO busy or crowded
What Can & Does the
Ruby - Severe
Person Do?
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Walks/wheels around a majority of the time when awake
May carry objects or rub/clap/pat with hands
Tends toward movement unless ‘asleep’
Uses hands poorly, not spontaneously, inconsistently
Follows gross demonstration & big gestures for actions
Limited awareness of others - may invade personal space
Gets stuck in ‘tight’ places
Leaves during ‘unpleasant’ experiences
What Can & Does the
Pearl – Very Severe
Person Do?
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Is bed or chair bound
Has more time asleep or unaware
Has many ‘primitive’ reflexes present -Startles easily
May cry out or mumble ‘constantly
Increases vocalizations with distress
Difficult to calm
Knows familiar from unfamiliar
Touch and voice make a difference in behaviors
Knowing the Person
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History
Values and beliefs
Habits and routines
Personality and stress behaviors
Work & family history
Leisure and spiritual history
Hot buttons & comforts
Health & Illness
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Mobility problems?
Pain?
Sensory problems?
Mental health issues?
Other diagnoses of importance?
Approach
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Use a consistent positive physical approach
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approach within visual range
approach slowly
offer your hand & make eye contact
call the person by name
stand to the side to communicate
respect personal space
wait for a response
Communication - interaction…
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Communicate with awareness
– look, listen, think!
– give your name
– make an empathetic observational
statement
• “You look busy...”
• “It looks like you are tired…”
• “It sounds like you are upset…”
– wait for a response
Giving information
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Keep it short and simple
– “ It’s lunch time”
– “Let’s go this way”
– “Here’s your socks”
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Use familiar words and phrases
Use gestures and props to help
Encourage Engagement
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ask a person to try
ask a person to help
you
give simple positive
directions - 1 step at
a time
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use props or objects
gesture
demonstrate
guide
distract
redirect
Environmental Factors &
Changes
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Setting
Props
Programming
Environmental Aids
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Setting
– Familiar – “Where am I?”
– Friendly – “Is this an OK place to be?”
– Functional – “What happens here?”
– Forgiving (safe) – What about mistakes?
Environmental Aids
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Props
– visible & invisible
– timely
– available
– matched to ability
– matched to interests
Daily Routines &
Client-Centered Programming
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Old habits and routines
Patterns during the 24 hrs
A time to rest, work, play…socialize
Your needs… my time
Resources
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Alzheimer’s Associations www.alz.org
www.dbs-sar.com (search info)
Project Lifesaver
– 877-580-LIFE (5433)
– http://www.projectlifesaver.org/
www.ssww.com & www.nasco.com (activities)
www.alzstore.com (devices & activities)
Concern About the Lost Elder: Dementia &
Wandering Behavior by Nina Silverstein et al
The Lost Alzheimer’s & Related Disorders
Subject New Research and Perspectives by R J
Koester
To Intervene…
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Where will you start???
– An idea –
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SAR education
SAR skill building
Facility education
Facility education
Community/Family awareness
Then…
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Observe & document the wandering behavior
thoroughly (especially new admits!)
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what is the pattern
when does it happen
where does it happen
who is involved
what is said, done, attempted
what makes it better… worse
Explore all of the following 
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Level of dementia
Personal background information
Health information
Caregiver approach & assistance
Environmental issues
Habits, schedules & time of day
Screen wisely – on interview
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history of wandering
disorientation episodes
diagnosis (level) & awareness of
impairment
typical reaction to distress or anger
previous daily routines and habits related to
going places/work/leaving
familiarity with the area
Meds & recent med changes
alcohol & drug use & history
Signs of the UN-diagnosed condition
What do searchers typically Do?
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Highly systematic
search or residence
Send patrols to
previous ‘found spots’
Canvass neighbors
Patrol along
routes/roads
Establish containment
points
Early use of trackers at
point last seen
Use tracking dogs
Search outward from
start point
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Use air scent dogs in
drainage, streams,
nearby
Check for signs along
roadways
Dog teams to sweep in
sectors
Search nearby home
sites
Repeat search of
residence > 2x day
Post flyers
Four Cases…
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Case One – Anita - Diamond
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Case Two – Frank - Emerald
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Case Three – Mary - Amber
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Case Four – Glenn - Ruby
Four Cases…
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Case One – Anita - Diamond
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Case Two – Frank - Emerald
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Case Three – Mary - Amber
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Case Four – Glenn - Ruby