Managing Wandering Behavior in the Nursing Home

One of the most challenging issues related to care of the resident with dementia is wandering behavior. It is estimated that dozens of mentally impaired elders die annually as a result of wandering.

The most dangerous form of wandering is elopement, in which the confused resident leaves the nursing home and possibly experiences injuries such as hypothermia, a serious fall, or is hit by a car. These injuries may even result in death.

The nursing home must provide an appropriate plan of care to prevent wandering, or manage it in a safe environment. When elopement happens, it is highly likely that the person has suffered from nursing home neglect.

How common is wandering behavior in the nursing home?

Over 50% of those in nursing homes suffer from some form of dementia, and about half of these individuals wander. Wandering is less likely to occur when staff members adapt their communication with residents and demonstrate an understanding of the resident’s history, preferences, routines, and values; this enhances the resident’s feelings of security. It is also important to remember that those who do not have dementia and wander may have a medical problem such as an infection, circulatory problem, or metabolic condition whose only symptoms are acute confusion and wandering.

What are the causes of wandering that could result in elopement from the nursing home?

Those who were highly sociable and had an active lifestyle prior to having mental decline are most likely to wander. The use of certain antipsychotic medications can cause side effects that increase the desire to wander and be in perpetual motion. Sedating medications can also increase the risk for wandering due to confusion. Other causes of wandering include the following:

• Memory deficits
• Poor vision
• Disorientation
• Language deficits
• Searching for security
• Searching to fulfill an unmet need such as to relieve hunger, thirst, pain, constipation, and the need to urinate
• Searching for a loved one
• Boredom

What are the positive and negative effects of wandering behavior?

For the resident, wandering may be positive if it fulfills a need for exercise, sensory stimulation, or purposeful behavior. Many nursing homes provide a safe environment on a locked unit for this reason. The negative side of wandering is it may lead to falls, excess fatigue, anxiety, accidental exposure to certain chemicals, altercations with other residents when wandering into their personal space, and suffering from heat or cold exposure if the resident wanders outside.

What are the facility’s responsibilities in managing wandering behaviors to meet the minimum expected standard of nursing care?

• Identify those at risk for wandering
• Create an individual plan of care to manage wandering
• Maintain adequate staffing to ensure each resident’s safety
• Provide a safe place to wander
• Provide lounge areas for residents to stop and rest while wandering
• Keep walking paths uncluttered and well lit
• Use tape to create a grid-like pattern on the floor (it creates an unstable appearance on the floor) in front of exits or restricted areas to decrease the risk of elopement
• Provide for sensory stimulation through a variety of meaningful activities to meet each resident’s individual needs
• Decorate rooms with favorite pictures and art that provide a sense of comfort and familiarity
• Camouflage exits
• Assign residents who wander to rooms located away from exits
• Provide signs and pictures around the outside of the resident’s room to assist him/her in finding it
• Use safety locks for closets and drawers that contain potentially hazardous materials
• Provide nutritious finger foods and drinks that the resident can carry while safely wandering. Elders who wander burn extra calories and may not sit to eat; they need the extra nutrition to prevent weight loss.
• Use bed alarms for those who wander at night
• Assess for and provide care for basic needs such as pain management, toileting, and adequate food and fluids
• In collaboration with the physician, diagnose and treat depression that often accompanies dementia, which increases the risk for wandering

Questions to ask the nursing home:

• What kind of activities do you provide for those who wander?
• How will you keep my wandering loved one safe?
• How do you train your staff to manage wandering behavior?
• If my loved one will not sit at mealtime and he/she wanders, what will you do to ensure maintenance of adequate nutrition and hydration?

Resources

Gaffney, J. (1986). Toward a less restrictive environment. Geriatric Nursing 7, 94-95.

National Institute in Aging Progress Report on Alzheimer’s Disease, Washington, DC; U.S. Department of Health and Human Services, Public Health Services, National Institute of Health NIH Publication No. 99-3636. (1998).

Tilly, J. & Reed, P. (2006). Falls, wandering and physical restraints: Interventions for residents with dementia in assisted living and nursing homes. The Alzheimer's Association