Hazardous Wandering
Wandering and Missing Incidents in Persons with Dementia
Wandering, a behavioral symptom of dementia, generally refers to repetitive walking or travel that is not associated with normal daily activities in terms of the times and locations that the behavior occurs. Some aspects of wandering maybe hazardous such as elopement, weight loss, fatigue, sleep disturbances, falls with injuries such as fractures, abuse from caregivers and other patients, premature institutional placement and untimely death. In the VHA, wandering is most often reported in long term care, psychiatric units, rehabilitation units where persons with brain injuries are treated, and in the community.
Missing incidents can be life-threatening and everyone with cognitive impairment is at risk even in the most closely monitored settings. In a prospective study, nearly half of the sample of Veterans with dementia had a missing incident in a year follow-up. Most only have a single incident but some individuals do have repeated missing incidents. The missing individual is most frequented unharmed on their own property or neighborhood. However for those not found quickly, both law enforcement and good Samaritans are essential in safe recoveries. For those missing more than 24 hours, the death rate can be as high as 50% with the most common causes of death being exposure to natural elements, drowning and vehicular accidents.
Home and Community Safety concerns include home emergencies such as fire, burns from the stove or iron, or floods. Persons with dementia (PWD) lack the cognitive skills to manage emergencies or to get out of harm’s way. Safety concerns increase for PWD who exit the home unattended, which can lead to them getting lost, injured, or even dying Many PWD experience altered sleep-wake patterns which may cause activity at night. This can lead to falls and injury caused by poor judgment, not using necessary walking aids or improper lighting. Some of the barriers to creating a safe home environment include:
- Conflicts between the care giver’s needs to accomplish daily tasks and the needs of the PWD for constant supervision, especially when there is only one care giver
- Care givers may not recognize the extent of the PWD’s cognitive impairment, leading them to minimize risks
- Care givers may be unwilling to make safety enhancing changes to the home, equating them with an institutional look or barricading the PWD in
- -The care giver may be dependent upon the PWD as a driver
Besides offering respite for caregivers living in the community, technologies were introduced and well received to assist with keeping the PWD safe in the community and reducing CG burden.
A. Wandering
A.1. Ongoing Projects
A.1.a. Early Trajectory of Wandering Project #NRI 04-184 (Joseph)
This HSR&D funded study was developed to characterize the early trajectory of wandering and to test a new conceptual model of hazardous wandering, address factors contributing to the onset of wandering, as well as the adverse events associated with types and intensity of wandering behaviors over time. Three products are expected to emerge from this study: (1) Risk Assessment Tool for Wandering for veterans at risk for hazardous wandering behavior in home settings; (2) Caregiver Guide for recognizing and safely managing wandering; and (3) Protocol to match interventions to dementia stage and settings of care.
Dissemination Products: In Process Contact PI for more information.
A.1.b. Safe Locomotion in the Community Project # XVA 95-012 (Moore)
A T21 grant funded by VISN 8 Geriatric and Extended Care project and is designed to support extended placement at home for veterans with dementia. The product from this project will be a Toolkit for Developing Safe Locomotion in Dementia Care Plans, specifically for VWD living in the community.
Dissemination Products: In Process Contact PI for more information
A.1.c. Relationship Between Wandering and Functional Status Project # E7503W (Bowen)
The goal of this RR&D funded project is to understand how functional status trajectories of older adults with dementia are affected by wandering -- particularly how random, frequent, and intense episodes of wandering activity vary functional status trajectories over time.
Dissemination Products: In Process Contact PI for more information
A.1.d. An Evidence-Based Patient Monitoring System to Improve Health Outcomes of Vulnerable Older Adults (Bowen)
This HSR&D funded project applies machine learning techniques to implement an evidence-based patient monitoring system into a clinical setting.
Dissemination Products: In Process Contact PI for more information
A.1.e. Development of Instrument to Measure Functional Status of Persons with Dementia Who Wander E7503W VA CDA II (Bowen)
This RR&D funded project examines commonly used measures of physical functioning among older adults with dementia (e.g., Barthel, Functional Independence Measure, Physical Performance Test) and tests a Modified Physical Performance Test (MPPT). The MPPT additionally accounts for cognitive changes over time and utilizes items from the other tools. This project aims to determine whether the MPPT is a sensitive and specific tool to measure the long-term changes in functional status in this population.
Dissemination Products: In Process Contact PI for more information
A.1.f. A Home Evaluation of Visual Exit Barrier Project # E6275-R (Moore)
An RR&D funded study designed to evaluate two widely used visual exit barrier interventions for efficacy in reducing pre-elopement wandering behaviors.
Dissemination Products: In Process Contact PI for more information
A.2 Completed Projects
A.2.a.Staff Educational Toolkit on Wandering for Community Living Centers: (Bulat)
The goal of this PSCI Consortium project was to develop two staff training videos. One DVD was for RNs to help them correctly assess and document hazardous wandering; the other, for LPNs and NAs demonstrating therapeutic strategies to use with patients who wander. The videos were developed and produced in collaboration with EES and disseminated to all VAMC and CLCs nationally. Managing Wandering Behavior is designed to help front line staff (RNs, LPN/LVNs, NAs, et al) manage wandering behavior among CLC residents. The program describes the types of wandering behaviors that are common in residents with dementia, explains some of the reasons that residents might engage in wandering behavior, points out some of the risks associated with wandering, and provides practical guidance on how to manage and protect residents who wander. Managing Wandering Behavior is designed for all CLC staff--especially those who work closely with residents who may be new to the CLC environment. The program is 16 minutes long.
Dissemination Products:
A.2.b. Assessing Wandering Behavior
Designed to help professional CLC staff assess residents for risks of wandering behavior. This includes both initial assessments of new residents, as well as re-assessments of longer term residents. It also includes regular updates of patient records when wandering behavior is observed by staff. Assessing Wandering Behavior is designed for staff who may be involved in making clinical decisions about CLC residents--staff such as charge nurses, social workers, and physicians. The program is 16 minutes long. Click below to download:
Wandering Resources (Word format[DoVA3])
Wandering Interventions Presentations (PowerPoint format[DoVA4])
A.2.c. The Informal Caregivers' Perception of Wandering (Houston)
Although the term wandering is routinely used by clinicians, researchers, and informal caregivers (ICs), the meaning of this term varies depending on the source of the definition and the context in which it is used. The purpose of this study was to examine the terms ICs used to describe different scenarios that have been identified in literature as ‘‘wandering,’’ determine their perception of risk, and compare their definitions of wandering with the perspectives of researchers. Structured interviews were conducted with 128 ICs of older adults with dementia. Informal Caregivers rarely used the term wandering to label different scenarios that had been previously identified in the literature as wandering. Responses to a survey of 17 wandering experts did not reflect agreement on a definition for wandering. These findings suggest that a broad set of terms should be used to describe this potentially dangerous behavior when health care providers communicate with ICs.
Amy M Houston, Lisa M Brown, Meredeth A Rowe, Scott D Barnett (2011) The informal caregivers' perception of wandering. American Journal of Alzheimer s Disease and Other Dementias, Volume 26(8):616-22
B. Missing Incident Projects
B.1. Ongoing Projects
B.1.a Extended SmartHome Project (subproject to monitor for unattended exits) – Bowen
Dissemination Products: In Process Contact PI for more information
B.2. Completed Projects
B.2.a. Dementia: Lost in the Community is a broadcast that covers: why PWD get lost; barriers to creating a safe environment; how staff can help prevent missing incidents; what to do if a patient becomes lost.
Dissemination Products:
B.2.b Lab Testing of Locating Technologies: The goal of this project was to evaluate, in a laboratory setting, technologies designed to monitor/ track those patients that are prone to wander and elope. An extensive review was conducted to determine all commercially available products. We tested 4 GPS and 3 RFID systems, and found GPS to be much more accurate for all 3 outdoor scenarios (open, wooded and urban). The effectiveness of RFID devices was mainly limited by their very short ranges. (Manuscript pending)
Dissemination Products:
Radio Frequency Identification Systems [RFID] (PowerPoint format[DoVA6])
Radio Frequency Identification Systems [RFID] (Word format[DoVA7])
Applegarth, SP, Rowe, M, Kearns, W, Bowen, ME. (2013). Activation thresholds and operating characteristics of commercial alarm products to provide surveillance for dementia caregivers Gerontechnology 2013;11(3):480-487.
B.2.c. Outdoor Evaluation of Tracking Technologies for Persons with Dementia: Michael Kerrigan, Shawn Applegarth, William Kearns, Tatjana Bulat, Jeffrey Craighead, Meredeth Rowe, funded by VISN 8 Patient Safety Center of Inquiry, “Preventing Adverse Events Associated With Mobility”.
This evaluative study looked at seven commercially available tracking devices designed for use by a single caregiver. Three of these devices were radio frequency (RF) based and four were global positioning system (GPS) based. This study employed realistic tracking scenarios to assess device efficacy in real-world conditions. This study was designed to limit the distances at which RF devices were tested, since they each have unique and finite signal ranges. Also, the GPS devices were tested at 0.402 km (1/4 mile) for logistical reasons. Finally, the missing person (MP) was stationary in all tracking trials. The main outcome measures were how long it took to find the missing person (time to discovery) and how far out of their way the tracker went in locating the missing person (tortuosity of tracker’s path). Based on these measures, the GPS devices were found to be approximately twice as efficient as the RF devices in locating a lost person across all scenarios tested. While the RF devices showed reasonable performance at close proximity, the GPS devices were found to be much more appropriate overall for tracking missing persons over unknown, and potentially large, distances.
Veterans Health Administration, James A. Haley Veterans Hospital, HSR&D/RR&D Center of Excellence, Tampa, FL
B.2.d. The Alzheimer’s Association’s Safe Return Project for Veterans with Dementia: PSCI. One goal of this project was to develop a toolkit to facilitate enrollment of veterans newly diagnosed with dementia in the Safe Return/Medic Alert program. We evaluated different recruitment strategies (direct mailing vs. provider-initiated referral). In two different efforts to expand the use of this program, we found that direct mailing was much more effective than provider-initiated referrals. About 25% of those invited to participate took advantage of the program.
Dissemination Products: In Process Contact PI for more information
Click here to download the toolkit[DoVA8]
Click here to download the enrollment letter[DoVA9]
Click here to download the enrollment brochure[DoVA10]
Click here to download the enrollment form[DoVA11]
Click here to download a copy of the care plan[DoVA12]
Click here to download a copy of the PowerPoint Presentation[DoVA13]
Link to the Alzheimer's Association Safe Return® Program This link is not on a Department of Veterans Affairs website. VA does not endorse and is not responsible for the content on the linked site[DoVA14].
Bass, E., Rowe, M.A., Moreno, M., & McKenzie, B., (2008).Expanding participation in Alzheimer’s Association Safe Return® by improving enrollment. American Journal of Alzheimer’s Disease & Other Dementias,Volume23 (5) 447-Sage
B.2.e. A second goal was to conduct a prospective study of missing incidents in Veterans with dementia living in the community. The rate of missing events was 0.65/year, but less than a quarter of patients wore the ID jewelry the majority of the time.
Bowen ME, McKenzie B, Steis M, Rowe MA. (2011), The Prevalence of and Antecedents to Dementia-Related Missing Incidents in the Community, Dementia Geriatric Cognitive Disorder. 406-412
B.2.f. Conceptual Development of Missing Incident: The behavioral symptoms of dementia often present the greatest challenge for formal and informal caregivers. One such behavior is the constant concern that the person with dementia will become lost in the community which has often been included in the concept of ‘wandering’. The purpose of this work is to propose a distinct concept of missing incidents.
Rowe M, Houston A, Molinari V, Bulat T, Bowen ME, Mutolo S McKenzie B. (In Process).The Concept of Missing Incidents in Persons with Dementia"
C. Home and Community Safety
C.1. Ongoing
C.1.a. Best Practices on Missing Incidents for Informal and Formal Caregivers: Objective: Provision of evidence-based practice products to formal and informal caregivers of persons with dementia. The purpose of this project will be to assimilate these evidence-based findings into an integrated educational/improved practices module.
C.1.b. Developing New Technologies to Assist Dementia Caregivers: The purpose of this project is to understand how technology can support relatives providing in-home caregiving to Veterans with dementia. While we identified a successful suite of technologies that could be used to enhance surveillance, there were few available technologies identified that could support other caregiver roles. These primarily include management of the Veteran with dementia’s emotional needs and support with activities of daily living. A qualitative study will be conducted with caregivers and professionals working with community-dwelling Veterans with dementia to identify problem areas that may have a technologic solution.
C.2. Completed
C.2.a. SafeHome: A Suite of Technologies to Support Extended Home Care of Veterans with Dementia: To report the implementation/adoption of the Safe Home Program to support CGs of persons with dementia (PWD) in 1) ongoing surveillance, 2) provision of care, 3) prevention of injuries, and 4) improving home safety. Using a patient-centered approach, four assessment questionnaires (the Safety Assessment Scale, Vigilance Scale, Peace of Mind scale and the Sleep Disorders Inventory) were administered to each CG/PWD dyad to understand their technological needs. After identification and installation of appropriate technologies and education of the CG, a final visit (at 3 months) determined whether technologies were useful and being used. The majority of CGs utilized technologies for ongoing surveillance; other technologies included an identification program and medication organizer. Technologies focused on ongoing surveillance for PWD in the home are needed. These technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for PWD.
Dissemination Products:
Evaluating a Home Safety Program for Veterans with Dementia (.pdf format)
McKenzie, B., Bowen, M.E., Keys, K., & Bulat, T. (2013). Safe Home Program: A Suite of Technologies to Support Extended Home Care of Persons With Dementia, American Journal of Alzheimer's Disease & Other Dementias, 28(4), pp 348-354. published online 15 May 2013, This link is not on a Department of Veterans Affairs website. VA does not endorse and is not responsible for the content on the linked site[DoVA15].
D. Wandering Consortium
The consortium is comprised of researchers and clinicians interested in understanding the conceptual and practical aspects of dementia-related wandering behaviors in the community and institutional settings. We recently conducted key work to differentiate the concept of missing incidents from wandering, and added this as an emphasis for the group.
Meetings/Workshops/Conferences: The consortium hosts semi-annual meetings in May and October, and bi-annual workshops during the PSCI Evidence Based Fall Prevention conference, and will conduct a one-day pre-conference workshop on Tuesday, May 16, 2013. Click here to go to the Conferences page for a full agenda and registration information.
Click here to go to our conference agenda/registration page. This link is not on a Department of Veterans Affairs website. VA does not endorse and is not responsible for the content on the linked site.
Consortium Membership: To join the Consortium's Google Discussion go to: and search for the International Consortium for Wandering and Missing Incidents[DoVA16]
Consortium members encompass a wide range of disciplinary perspectives including: engineering, geriatrics, gerontology, nursing, psychology and social work and countries across the Globe including Australia, Korea and the United States. We welcome additional collaborators to the consortium. If you are interested in joining the group or our listserv, please send your contact information to Meredeth Rowe at
E. Select References works from Consortium members
Algase DL, Antonakos C, Beattie ER, Beel-Bates CA, Yao L. Empirical derivation and validation of a wandering typology. J Am Geriatr Soc. 2009 Nov; 57(11):2037-2045.
Bass E, Rowe MA, Moreno M, McKenzie B. Expanding participation in Alzheimer's Association Safe Return by improving enrollment. Am J Alzheimers Dis Other Demen. 2008 Oct-Nov;23(5):447-450.
Beattie ERA, McCrow JM, Kearns WD, Applegarth SP. Attitudes and expectations of technologies to manage high risk wandering and elopement in persons with dementia: An Australian perspective. Gerontologist. 2009;49(Suppl 2);93.
Bowen ME, Steis M, McKenzie B, Rowe MA. The Prevalence of and antecedents to dementia-related missing incidents in the community. Dem Ger Cog Dis.2011; 406-412.