Clinical Geriatrics

Case Presentation
Mr. C is an 82-year-old married male who was diagnosed with dementia of the Alzheimer’s type four years ago. He lives with his 80-year-old wife in a basement apartment that the couple has shared since they married 58 years ago. Mrs. C has cared for her husband since he first started showing signs of confusion and forgetfulness. The couple has no children, and their only relative is a niece who lives in a distant state.

Mrs. C has never had any formal help in caring for her husband. She takes him with her to run errands and go shopping, and regularly keeps appointments at the barber shop to have his hair and mustache trimmed. Mr. C suffers from mild hypertension treated with lisinopril 10 mg once daily. He also takes donepezil 10 mg daily that was started four years ago for dementia. Both Mr. and Mrs. C visit their primary care physician every six months, but have had few problems.

Mr. C begins getting up frequently during the night and pacing in the apartment. For many months, he goes back to bed after a few hours and returns to sleep. Mrs. C is concerned because she starts finding the refrigerator door open and food left out in the kitchen. She puts safety locks on the cabinets, stove, and refrigerator, and leaves Mr. C a snack on the table at night. Mrs. C tries to keep her husband awake during the day, but he takes several brief naps and continues to get up during the night. Early one morning, Mrs. C awakens to find the front door to the apartment open, and she is unable to locate Mr. C. She becomes overwhelmed and anxious and starts to call the police when a tenant from one of the upstairs apartments brings Mr. C home. The tenant explains that Mr. C knocked on the door asking to fix a leak in the faucet.

Over the next four to five months, Mr. C wanders out of the apartment almost weekly. He usually stays in the building and Mrs. C or one of the neighbors finds him. Mrs. C starts sleeping less, becomes tired, and is less able to keep up with the errands and chores. Her friends suggest that it may be time to put Mr. C in a nursing home, but Mrs. C feels strongly that they vowed to stay together for the rest of their lives.

One morning, Mrs. C wakes up later than usual and is unable to find her husband. She looks around the building and neighborhood, but no one has seen Mr. C. She goes to the local police precinct to report Mr. C missing. After waiting at the precinct for several hours, Mrs. C is advised to go home and wait. She is so upset that she begins hyperventilating and is taken to a local hospital. While Mrs. C is being evaluated, she receives news that Mr. C was found trying to take a bus to Atlantic City. He is brought to the same hospital for evaluation. Mrs. C is relieved to see him but is worried about the future. Mr. C has been wandering more and going farther away from their apartment. She is becoming tired and overburdened, and does not know how to manage his behavior.

Mrs. C takes her husband to see their primary care physician, who finds them both to be in good health with no acute medical problems. He gives Mrs. C information on nursing homes, but she again rejects this, and feels that the doctor does not understand her desire to care for her husband at home.

Discussion
Wandering is one of the most common behavioral problems found in patients with dementia.¹ Wandering has many definitions, but the common features include aimless or purposeful motor activity that involves leaving a safe place, getting lost, or intruding into inappropriate situations.² Walking away from a safe environment is one of the most common forms of wandering.³ Among community-dwelling patients with dementia, 50-60% engage in some type of wandering behaviors.