Clinical Geriatrics

To the Editor:

The article “Wandering in Dementia” by Melinda S. Lantz, MD, from the November 2007 issue of Clinical Geriatrics¹ uses a case description that is all too typical, but also an example of several common errors in medicine that are overlooked, not discussed, and were not addressed by the author.

First, a diagnosis of dementia is not sufficient for initiation of treatment with a cholinesterase inhibitor, although in my experience this occurs all too commonly. This is like prescribing a medication for heart disease without doing a complete evaluation to determine whether the underlying diagnosis is heart failure, myocardial infarction, arrhythmia, or something else. This would not be acceptable care for heart disease (or any other condition) and should not be acceptable for care of patients with dementing illnesses. If the primary care provider does not feel capable of conducting an evaluation for diagnostic etiology of the dementia due to lack of time or expertise, then, just as for any other condition, the patient should be referred to an appropriate specialist for consultation, as was eventually done in this case.

Second, when the patient’s wife takes him to the primary care provider after wandering away, the physician’s action was to give her “information on nursing homes.” Again, this is unacceptable and inappropriate care. At minimum, one would expect that even a busy community practice physician should provide information at this point about Safe Return®, the best insurance policy there is for wandering (although ideally it would have been provided at the time of initial diagnosis), and a referral to either the Alzheimer’s Association or some other community agency (Area Agency on Aging, Family Caregiver Alliance, etc).

Third, and lastly, while the article states “medications are only an adjunct to the management of wandering,” it fails to make the point that there are no pharmaceutical agents, antipsychotic or others, that are either FDA-approved or have been shown in any study to be a safe and effective treatment for wandering. This points up again where the primary care provider’s care was inadequate. The failure to acknowledge the potential for wandering in a patient with dementia, advise the caregiver of this possibility early on, and provide education on preventive measures led to poor outcome for the patient, and negatively impacted the caregiver’s health.

Freddi Segal-Gidan, PA, PhD
Keck School of Medicine
U. of Southern California,
Los Angeles
Rancho Los Amigos National Rehabilitation Center
Downey, CA

Reference
1. Lantz MS. Wandering in dementia. Clinical Geriatrics 2007;15(11):21-24.

Dr. Lantz responds:
Dr. Segal-Gidan highlights the very important point that caregiver education and support is a basic and vital part of all dementia care. While the case patient, Mr. C, received a thorough physical examination, laboratory work-up, and neuroimaging early in the course of his dementia, his wife and sole caregiver was never given the tools and referrals that would have assisted her.¹ Wandering is a difficult symptom to manage, and results in significant caregiver distress.² Unfortunately, our evidence is limited in both the medication and nonpharmacological interventions for this behavioral problem.³ Greater attention to practical solutions for problematic behaviors will go a long way in assisting caregivers like Mrs. C who remain devoted to caring for relatives with dementia in their own homes.

References
1. Lantz MS. Wandering in dementia. Clinical Geriatrics 2007;15(11):21-24.

2. Creese J, Bedard M, Brazil K, Chambers L. Sleep disturbances in spousal caregivers of individuals with Alzheimer's disease. Int Psychogeriatr 2008;20(1):149-161.

3. Hermans DG, Htay UH, McShane R.