Letters to the Editor
Wandering in Dementia
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
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.
- Lantz MS. Wandering in dementia. Clin Geriatr. 2007;15(11):21-24.
- 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.
- Hermans DG, Htay UH, McShane R. Non-pharmacological interventions for wandering of people with dementia in the domestic setting. Cochrane Database Syst Rev. 2007;(1):CD005994.
An Elderly Male Found Malnourished and Dehydrated: When Healthcare Systems Fail
To the Editor:
This article1 was quite odd. Its title suggests the author will show an example of a “health-care system” failing to provide necessary services. Instead, we see how ridiculous it can be to attempt to maintain independence at all costs. The 62-year-old-man does not even live in the same state as his father, who had a severe stroke. He was concerned enough to arrange home care, cut could not be bothered to move Dad within driving distance or, better, into assisted living. Instead, he foisted off those care responsibilities to the state of New Jersey, which the state is more than happy to attempt to provide. The family failed, not “healthcare.”
By my estimation, the 87-year-old father has the dependence needs of a 5-year-old. If a responsible adult left a 5-year-old to fend for himself in this way, Child Protective Services would remove the child from the home. The son and the father made several poor choices, and the author blames New Jersey.
Expanding the definition of “healthcare” to include essentially every single aspect of this man’s life is ludicrous. The state had someone fall through its cracks. What a surprise is this? The state will forever have this occur, as it is necessarily and irreparably an inefficient entity; its incentives lie elsewhere and always will. That is the nature of the state; to believe otherwise is foolish. The story instead gives evidence that deleting the family from primary responsibility removes the once-insuperable filial incentive to tend to the needs of the family members. The state does not have and cannot replicate those incentives.
The author seems to think if the state takes over more and more of the family duties that this will not occur again. But she wrong. No state can afford the expense of providing this intensity of services for an enlarging population of elderly. It cannot be done. The healthcare system did not fail here. But we’re no longer allowed to criticize anything but healthcare, so that’s what we blame.
Kevin Fleming, MD Geriatrician, Mayo Clinic Rochester, MN
Dr. Lantz responds
Dr. Fleming raises the issue of responsibility for the care of an aging relative. The case illustrates an increasingly common scenario of families who no longer live in close proximity and an older adult with impairments who wishes to remain in his own home.1 What should we do when an older adult refuses offers to relocate to another state or move to an assisted living facility?
The 87-year-old case patient, Mr. B, was provided with a great deal of assistance that was supported through state and federal programs.2 His son remained very involved, even from a distance. Termination of services without any notification to an involved family member is a failure of a healthcare system.
Older adults increasingly rely on a patchwork of formal and informal assistance. We need to support informal and family caregivers in addition to regulating those agencies who receive government funds to provide formal care. Breakdowns in communication in a healthcare system that is increasingly fragmented can and often do lead to near-tragic results.3
Melinda S. Lantz, MD, chief of Geriatric Psychiatry at Beth Israel Medical Center in New York, NY
- Lantz MS. An elderly male found malnourished and dehydrated: When healthcare systems fail. Clin Geriatr. 2007;15(9):13-16.
- McCallion P, Toseland RW, Gerber T, Banks S. Increasing the use of formal services by caregivers of people with dementia. Soc Work. 2004;49(3):440-450.
- Lang A, Edwards N, Fleiszer A. Safety in home care: A broadened perspective of patient safety. Int J Qual Health Care. Published online December 23, 2007.