Start with an open question

Begin by encouraging George, and Margaret where possible, to describe what has changed.

“Can you tell me what’s been happening with Margaret?”

“What’s made you most worried lately?”

Ask what has already been tried:

“Before today, what support have you tried to keep Margaret safe?”

Time-efficient data gathering

Use the story to identify the pattern, triggers and risk.

Clarify:

• How often Margaret wanders.
• When it happens.
• Where she tends to go.
• How long she has been missing on each occasion.
• What triggers the behaviour.
• Whether there have been near-misses or emergencies.
• Whether police or other services have been involved.
• Whether George can manage alone.
• What family or community support is already in place.
• What has and has not worked.

High-yield questions

Wandering and immediate safety

Ask:

• “Is Margaret currently missing or at risk of leaving now?”
• “Can she find her way home?”
• “Can she tell someone her name or address?”
• “Are there roads, water or other hazards nearby?”
• “Has she fallen or been injured when out?”
• “Has she ever been exposed to cold or heat?”
• “Does she have a pendant, identification or tracking arrangement?”
• “Is there anyone else who can help supervise her?”

Possible acute or reversible causes

Ask about:

• Fever or infection symptoms.
• Pain.
• Urinary symptoms.
• Constipation.
• Changes in sleep.
• Reduced food or fluid intake.
• New medication.
• Medication changes or missed doses.
• Sedation or agitation.
• Sudden changes in confusion or behaviour.

Impact of wandering

Explore whether Margaret has experienced:

• Falls.
• Injuries.
• Dehydration.
• Missed medication.
• Inability to access food.
• Inability to access toilet facilities.
• Distress when she cannot find her way.

George’s wellbeing

Ask George about:

• Sleep and exhaustion.
• His physical health.
• His mental health.
• Whether he feels overwhelmed or isolated.
• Whether he feels guilty.
• Whether he can leave Margaret alone.
• Whether he can maintain his own health.
• Whether he feels able to continue caring safely.
• Whether he has reached a crisis point.

Functional, psychosocial or contextual assessment

Explore Margaret’s baseline and current function:

• Usual routine.
• Level of independence.
• Communication.
• Ability to manage at home.
• Triggers for wandering.
• Response to changes in environment or routine.
• Preferences and wishes where these can be understood.

Explore George’s caring context:

• Whether he has family support.
• Whether he has practical help.
• Whether he gets breaks.
• Whether he can sleep.
• Whether caring is affecting his own health.
• Whether current arrangements are sustainable.

Explore ideas, concerns and expectations

Clarify what George and Margaret need most urgently.

Possible goals include:

• Immediate safety.
• Better sleep for George.
• Respite or short breaks.
• More support at home.
• Understanding whether this is dementia progression.
• Identifying and treating reversible causes.
• Preserving Margaret’s independence where possible.

Useful phrase:

“Are you looking for more support day-to-day, or perhaps you need a short break from being a carer to get your energy back?”

Include Margaret in goal-setting as far as possible, taking account of her communication and capacity.

Recognise and respond to cues

Respond to George’s emotional and non-verbal cues.

If George looks exhausted:

“You seem really tired. I can see this is having a big impact on you.”

If he describes burnout:

“It’s understandable if you feel burnt out. Being a full-time carer is a huge challenge.”

Explore:

• “What worries you most when Margaret goes missing?”
• “How have you been coping yourself?”
• “Do you feel able to continue caring safely at the moment?”

Useful consultation phrases

“Alzheimer’s can cause people to wander and become confused. Sometimes things like infections or pain can make this worse, so I’ll want to check for those.”

“You’re not alone — lots of carers feel overwhelmed.”

“I’m concerned about how difficult it is to keep Margaret safe when she goes missing, and I think we need more support around both of you.”

“We need to find the safest plan that preserves Margaret’s dignity and independence as much as possible.”

Consultation flow and signposting

1. Explore Margaret’s recent behaviour and wandering.
2. Establish the immediate level of risk.
3. Look for infection, pain, delirium or medication effects.
4. Review Margaret’s baseline and dementia progression.
5. Explore George’s wellbeing and coping.
6. Discuss safety adaptations and support.
7. Consider capacity, autonomy and confidentiality.
8. Agree immediate and longer-term management.

Use signposting:

“I’d like to understand the wandering first, then check whether anything physical might be making Margaret more confused, and then talk about support for both of you.”

Summarising and checking understanding

Summarise before moving into management.

“Margaret’s wandering has become more concerning, and you’re finding it difficult to keep her safe. I also want to check whether an infection, pain or medication problem is making the confusion worse.”

Check:

• Whether George agrees with the summary.
• Whether he understands the immediate safety plan.
• What he feels able to manage.
• Whether Margaret understands and can participate in decisions.
• What questions or concerns remain.

Data gathering self-check

Before moving to management, the trainee should know:

• Whether Margaret is currently safe.
• Frequency and circumstances of wandering.
• Whether she has been missing, injured or exposed to danger.
• Whether there has been sudden deterioration.
• Symptoms suggesting infection, pain, delirium, dehydration or constipation.
• Recent medication changes or missed doses.
• Margaret’s baseline function and preferences.
• George’s level of exhaustion and ability to continue caring.
• What support is already in place.
• Whether there are safeguarding concerns.

Assessment domain mapping

Data gathering

• Wandering pattern and immediate risk.
• Reversible causes of deterioration.
• Medication changes and adherence.
• Margaret’s baseline, preferences and function.
• George’s carer strain and ability to cope.

Clinical management

• Urgent assessment where needed.
• Safety planning and home adaptations.
• Social-care referral, respite and Carer’s Assessment.
• Medication review.
• Dementia support and specialist services.
• Safeguarding where risk is significant.

Relating to others

• Supporting George without blame.
• Involving Margaret as far as possible.
• Balancing autonomy and safety.
• Clear, concise explanations for an exhausted carer.

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Prioritised differential diagnosis or clinical reasoning

Possible explanations for Margaret’s change in behaviour include:

1. Progression of Alzheimer’s disease.
2. Delirium, including from:
   
   • Infection.
   • Pain.
   • Medication effects.
   • Dehydration or other acute illness.
3. Emotional distress related to a change in environment or routine.
4. Medication side effects or polypharmacy.
5. Serious safeguarding concerns or carer breakdown.

Do not assume all behavioural change is dementia progression. Look for reversible or urgent causes.

Clinical reasoning script

“Margaret’s dementia may be progressing, but sudden or worsening confusion can also happen with things like infection, pain, dehydration or medication problems. We need to check for those while also making sure she is safe and that you have enough support.”

Red flags and risk assessment

Assess whether Margaret is at immediate risk through:

• Going missing.
• Access to roads, water or other hazards.
• Falls or injury.
• Exposure to cold or heat.
• Dehydration.
• Missed medication.
• Inability to access food or toilet facilities.
• Distress when unable to find her way.
• Being left without adequate supervision.
• George being unable to continue caring safely.

Urgent assessment may be required if there is:

• Sudden change in confusion.
• Marked deterioration.
• Immediate safety risk.

Decision points

Key decisions include:

• Is Margaret currently safe?
• Is urgent medical assessment needed?
• Could infection, pain, delirium, dehydration, constipation or medication effects explain the deterioration?
• Can George safely supervise Margaret at home?
• Is urgent social-care input needed?
• Does George need respite or emergency support?
• Does Margaret have capacity for specific decisions?
• What is the least restrictive safety plan?
• Is there a safeguarding concern?
• What information needs to be shared, and with whom?

Management priority

The management priority is to create a dual safety plan:

• Protect Margaret from harm while preserving dignity and independence where possible.
• Support George so that caring remains safe and sustainable.

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Management options

 1. Immediate clinical assessment

Arrange appropriate assessment for:

• Infection.
• Pain.
• Delirium.
• Medication problems.
• Dehydration.
• Constipation.
• Injury after wandering.
• Other acute physical illness.

If there is sudden confusion, marked deterioration or immediate safety risk, urgent assessment may be required.

2. Immediate safety management

Develop a plan to reduce the risk of Margaret going missing or coming to harm.

Consider:

• Increased supervision.
• Careline or pendant alarm.
• Identification details or identification bracelet.
• Door sensors.
• Locks or other home adaptations.
• Informing neighbours where appropriate.
• Contacting the police or local missing-person service if she goes missing.
• A clear emergency plan for George.
• Involving family members who can help with supervision.

Safety measures should be proportionate and preserve Margaret’s dignity and independence where possible.

3. Social-care and respite support

Arrange urgent referral to social services for:

• Needs Assessment.
• Respite care.
• Short breaks.
• Day-centre support.
• Additional care at home.
• Support with supervision.
• Review of whether the current care arrangement remains sustainable.

4. Carer support for George

George has a statutory right to a Carer’s Assessment under the Care Act 2014.

Discuss:

• Respite care.
• Day centres.
• Local carer support.
• Carers UK.
• Counselling.
• Support groups.
• Practical help at home.
• Sleep and rest.
• George’s own physical and mental health.

Ask directly whether he feels able to continue caring safely.

5. Medication review

Review Margaret’s medicines for:

• Sedation.
• Agitation.
• Anticholinergic effects.
• Recent changes.
• Missed or duplicated doses.
• Polypharmacy.
• Medicines contributing to falls or confusion.

Involve pharmacy or specialist services where appropriate.

6. Dementia and specialist support

Consider:

• Alzheimer’s Society advice.
• Local dementia support groups.
• Admiral Nurses.
• Memory services.
• Elderly-care psychiatry if behavioural and psychological symptoms are severe.
• Community mental-health or dementia teams.

7. Home adaptations

Consider practical adaptations such as:

• Door sensors.
• Locks.
• Improved lighting.
• Clear signs around the home.
• Reduced trip hazards.
• Safe areas for walking.
• Identification or tracking systems.
• Arrangements to alert George if Margaret leaves the house.

Personalised plan

Tailor the plan to:

• Margaret’s level of dementia.
• Her routines and wandering triggers.
• Her preferences and independence.
• George’s physical and emotional health.
• Availability of family support.
• Safety of the home.
• Urgency of the risk.

A practical plan might include:

• Immediate medical assessment for infection, pain or delirium.
• Medication review.
• Door sensors or other adaptations.
• Social-services referral.
• Carer’s Assessment for George.
• Respite or day-centre support.
• Alzheimer’s Society or Admiral Nurse involvement.
• Follow-up with the GP or dementia team.
• Clear emergency plan if Margaret goes missing.

Shared decision-making

Involve Margaret as far as possible, depending on her communication and capacity.

Discuss with George and Margaret:

• What safety measures feel acceptable.
• What Margaret’s routines and preferences are.
• Whether increased supervision can be arranged.
• Whether family can help.
• What type of respite or day support might be acceptable.
• What George can realistically manage.
• What support is needed urgently.

Safety-netting

Agree a clear emergency plan.

George should know what to do if:

• Margaret goes missing.
• She is injured.
• She becomes suddenly more confused.
• She develops signs of infection or pain.
• She stops eating or drinking.
• She misses medication.
• He feels unable to keep her safe.
• He reaches crisis point as a carer.

The plan should include who to contact, including relevant emergency, social-care or local missing-person pathways as appropriate.

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Ethical, legal and safeguarding considerations

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Capacity

Assess capacity for each specific decision. Do not assume Margaret lacks capacity because she has dementia.

Consider whether Margaret can:

• Understand relevant information.
• Retain and weigh the information.
• Communicate a decision.

Consider:

• Margaret’s wishes and preferences.
• The least restrictive option.
• Her views about supervision, home adaptations and support.

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Safeguarding

Wandering in a person who may lack capacity can represent a safeguarding risk, particularly if Margaret is:

• Frequently going missing.
• Unable to find her way home.
• At risk from traffic, water or exposure.
• Being left without adequate supervision.
• Dependent on a carer who is no longer able to cope safely.

Refer promptly where there is significant safeguarding concern.

“I’m concerned about how difficult it is to keep Margaret safe when she goes missing, and I think we need more support around both of you.”

Confidentiality and information sharing

Respect Margaret’s confidentiality while recognising that information may need to be shared if there is a serious safety risk.

Assess:

• What Margaret consents to sharing.
• Whether she has capacity to decide who should be involved.
• Whether George has authority to receive information or make decisions.
• Whether information sharing is necessary and proportionate.
• What information needs to be shared with social care, family or other professionals.

If there is a significant safety risk, confidentiality may need to be overridden only to the extent necessary to protect Margaret.

Documentation points

Document:

• What has changed and when.
• Wandering episodes, triggers and immediate risks.
• Any injuries, near-misses or emergencies.
• Reversible causes considered.
• Medication review findings.
• George’s carer strain and ability to cope.
• Margaret’s capacity and wishes for each relevant decision.
• Safety plan agreed.
• Social-care, respite or dementia-service referrals.
• Safeguarding concerns and actions taken.
• Information shared, with whom and why.
• Follow-up arrangements.

Common unsafe management plans

Avoid:

• Assuming deterioration is inevitable dementia progression.
• Failing to assess whether Margaret is currently safe.
• Ignoring George’s exhaustion.
• Offering only reassurance without social-care action.
• Restricting Margaret unnecessarily without considering least-restrictive options.
• Assuming incapacity globally.
• Not considering safeguarding when wandering creates serious risk.
• Sharing information without considering necessity and proportionality.
• Not documenting capacity, risk and information-sharing decisions.

Follow-up and coordination with other professionals

Coordinate support with:

• GP practice.
• Social services.
• Dementia support services.
• Memory services.
• Community mental-health or dementia teams.
• Admiral Nurses.
• Alzheimer’s Society.
• Local respite and day-centre services.
• Family members where appropriate.
• Pharmacy or specialist services where medication issues are relevant.

Follow-up should review:

• Whether Margaret remains safe.
• Whether reversible causes have been assessed or treated.
• Whether adaptations are in place.
• Whether social-care input has started.
• George’s sleep, health and coping.
• Whether further safeguarding action is required.

Learner checkpoint

Have I made a plan that is safe for Margaret and sustainable for George?

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Relevant guidance areas 

• Dementia assessment, management and support.
• Support for carers of people living with dementia.
• Local dementia and safeguarding pathways.
• Carer’s Assessments under the Care Act 2014.
• Wandering and carer support.

NICE guidance

• NICE NG97: Dementia — assessment, management and support for people living with dementia and their carers.

GMC, DVLA or safeguarding guidance

This includes:

• Local dementia and safeguarding pathways.
• Safeguarding considerations where wandering creates significant risk.
• Information sharing only as necessary and proportionately.

Patient, carer and family resources

• Alzheimer’s Society — advice on wandering.
• Alzheimer’s Society — carer support.
• Carers UK — Carer’s Assessment.
• Local dementia support groups.
• Admiral Nurses.
• Local respite and day-centre services.

Key principles to remember

• Start with an open account of what has changed.
• Explore what support has already been tried.
• Consider infection, pain, delirium and medication effects before assuming dementia progression.
• Assess the immediate risk when Margaret goes missing.
• Explore George’s wellbeing directly.
• Offer a Carer’s Assessment and respite support.
• Assess Margaret’s capacity for each decision.
• Balance autonomy with safety and least-restrictive care.
• Recognise wandering in a person lacking capacity as a potential safeguarding concern.
• Share information only as necessary and proportionately.
• Document risk assessment, capacity considerations and information-sharing decisions.
• Provide a practical plan for both Margaret and George.

Transferable learning for future cases

In dementia consultations with behavioural change:

• Do not assume all deterioration is disease progression.
• Ask what has changed, how quickly, and what risks have occurred.
• Look for reversible causes.
• Assess the carer’s ability to continue safely.
• Involve the person with dementia as far as possible.
• Balance dignity, autonomy and safety.
• Use social care, respite and dementia services early.
• Document capacity and safeguarding reasoning clearly.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Recognition of wandering as a significant safety issue.
• Assessment for reversible causes of deterioration.
• Exploration of George’s carer strain.
• Capacity assessment by decision, not diagnosis.
• Least-restrictive safety planning.
• Appropriate social-care, respite and dementia support.
• Safeguarding awareness.
• Clear documentation and follow-up.

Final learner takeaway

In dementia, wandering is both a clinical and safety problem: assess reversible causes, protect the patient, and support the carer before the situation breaks down.

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