Lost with Dementia

Patterns exist for people who get lost. Whether joggers, hikers, children, or those diagnosed with dementia, different groups exhibit different lost person behaviors. Knowing these patterns would help in finding them. Robert Koester's groundbreaking research has greatly expanded our understanding of “Lost Person Behavior” (Koester, 2008).  

This evolving line of inquiry  is becoming the bedrock for Search And Rescue (SAR) protocols. SAR  personnel consider variables such as behavioral profiles, activity, terrain, health, and personal characteristics to help predict the behavior of people who are declared lost. Koester has analyzed more than 50,000 cases world-wide to identify patterns of behavior that lost people tend to follow, including a special section for people with any variant of dementias—Koester’s specialty.

Older adults with dementia typically get lost through wandering behavior. Six in 10 people with dementia will wander—take off in an aimless way—becoming disoriented and perhaps not remembering their name, address, or their location.  Although effective programs exist in the United States—including MedicAlert®, Safe Return® Comfort Zone® and Comfort Zone Check-In®—the majority of people are not enrolled in such electronic tagging. Either they cannot afford the monthly premiums or they assume that they would never need such services. Due to America’s demographic changes, one thing is certain—people with dementia comprise an increasing concern for volunteer SAR teams, as well as state and federal agencies.

For SAR teams all dementias are treated the same. Koester & Stooksbury (1995) reported that when normal older adults got lost they traveled on average a greater straight-line distance (2.56 km) from the Point Last Seen (PLS) than older adults (in this case older than 40 years of age) with dementia (0.88 km). Although statistics indicate greater variability of distance traveled among dementia patients,here are some outliers where some might only travel a short distance while others travel greater distances (one in ten travel an average of 52 miles). Surprisingly, age did not emerge as an important consideration in how people with dementia behave when they get lost.

Dementia patients generally leave their own residence or nursing home and start traveling along roads. The patient is usually located (in 89% of cases) within one mile (1.2 km) of the PLS.  If the patients were not on a road (14%), they were usually found in a creek/drainage (28%), and/or caught in briars/bushes (33%).

The majority of patients succumb to the environment. One in five dementia patients (42 cases in this study) were found deceased due to hypothermia, dehydration, or drowning. No fatalities were found among dementia patients when they were located within 24 hours. If they were not found within this 24-hour window, half of dementia patients were likely to be found dead.

Consequently, searches for dementia patients are considered urgent and require an aggressive SAR response. Koester highlights that the diagnosis of dementia is important to elicit urgency. However, he also points out that most primary care physicians fail to administer cognitive status tests, and therefore only correctly identify 58% of the cases as possible dementia. This is particularly true of patients who become lost in wilderness and rural settings, who often belong to disadvantaged socioeconomic groups and who receive minimal health care. Not knowing that the lost person has dementia diminishes the search’s urgency, with potentially detrimental effects.

A key hypothesis  among SAR responders when looking for lost dementia patients is referred to as the “path of least resistance.”  This theory states that when people with dementia start wandering they tend to follow terrain that provides less resistance (down rather than uphill, roads rather than meandering paths, or railway tracks rather than steps).

A considerable number (28%) of dementia patients were found in drainages or creeks—indicating that they most likely walked downhill—supporting the path of least resistance hypothesis. Another 33% of the patients appear to have become stuck in thick brush or briars. This insight is important because untrained searchers, or searchers working at night often avoid looking into brush or briars because most people tend to try to make themselves visible. Getting stopped in drainages, creeks, brush and briars  support research indicating that lost patients with dementia are traveling a path of least  resistance until they reach an insurmountable barrier.

Because prevention is the best cure, reducing wandering becomes the best first line of defense. A personal care plan that reduces agitation and depression will help minimize wandering. Because people with dementia tend to leave few clues when they are lost and often do not respond to shouts or voice-based searching, getting expert help as early as possible is crucial. Knowing how to look for lost people with dementia requires an urgency that only expert help can provide.

Local dementia organizations counsel families that when someone with dementia goes missing, SAR efforts should be initiated immediately. Ninety-four percent of people who wander are found within 1.5 miles of where they disappeared. After the family and/or caregivers search the immediate area for no more than 15 minutes, they should call "911" and report to the police that a person with dementia—a vulnerable adult—is missing. Reporting parties should provide enough detail, including any places nearby that might have been important in childhood for the missing person.  Reports should include information on fears or phobias that the person might have, and what medications they are on.  A Missing Person Report should be filed so that police will also initiate a search.

In addition, even if a concerned party is not enrolled in a locator program, they should file a report with MedicAlert+ Alzheimer's Association Safe Return at 1-800-625-3780.  First responders are often trained to check this resource when they locate a missing person with dementia. Additional help can be accessed from the Alzheimer's Association 24/7 Helpline, 1-800-272-3900, which provides information and support to those who need assistance.Getting help as fast as possible might be the strategy that saves the lives of lost people with dementia.

Further Reading:

Perkins D & Roberts P (2000). Search Management for the Initial Response Incident Commander 2000. ERI International Inc. 

Twardy CR, Koester R & Gatt R (2006). Missing Person Behaviour An Australian Study Final Report to the Australian National SAR Council. Accessed online: http://www.esf.com.au/documents/reports/RobertGatt2002VicPol.pdf (link is external)

Koester RJ & Stooksbury DE (1999). Behavioral profile of wandering Alzheimer’s patients.  Wilderness and Environmental Medicine, 6,34-43 (1995)

Koester RJ (2008) Lost Person Behavior: A Search and Rescue Guide on Where to Look - for Land, Air and Water. Dbs Productions; Spi edition.

© USA Copyrighted 2015 Mario D. Garrett

Legal Consequences of Dementia

In most states, dementia is a reportable disease. Since 1988 physicians in California are required by law to report patients with dementia to their local health departments, information that is then shared with the Department of Motor Vehicles (DMV). Similar to sexually transmitted diseases, infections, and food borne illnesses, dementia is reported to both state and federal agencies. Unlike transmittable diseases however, the diagnosis and reporting of dementia initiates a cavalcade of medical, financial and legal consequences that might strip you of some of your rights as a citizen.
If you are diagnosed with dementia the first thing that you will notice is that the DMV informs you that you need your driving skills to be re-examined—if you are lucky and your physicians indicated that you have mild rather than severe dementia which in the eyes of the DMV renders you unsafe to drive and you automatically lose your license.  Statistically drivers with dementia are eight times more likely to be involved in a car accident. The DMV will schedule a meeting for you to meet with one of their driving instructors to determine your level of awareness, cognitive processes, and perception. Failure to pass these tests will results in your driving privilege being revoked. But if this meeting goes well then you will be scheduled for a special drive test, which includes vision screening. If you are successful at this test as well, then your license might be re-issued but it might come with some restrictions (driving at night driving on certain routes). From here on you will be reevaluated usually every 6 months or less. If the tests are unsatisfactory, you will lose your license.  This loss will jeopardize your ability to work and provide for your dependents, restrict your social participation, diminish your involvement in personal interests, and severely curtail participating in community activities.
The second metamorphosis will involve your relationship with your bank. Banks are catching up slowly to the consequences of dementia both in terms of financial abuse and mismanagement of accounts. Banks are however blind to the diagnosis unless your diagnosis is reported by your spouse, business partner, or family. If you owe a lot of debt, own or manage or a company with a board of directors then it is likely that knowledge of your diagnosis will change your status dramatically. At this stage you can be declared incompetent and treated as such. But you might also be tricked into buying or investing in low-interest or volatile stocks/shares, or sign over assets by your bank or lawyer. Although rare, bankers and lawyers have been found guilty of such abuses. Especially when banks are actively trying to sell new policies, you might be an attractive customer to them despite your diminished capacity. Bankers cannot judge your capacity, and in most cases will not assume that you are incompetent, unless it is to their determent. Whether you like it or not, your spouse or family will become more important to you. Not only because they are privy to your diagnosis but because they can also determine your legal standing. They can submit legal motion to declare you incompetent and take over your estate and business dealings.
A diagnosis of dementia is life changing. In the eye of a personal storm there are important legal and financial questions. In a complex legal field that is evolving, your best bet is to access professional legal advice as soon as possible.   Legal Aid Society, the local Area Agency on Aging, or the Alzheimer's Association might be able to provide you with the names of attorneys practicing in your area who deal with these issues. The obvious start should be determining your eligibility for Medicaid, investigating long-term care insurance, writing a living will and assigning a durable power of attorney for health care.

https://stocksnap.io/photo/6D2BBBEF99
Source: https://stocksnap.io/photo/6D2BBBEF99
For those that have assets,, gather your wills and trusts, prior tax returns, health and life insurance policies, pension information, deeds, mortgage/s, bank accounts (and PIN numbers), and information on other financial investments including ownership of property. Discuss the benefits and implications of transferring assets. If you do not have family or friends that can manage your accounts or business there are fiduciary agents who are certified to do this work for you. In some states you can prepare all your documents and then have them applied at a later period when your diagnosis become more severe. For those who have no or few assets, it is important to realize that you still need help with living arrangements and health directives.
In some cases, especially among people with extensive wealth, the strategy is not to get the diagnosis of dementia in the first place. They either go abroad where mandatory reporting is non-existent, or they go to a private physician and present a different identity. There are obfuscations from the patient as well. The central kingpin in all this is the family practitioner. His or her determination will guide bankers, lawyers and fiduciary agents. This is why a relationship with your primary care physician is important because he or she can help you coordinate and in some cases maneuver this complex medical and legal field.

© USA Copyrighted 2015 Mario D. Garrett

The Psychology of Physics

Physics—the study of the material world—was transformed in the late 1600s by the all-pervasive power of (Isaac) Newton's mechanics and then again in the late 1800s by (James Clerk) Maxwell's electromagnetic theories. These two British men established the Classical Theory in physics. Isaac Newton’s work was the culmination of centuries of philosophical debate about the nature of the world and the composition of material objects. The vindication of these philosophical thoughts came by Newton’s Classic Mechanics which pictured the universe as a perfect machine. Classical Mechanics uses common-sense notions of how matter and forces exist and interact. It assumes that matter and energy have definite measureable attributes such as where an object is in space and its speed. It also assumes that objects may be directly influenced only by their immediate surroundings, known as the principle of locality. The universe was seen as a tangible, orderly system that followed very exact and specific mechanical rules:

1. A body remains at rest or moves with constant velocity when an external force acts on it.

2. The rate of change of momentum of a body is proportional to the force on the body

3. When two bodies interact they exert on each other equal, but opposite forces.

Maxwell's electromagnetic theory, expanded this view of the world, and by consolidating a lot of independent research, established a classic view of electrodynamics. Primarily this theory explained how the related fields of electricity and magnetisms behave through waves. Although Maxwell’s electromagnetic theory was a stepping-stone for Einstein’s 1905 paper “On the Electrodynamics of Moving Bodies” (the first sentence starts by referencing Maxwell), at the time this theory was the ultimate expression of Classical Theory.

The beauty of Classical Theory was that it worked. Classical Mechanics had specific and definitive applications. We could predict the motion of objects in the world and the motion of celestial bodies in the Universe. All that we could observe was explainable. Best of all, Classic Mechanics is intuitive and all encompassing. For more than half a century Classical Theory reigned supreme to such a degree that physicist in the 1900s believed—as Philipp von Jolly counseled the 16-year-old Max Planck when he was admitted to the University of Munich—that the objectives of physics in explaining the material universe was more or less accomplished. The belief was that the main theories were in place and that all the great discoveries had been made, and only a few minor details needed filling in. Classical Theory was that good.

But Classical Theory was short on explaining constructs that we intuitively “knew.” What is “force” “body” and “interact” what is “attraction”, “gravity” and “energy”? These concepts have no explanation in physics. Our current knowledge is limited to defining how they behave, but we are unable to understand what these concepts are. The only place where these concepts have meaning is in our thinking because these concepts are intuitive. We know instinctively what a “body” is, or gravity or energy. These are constructs that we seem to accept readily as though we see the world through such constructs. Our perception—of seeing reality in chunks and simplified action—is so strong that we seem to preconceive the world, without questioning.

It was the work of Gestalt psychologists that brought such preconceptions to light. In 1912, Max Wertheimer published his paper on phi motion—which examined the impression of movement through flickering of lights—widely recognized as the start of Gestalt psychology. Together with Wolfgang Köhler and Kurt Koffka they helped establish theories of Gestalt psychology. The central theorem was that the whole is other than the sum of the parts and they argue that the whole exists independently from its parts. That is why we “see” a body, we see “interactions” and movement and “force” (push and pull). The fundamental principle of Gestalt perception is the law of prägnanz (German for pregnant but meaning pregnant with meaning as in brevity)—a shorthand and simplified version of reality. Gestalt psychology argue that we simplify the world in order to perceive it. We tend to organize our experience of the world in a manner that is regular, orderly, symmetrical, and simple. Gestalt psychologists have identified eight methods we use to simplify the world, primarily by grouping objects together. In an every changing world, having the ability to summarize and simplify the world means that we can perceive situations quicker, predict outcomes faster and thereby gaining time in order to be able to react earlier. We group things together and make them coherent. These are the tricks of magicians. Gestalt psychologists have defined such methods as laws and include the Laws of Proximity, Similarity, Closure, Symmetry, Common Fate, Continuity, Good Gestalt and, Past Experience.

1. Law of Proximity—When objects are close to each, sharing similar motion or sequence we see them as related. We see the behavior of one influencing the other so they share an affinity a similar fate.

2. Law of Similarity—Similar objects on the basis of function, behavior, shape, color, threat and other characteristics that we are sensitive to are seen as related.

3.Law of Closure—Our intent on making things whole extends to when objects have missing parts. This eliminates a lot of the variance so that despite the uniqueness of faces, for example, we see the face despite irregularities. If the law of closure did not exist we will have to interpret each face as a jumble of features.

4.Law of Symmetry—We balance objects in space. A symmetrical field of vision is easier to see because it simplifies the multiple objects into aa pattern, a perceptual algorithm. All we need to see is the symmetry, the uniform pattern rather than individual elements.

5. Law of Common Fate—We see the path that objects travel from and heading towards. We see objects that share similar paths of motion, or direction of motion as grouped together.

6. Law of Continuity—when an object is hidden from view we tend to still see it despite that the object might be behind another object, or when an object is partly hidden we assume that it is whole the the object in front is obscuring the backround object. We are less likely to see objects that change direction quickly or change shape quickly.

7. Law of Good Gestalt—We aim to eliminate variance, complexity and unfamiliarity which implies a global order to the world.

8. Law of Past Experience—history and temporal association implies that under some circumstances visual stimuli are categorized according to past experience. The experience of grouping two objects together in the past determines that we are likely to see them as grouped in the future.

These individual laws of grouping are not separate processes. They define a perceptual bias to group objects into a pattern. Each of these laws defines how we conceive of the world as a model with individual units sharing common attributes. We can say that the capacity to group things together exposes our perception as an algorithm, a formula. We do not perceive a visual reel of reality, a cinematographic version of reality in our heads—although we might conceive of our perception as such. In fact what these Gestalt laws tell us is that we see patterns in our experience of the world—we are not forming patterns, we are seeing patterns.

Algorithms, patterns, formulas or heuristics simplify the world into generalizable configurations.  This view of perception is supported by studies from preliterate societies and how they manage to count and subtract. Like a map that represents the geography of a place, preliterate societies have mathematical maps that help them to work out numerical outcomes. We simplify our experience with the physical world through formulas and algorithms. This is how our brain works.  In 2008, Michael Frank with the Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, and his colleagues reported how the Pirahã Amazonian tribe despite having no language to express numbers, not even one, are able to perform exact matches with large numbers of objects perfectly. Although they were inaccurate on matching tasks involving memory, because they did not have the benefit of language to retrieve information, their capacity to conceive of numbers was equal to other literate groups. They had a schematic way of conceptualizing numbers. We do this algorithmically, using perceptual formulas and patterns to conceive our material world.

Having such a translation of reality embedded within us, the question is whether we also preconceived classical physics. Whtether Classical Theory was indeed physics or a study of our own preconceived perceptual biases. We can see the similarity between the laws of Gestalt psychology and those of Classical Mechanics: 1. A body remains at rest or moves with constant velocity when an external force acts on it, 2. The rate of change of momentum of a body is proportional to the force on the body, 3. When two bodies interact they exert on each other equal, but opposite forces. All of these laws conform to the laws of Gestalt perception. Our perceptual biases are in tune with Newtonian physics. So is Classical Mechanics similarly a biased view of the world?

The fact that we have a mathematical formula—through Classic Mechanics—that predicts the speed, direction and change of objects is an indication of how we perceive objects in motion rather than an indication of the reality. Although our perception is necessarily based on a physical reality that we—like physicists—are trying to predict, our perception is not a reflection of reality but a translation. A translation based on prediction. Predicting reality is very different from “seeing” reality. Just because I can predict an outcome does not mean that, because of my accurate prediction, I understand the reality. Betting shops do this all the time. The problem is Quantum Mechanics. Here comes a theory that challenges what reality is, not as we perceive it to be (Classic Mechanics) but as it seems to be (Quantum Mechanics).

In physics, a quantum is the minimum amount of any physical entity involved in an interaction. Although many scientists have used the term before, it was Max Planck in 1900 that used "quanta" to mean "quanta of matter and electricity, gas, and heat.” Leading Albert Einstein to suggest in 1905 that radiation existed in spatially localized packets that he called "quanta of light". Einstein renamed Planck’s quanta packages as photons and used Planck’s quantum theory to describe the photoelectric effect, for which he would receive his Nobel Prize in 1921. The penultimate expression of quantum physics is Schrodinger’s cat paradox where quantum superposition—entanglement theory—dictates that a cat (in Schrodinger's example) has to be both simultaneously alive and dead at the same time. Although this IS weird—leading Einstein to talk about “spooky action at a distance” and Schrodinger himself to give up quantum physics to focus on philosophy and biology—this is a reality that must be necessarily uncomfortable because it disrupts our own perceptual framework of how the world behaves. Our psychology is insulted.

For the first time we are exploring the world as it truly is rather than how we think it should be. The Greek philosopher Heraclitus wrote around 500 BCE that we can never step in the same river twice. With this observation we have some semblance of what true reality looks like. A universe eternally in a state of flux, having multiple realities, depending on where I—the observer—am.

Did Classical Mechanics simply reflect a detailed exposition of Gestalt psychology? Quantum physics is saying yes. We do not know what reality is except what we are now learning through Quantum Mechanics. Classical Mechanics exposed the psychology of perception. Quantum physics will start to help us understand the weird and the wonderful—what we will come to know—reality.

References:

Franka, M. C., Everettb, D. L., Fedorenkoa, E., & Gibsona, E. (2008). Number as a cognitive technology: Evidence from Pirahã language and cognition. Cognition, 108, 819-824.

For an intriguing perceptive of how psychology was enfluence by physics--which was brought to my attention after this blog was published--please refer to this very readable paper, I have Dave Edwards to thank for this edification:

Wilcox, S., & Edwards, D. A. (1982). Some Gibsonian perspectives on the ways that psychologists use physics. Acta Psychologica, 52(1), 147-163.

© USA Copyrighted 2015 Mario D. Garrett

Ontological Question

Relationships have history. The relationship we have with our environment has a history, a memory. The relationship we have with others has a history, and the relationship we have with ourselves also has a history. Our history determines how we interact with all these facets of life.

As very complex beings we learn, and continue to learn throughout our life, how we interact with our environment in the most efficient way possible. Efficient might mean taking shortcuts however.

Our brain does most of this automatically. We are not aware, unless we need to address something unexpected or something of importance. Most of the time we interact with the world through shortcuts. If we are wiping our hands we pick up a towel and use it. We might not be aware of the towel unless it is different (bright pink with green dots.) Otherwise, the utility of the towel suffices. We do not need to go deeper than that. The brain is very efficient at parsing the reality that we need, and nothing more. This is efficient and sensible with wiping our hands, but limited when we try and understand our world.  Martin Heidegger the german philosopher in Being and Time (1927) called this form of shortcut "ready to hand." Such an awareness of an object that is limited to its utility. We forget the structure of an object and focus on its utility, it function gains prominence in our mind and all else is diminished. Taking this idea further, we can (and do) apply this utility to people around us. We forget the humanity behind a person and get angry when their utility is not realized (they wanted to do something other than fulfill our desires or needs.)  And we do this with our own behavior as well.  Most of the time we function as complex robots. We undertake repetitive task unconscious, as a matter of habit. Driving to work, driving back home, it is all done with minimal conscious thought. This is Pierre Bourdieu's concept of habitus, action that is relegated away from consciousness. And there other other facets of life where we hold a subconscious reality of networks.  Especially as we become older and have more experience living, we build these habitus events to such an extent that we live our lives in an unconscious trance, what Heidegger calls "the nothing". Older adults get very good at this until something unexpected happens. Then what we thought was a simple task like driving, becomes an extremely complex and confusing task.

The reduction of competence among frail older adults is a perfect example of examining how these concepts determine our lives without us being aware of them. The easiest way to perceive this relationship with the world is that these layers of habitus build up into a source of capital. Capital refers to an investment--that we or others make--that we have access to.  In most cases, capital resides independent of us.  Bourdieu (1977) identified and separated such accumulated experiences into four basic capitals: individual’s economic capital (material wealth), social capital (social networking our friends and contacts) and cultural capital (knowledge, skills, education, and advantages that a person has, which give them a higher status in society), later he included symbolic capital (honor, prestige or recognition). To this list we also included body capital (Antoninetti & Garrett 2012) which is the expectation, by you and others, that your body will function as expected within a familiar environment. And there are other types of capital. Civilization is an investment, a civic capital that we can access. Economist talk about "human" capital. The investment in yourself which is normally defined by formal educational. While biologists talk about biological capital (Kemp & Moore 1979). Geography has “place capital” (structures that enhance the utility of a place, eg roads, walkability, street lightning). The interaction between individuals and their environment takes place in a nebulous dimension. And you can further break the type of capital  into different dimensions. But the gist is that relationships have history and build habits.

All philosophers extoll us that despite these unconscious constraints, we are however free. We are free to decide and self-determination. From Martin Heidegger to Paul Sartre there is this belief that being human means that we have some control. But why would we suffer this "anguish" of existence when we can ignore it and live in an unconscious mode? Why is Dasein--being in the present-- so important for Heidegger? Being a contrary, why not live in "they-selves" if the "our-selves" is so painful? If I was designing a new way of existing, would I elect to be aware of "being" and why?


Further readings:
Antoninetti, M., & Garrett, M. (2012). Body capital and the geography of aging. Area, 44(3), 364-370.
Bourdieu, P. (2011). The forms of capital.(1986). Cultural theory: An anthology, 81-93.

© USA Copyrighted 2015 Mario D. Garrett