IN FOCUS: How can we help people with dementia find their way home when they are lost?

CNA

3 days ago

SINGAPORE: Every day without fail, 82-year-old Lau Sung Pong would leave his home in Braddell Heights at 10am and follow a routine he had been going at alone for years.
With only an umbrella-walking stick and a bag, the elderly man would make his way to Cheng San food market in Ang Mo Kio, then to Chinatown, all via public transport, before returning home.
But in May, Mr Lau failed to come home at his usual hour, prompting a frantic search that continued unabated for six days.
Mr Lau has been living with dementia for the past decade.
His daughter, Mdm Lau, turned to the media after days of fruitless searches, desperate to find her father, who needs daily medication.
The usual methods of locating Mr Lau failed – he misplaced his phone the day before and an Apple AirTag failed to pick up his location.
Mr Lau is one of the many vulnerable adults who go missing every year.
Dementia Singapore, a social service agency, said its CARA app – through which people can report missing family members with dementia – gets one report every month on average.
With Singapore projected to reach 'super-aged' status next year – where one in five people are 65 and above – the number of people with dementia is expected to rise.
In 2018, about 82,000 people in Singapore had dementia. That figure is expected to increase to 152,000 by 2030, according to the Ministry of Health.
Mr Lau was found on the seventh day. But there are more who suffer from this invisible condition who go unnoticed, even when they need help the most.
LIVING WITH DEMENTIA
Dementia – the loss of a person's cognitive functioning, such as thinking, remembering and reasoning – affects people to varying degrees depending on the stage of the illness.
There are three main stages: early, moderate and advanced. Those in the latter two stages are the ones who tend to go missing, said Lions Befrienders' executive director Karen Wee.
'Dementia is very much like an onion. The more you peel the layer (to) the core, that's the preserved (part) it protects,' Ms Wee said, referring to a patient's older memories. Many dementia patients are less likely to retain recent memories.
Institute of Mental Health's (IMH) Dr Yao Fengyuan said that while short-term memory is lost long before long-term memory, patients will start to lose their long-term memory as the condition progresses.
A person who has been residing in the same home since their youth can better recognise their home until late-stage dementia.
A person in a new place would likely not be able to remember and recognise their new environment even though he or she has early-stage dementia, explained Dr Yao, senior consultant and chief of IMH's Department of Geriatric Psychiatry.
Mr Rosli Anjang was diagnosed with Lewy Body Dementia in 2017 – a condition where clumps of protein form inside brain cells. He was given only three to five years to live.
Eight years later, Mr Anjang is still up and about, and recently completed the Haj.
He admitted that he has been lost several times before, but despite straying into strange territory, he has always managed to find his way home.
The trick is not to panic. When in unfamiliar territory, Mr Anjang simply sits down to calm his mind before thinking of the next step.
On one occasion, he exited the lift at the wrong floor of his block and found a strange gate where he thought his unit was.
He took a seat on the staircase to recall his floor, telling himself there was 'nothing to harm' him.
He found his way home just by hazarding a guess at a different floor, but told CNA he would have 'just kept on trying' even if it was wrong.
Keeping a routine is key to building up muscle memory, he said. If you take a route to a destination, take the same path back. No shortcuts.
On occasions when Mr Anjang misses a stop or falls asleep on the bus, he would simply take the bus to the interchange to seek help.
Bus interchanges and MRT stations are designated as dementia go-to points, where staff are trained to help.
Currently, there are more than 800 go-to points across Singapore, including supermarkets and senior activity or eldercare centres.
Aside from these measures, schemes to help people with dementia find their way home in the heartlands have also been mooted over the years.
In Kebun Baru, recognisable icons or murals of traditional snacks at housing blocks are meant to help those with dementia recognise their way home. The icons are part of a wayfinding project led by Dementia Singapore in 2019.
Such identifiable elements could help those who have moderate-stage dementia, All Saints Home's clinical director Low Mui Lang said.
'So with the wayfinding, either colour or pattern or food, you remember that is your key point,' said Ms Low, adding that those with dementia tend to remember colours, followed by numbers and words.
Mr Anjang relies heavily on visual clues to navigate around the bustling Woodlands Transport Hub.
Colourful arrows and images of fruit on the ground guide commuters from the MRT gantry to exits and the two bus interchanges.
Blocking out the clutter of overhead signs with exit numbers, Mr Anjang follows the dragonfruit to the underground bus interchange, where he can board the bus home.
The markers are part of a wayfinding project between SMRT and Dementia Singapore to help commuters with cognitive disabilities.
The arrows are more helpful than the signs showing exit numbers, especially since people with dementia tend to have tunnel vision, Mr Anjang pointed out.
Larger font sizes on the arrows and images of fruit at entrances would be more ideal, he said.
The former chemical plant superintendent said he hoped to see such directional arrows or murals around his home in Marsiling, where he moved to this year after 28 years in neighbouring Woodlands.
At his new home, housing blocks are painted two uniform colours, and void decks are indistinguishable.
Directional arrows and large block numbers at eye level along commonly-used paths would be a simple way to make life easier, he said.
GOING OUT WITH A PURPOSE
After Mr Anjang and his wife, Madam Sarimah, moved to Marsiling, she took time to get her husband acquainted with the amenities and transport around their new home.
Part of the game plan was to formulate 'standard' routes to intended destinations. Another part involved Mr Anjang fixing the journey in his mind before stepping out of the house.
He plans his route from doorstep to destination, so he "won't have to think so much" while on the go.
"So if I have to go out by myself, then my wife will remind me. The first thing is very important, I know where (is) the bus stop that goes to the interchange.'
Armed with a single walking aid that he handles with gloved hands, Mr Anjang, a father of three and grandfather of more, leaves the house with his CARA card attached to a lanyard around his neck.
The card has his identity and status as a person with dementia, along with a way to contact Mdm Sarimah.
Mr Anjang also avoids 'wandering around'. For example, at night, Mr Anjang makes it a point to speak to the elderly people around his neighbourhood.
Instead of wandering the void decks in the hopes of speaking to someone, he targets a certain block and takes a specific route there. When he is done, he retraces his steps home.
Every deliberate step, with Mr Anjang
Half the day had passed by the time I knocked on Mr Anjang's front door at 2pm, but for him, the day had just begun.
Dementia has not only affected Mr Anjang's mental processing skills, but also his ability to keep normal sleeping hours.
Mr Anjang's days start past noon, but he keeps to a routine as much as he can. After prayers, the elderly man takes bread and washes that down with tea, before taking an array of medications and an injection for diabetes.
Only then was he ready to speak to me.
Despite his condition, Mr Anjang only needed the occasional prompt when certain words escaped him.
He never lost sight of the interview's objective: to explain and demonstrate how he gets around.
We took a private-hire car to a nearby Al-Ameen coffee shop, which he frequents every other week with friends. The rojak there is good, he said.
With his walking aid, Mr Anjang navigated his block's corridor and void deck with ease, making his turns confidently as he guided me to the car park – as if the movements were muscle memory.
In the car, the elderly man pointed out to me routes he would follow, while recounting snippets of his life, both pre- and post-diagnosis.
Once a superintendent at a petrochemical plant, Mr Anjang's first inkling that something was amiss was when a fire broke out at his workplace around 2007.
In that high-pressure moment, 'everything went blank', he recounted to me. 'I cannot remember anything … until they came to me for instruction, I didn't know what to say.'
His condition remained undiagnosed until a decade later, when his wife saw him coming out of his home toilet with a cup of coffee and asked him about it.
'To me, (as) I saw it, the toilet was not the toilet. I saw something else,' Mr Anjang said. That moment spurred the couple to seek medical help.
Now, eight years after his diagnosis, Mr Anjang has found ways to manage his situation and has come up with a personal mantra: Move with deliberation.
He directed the driver to the eating house at Marsiling Industrial Park. Throughout, Mr Anjang took pride in showing me just how familiar he was with the coffee shop, down to the slight kerb that separated the indoor and outdoor seating areas.
As I watched him, Mr Anjang made eye contact with me and gestured at the kerb before stepping over it.
Like he said, every step – deliberate.
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GOING OUT WITH PRECAUTION
Mr Lau was diagnosed with dementia about a decade ago.
In the early years, Mr Lau would travel with his wife, establishing a routine that took him to the same locations and back. He continued the drill even after her death more than four years ago.
"The doctor told me to ... let him continue with his familiar routine because he is very used to it, together with my mum last time,' his daughter Mdm Lau said.
"If we stop this routine, he will deteriorate even faster.'
On weekends and public holidays, Mdm Lau, who is a full-time senior management consultant, would take her father out on visits to his usual haunts to reinforce his memory of these locations.
A fiercely independent man, Mr Lau disliked company on his weekday jaunts, so his daughter devised ways to protect him. His phone was tracked and he carried an AirTag.
Every one to two months, she would quietly tail her father to ensure that she stayed up to date with his route.
Lions Befrienders' Ms Wee said this is useful as a family member would have an idea where to start a search should someone go missing. But this requires much time and effort by the caregiver.
On days she was not with him, Mdm Lau checked her father's whereabouts every few hours to make sure he was keeping to his routine.
If he strayed, the 55-year-old would call the elderly man and pick him up.
As an additional safeguard, Mdm Lau 'recruited' hawkers at the coffee shops Mr Lau frequents as her 'eyes and ears'.
These hawkers would remind Mr Lau to go home if he lingered for too long, and had Mdm Lau's phone number.
WHEN DAD WENT MISSING
On May 1, Mr Lau left home at around 10am dressed in a pink-red shirt, dark-coloured trousers and black leather shoes.
A helper accompanied him to his bus stop and snapped a photo of him to remember his outfit before he boarded the bus to Ang Mo Kio.
Mr Lau would usually take a bus to Ang Mo Kio bus interchange before transferring to another bus to Cheng San Market. His journey would take him to Chinatown before he headed home.
That day, however, Mr Lau took several trips between Ang Mo Kio bus interchange and Cheng San food market before he tapped into the gantry at Ang Mo Kio MRT station past 6pm.
He remained at the platform for 11 minutes before exiting the station.
According to SimplyGo records, Mr Lau then took a bus and eventually ended up at the bus stop near Alkaff Lake in Bidadari Park near 9pm.
By then, Mr Lau was way off his usual schedule and in an unfamiliar location in the dark.
His AirTag traced him to a junction near Block 212 Bidadari Park Drive before the trail went cold.
His distressed daughter activated her grassroots and past school's network, with Member of Parliament Denise Phua putting out a call for help. Mdm Lau also alerted the police.
These groups were vital in helping Mdm Lau's family narrow their search area over the next few days.
The family put up posters of Mr Lau around the Bidadari area, but that did not yield results.
Social media was an option, but Mdm Lau came to realise that information or a potential lead quickly became outdated.
'On social media, many people when they see someone they think (is my father), they just post. So there are no facts, and no way to verify.
'When we wanted to verify, we felt that it's really a bit too late. So to me, that was not a very good way to get help,' she said. Her search went on nearly around the clock every day.
Dementia Singapore's CEO Jason Foo told CNA that confusion and disorientation are common symptoms of dementia.
Depending on the stage of their condition, they can get lost in their neighbourhood, he added.
'Families cannot keep their loved ones with dementia locked up at home all the time. It is beneficial for people with dementia to go out regularly but the caregivers need to be very vigilant.
'A split-second lapse in supervision and the person with dementia can wander off.'
Caregivers should not be distracted by errands when out with a person with dementia. If they have to run errands, someone else should accompany the person with dementia, he said.
'We should also try not to allow persons with dementia, especially those in their later stages of dementia, to go out on their own,' Mr Foo said.
Caregivers can design a daily routine to provide loved ones with some structure. Activities they enjoy can help reduce agitation and improve mood, and this may also reduce their desire to go out.
For those who have moderate to severe dementia but wish to go out, Mr Foo suggested using a GPS tracker. It is more effective than an AirTag, which uses an available network of Apple devices in the vicinity to work accurately, he said.
Caregivers can also report a 'missing person' on the CARA app, where all members will receive a push notification. This notification is also disseminated through the OneService App, which has more than 500,000 members.
A majority of these cases are resolved within eight hours, according to Mr Foo. Caregivers should make a police report immediately.
The Singapore Police Force told CNA that it would interview the person who lodged the report to obtain background facts such as the missing person's state of mental health.
It will then disseminate lookout messages to all police resources, including those within the area where the missing person was believed to be.
Priority would be given to vulnerable missing persons - including young children and elderly - as they may be at higher risk. Officers may then review police camera footage for possible sightings.
The police also collaborate with other government agencies to locate missing people, and can issue appeals for information.
'For missing persons who have not been found for some time, the police conduct regular reviews of the missing person cases, to look for leads,' the spokesperson added.
SIX DAYS MISSING
Mr Lau was found six days after he went missing. He turned up where he was least expected: on the roof of an unoccupied Build-to-Order block in Bidadari.
He was found by a construction worker conducting maintenance work on the roof's water tank, lying under a structure for shelter.
He had hung his umbrella-walking stick on a staircase railing and despite his limited mobility, made his way up the ladder to the roof somehow, Mdm Lau recalled.
When he was found, Mr Lau's AirTag finally pinged his daughter, informing her of his whereabouts.
She immediately told the police while making her way down to Bidadari anxiously, several possibilities running through her mind. Is he alive? He had gone days without his medication.
He might have gone up to the roof after two to three days of going missing, she surmised, as he used to work on water tanks in his previous job.
"In the ambulance, the paramedic briefed me or updated me on his condition … his blood glucose was still normal, except that he was badly dehydrated and badly sunburnt."
The elderly man responded when called by name, but appeared to be in a daze.
His condition improved after receiving treatment in hospital and he was transferred to a rehabilitative facility, with a view to his discharge.
However, complications arose after he refused to eat and he had to be restrained due to a tendency to scratch his skin. His condition worsened and he was transferred back to hospital.
Mdm Lau showed all the strain of a six-day, frenzied search. With red eyes and a strained voice, she said: "It's really quite tough, quite tiring, emotionally quite draining also."
AN INVISIBLE CONDITION
Eldercare experts Ms Low and Ms Wee said that those who go missing may remain undetected as there are few signs to show that they are in distress or need help.
People are usually on their mobile phones when they are out and about, and do not pay much attention to others around them, said Lions Befrienders' Ms Wee.
They might not realise that someone with dementia might need help.
Asked if anything more could have been done to keep her father safe, Mdm Lau paused to think.
'This is a question that I really can't answer, and I really don't know how, except that the only thing is to get another person or helper to just really follow him, even if he doesn't like or gets frustrated, just get them to follow at the back," she said.
There are limitations with the current initiatives, said the eldercare experts.
Ms Wee said as wayfinding markers are only within certain communities, a person would likely be lost if they strayed beyond the usual boundaries.
Markers help a lot, but if a person is at the wrong MRT station to start with, they may already be disoriented.
Ms Low said that murals would be of limited assistance given how dementia patients tend not to have recent memories.
If they cannot remember where they stay, the images of foods on walls 'mean nothing to them', she added.
A better way is to make sure they are familiar with the area, and to give them chairs to rest so they can calm down and think.
But despite the full suite of measures - the app, an alert system, a community network and the wayfinding markers - there will be 'outliers' due to limited resources, Ms Wee said.
The effectiveness of environmental modifications for people with dementia varies with the stage of dementia and setting, said IMH's Ms Ong Xin Ling, senior occupational therapist at the Department of Geriatric Psychiatry.
In familiar environments, murals and signs with individualised meanings can be particularly beneficial for those in the mild stages of dementia.
However, in a public space, the effectiveness of tailored visual cues is limited as they cannot be customised to the individual, Ms Ong said.
She suggested more general environmental modifications like clear signs with simple language and large lettering.
Ms Ong cautioned against having unnecessary or repetitive signs as they could overwhelm people with dementia.
'Reducing the sensory load for persons with dementia in public spaces allows them to focus on important details and landmarks, leading to better identification of their surroundings,' she added.
Dementia Singapore's Mr Foo suggested having distinct landmarks, such as landscaping features at the front of housing blocks, that could serve as visual cues. Commonly used amenities should be located within walking distance, and designs and markings of key infrastructures should be legible.
Both Ms Wee and Ms Low encourage those who spot seniors who appear confused or lost to gently approach and ask if they need help.
People need to know how to interact with someone who has dementia.
'The questions to ask are important … We will have a lot more to learn to educate our public. Now we know dementia go-to points but nobody tells us how to get somebody to dementia go-to points,' she said.
Mr Foo said people are increasingly aware of the condition.
'But that knowledge needs to be deepened so that they can recognise the symptoms and know how to provide some basic support if required. Recognising a person with dementia in the community and accepting them when they display unusual behaviours will be very helpful,' he added.
Mr Anjang said he feels particularly thankful when strangers offer him help.
He told CNA that he has pretended to be lost at Woodlands Transport Hub just to see who might step up. All those who did were students.
As he was pointing out directional markers, a man approached to ask if he needed help, lighting a smile on the face of the elderly man who clasped the stranger's hand in gratitude.
In turn, Mr Anjang pays it forward for other people in the same boat with his advocacy work with Dementia Singapore.