ArticlePDF AvailableLiterature Review

Wandering and dementia

Authors:
  • Hospital of Versilia
  • Azienda Sanitaria Locale Pisa

Abstract and Figures

Wandering represents one of many behavioural problems occurring in people with dementia. To consider the phenomenon of wandering behaviour in demented patients, we conducted searches using Medline and Google Scholar to find relevant articles, chapters, and books published since 1975. Search terms used included 'wandering', 'behavioural and psychological symptoms', 'dementia', 'nursing', and 'elopements'. Publications found through this indexed search were reviewed for further relevant references. The term 'wandering' covers different types of behaviour, including aimless movement without a discernible purpose. It is associated with a variety of negatives outcomes. The aetiology of wandering is poorly understood and it remains an unsolved riddle. Wandering is an acutely distressing problem worldwide, both for the patients and caregivers, and it is a major reason for nursing home admission. Evidence on the effectiveness of pharmacological and non-pharmacological interventions is limited. It is possible that management of coexistent psychopathology would help to ameliorate this problematic behavioural disorder.
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REVIEW ARTICLE
Wandering and dementia
Gabriele CIPRIANI, Claudio LUCETTI, Angelo NUTI and Sabrina DANTI
Neurology Unit, Hospital of Viareggio, Lido di
Camaiore, Lucca, Italy
Correspondence: Dr Gabriele Cipriani MD,
Department of Neurology, Versilia Hospital, Via
Aurelia, Lido di Camaiore, Lido di Camaiore, 55060
Lucca, Italy. Email: cprgrl@gmail.com
Received 2 October 2013; revision received 10 January
2014; accepted 21 January 2014.
Abstract
Wandering represents one of many behavioural problems occurring in
people with dementia. To consider the phenomenon of wandering behaviour
in demented patients, we conducted searches using Medline and Google
Scholar to find relevant articles, chapters, and books published since 1975.
Search terms used included ‘wandering’, ‘behavioural and psychological
symptoms’, ‘dementia’, ‘nursing’, and ‘elopements’. Publications found
through this indexed search were reviewed for further relevant references.
The term ‘wandering’ covers different types of behaviour, including aimless
movement without a discernible purpose. It is associated with a variety of
negatives outcomes. The aetiology of wandering is poorly understood and it
remains an unsolved riddle. Wandering is an acutely distressing problem
worldwide, both for the patients and caregivers, and it is a major reason for
nursing home admission. Evidence on the effectiveness of pharmacological
and non-pharmacological interventions is limited. It is possible that man-
agement of coexistent psychopathology would help to ameliorate this prob-
lematic behavioural disorder.
Key words: behavioural and psychological
symptoms (BPSD), dementia, elopements, nursing,
wandering.
INTRODUCTION
Dementia as a clinical syndrome is characterized
by global cognitive impairment, which represents a
decline from previous levels of functioning. It is asso-
ciated with impairment in functional abilities and,
in many cases, behavioural and psychiatric distur-
bances. Wandering is a frequent behavioural disorder
in demented patients and one of the most exhausting
for caregivers.1The term ‘wandering’ describes a
series of different behaviours based on the attributes
walking and locomotion.2Although wandering is com-
monly recognized clinically, lack of a standard defini-
tion has been a persistent problem. In addition, the
term ‘wandering’ is often conflated within agitated
behaviour.3It is frequently used in the literature as a
broad term encompassing a diverse set of behaviours
(Table 1), but most researchers and health-care
providers agree that wandering refers to seemingly
aimless or disoriented ambulation throughout a facil-
ity, often with observable patterns such as lapping,
pacing, or random ambulation.21,24 Only two features
among various definitions of wandering seem to be
common to all: those of an individual moving through
space and of being cognitively impaired.25 In 2007,
a team of researchers proposed the following defini-
tion of wandering: ‘a syndrome of dementia-related
locomotion behavior having a frequent, repetitive,
temporally-disordered, and/or spatially-disordered
nature that is manifested in lapping, random, and/or
pacing patterns some of which are associated with
eloping, eloping attempts, or getting lost unless
accompanied’.15 Although mobility is a prerequisite for
wandering, caregivers may not recognize that it can
occur when residents use alternative modes of mobil-
ity, including assistive devices (e.g. walker or cane) or
wheelchairs (propelled forward or backward).18
EPIDEMIOLOGY
A 2006 study reported that one in five people with
dementia wander,26 but estimates of the prevalence
of wandering vary, with rates having been reported
as 17.4% in community-residing seniors,27 50% in
severe dementia,29 and 63% in community dwellers.29
Peak incidence of ambulation in the nursing home
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doi:10.1111/psyg.12044 PSYCHOGERIATRICS 2014; ••: ••–••
1© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society
Table 1 Varying definitions of wandering published in the scientific literature upon the last 30 years
References
Type of
definition
Category of
definition Definition of wandering Main topic of article
Applied to
resident
patients
Cohen-Mansfield &
Billig (1986)4
O Challenging behaviour A type of challenging behaviour with a manifestation of agitation Conceptual framework of agitation Not only
Hope & Fairburn5O Spectrum of
behaviours
Wide range of distinct behavioural abnormalities Descriptive typology of wandering Not only
Allan2C Acts of locomotion Series of types of behaviour based on the attributes walking and
locomotion
Management of wandering Yes
Morris et al.6C Behavioural symptom Locomotion with no discernible, rational purpose; may be manifested by
walking or by wheelchair
Assessment and management of wandering Yes
Matteson & Linton7O Challenging behaviour The most difficult aimless behaviour to menage in demented patients Aetiological factors and factors related to
wandering
Yes
Coltharp et al.8C Goal-directed
behaviour
The natural consequence of a search for something that becomes
threatening for people with dementia
Causes and management of wandering Not only
Kiely et al.9O Challenging behaviour Serious problem for nursing home staff and wanderers Risk factor and causes of wandering Yes
Maher10 C Goal-directed
behaviour
A motor behaviour driven by an intention not always understood by
caregivers
Revising the definition of wandering and its
management
Not only
Lai & Arthur11 O Spectrum of motor
behaviours
A multitude of behaviours, frequently aimless, charateristic of cognitively
impaired individuals that moving through space
Integrative review and meta-analysis of
wandering in subjects with dementia
Not only
Rowe & Bennet12 O Challenging behaviour Significant behavioural problem in dementia different from becoming lost in
the community
Consequences of wandering Not only
Silverstein & Flaherty13 C Challenging behaviour A common life-threatening behaviour associated with Alzheimer’s disease
and related disordes
Costs and consequences of wandering and
its management
Yes
Dewing14 C Acts of locomotion A complex and necessary activity for many persons with dementia Screening tools for wandering Not only
Algase et al.15 O Acts of locomotion A form of locomotion, most often walking, with a frequency or rate that can
be problematic in people with dementia
Finding a standardized definition of
wandering
Not only
Marcus et al.16 C Challenging behaviour A major issue in the behavioural management of Alzheimer’s disease that
often places patients at great risk
Assessment of wandering Not only
Robinson et al.17 O Spectrum of motor
behaviours
A wide range of agitated behaviours common in people with dementia that
may be beneficial (i.e. form of exercise) but also harmful
Management of wandering Not only
Schonfeld et al.18 O Challenging behaviour Seemingly aimless or disoriented ambulation throughout a facility often with
observable patterns such as lapping, pacing, or random ambulation
The factors associated with male residents
who wander and the extent of this
behaviour
Yes
Algase et al.19 O Challenging behaviour Wandering pattern is a specific clinical phenomenon, deals with a discrete
behaviour within a limited class of motor behaviours (i.e. walking), also
reflected within but not exclusively byphysically nonaggressive agitation
Definition of wandering Not only
Rowe et al.20 O Challenging behaviour Unique locomotion behaviour characterized by repeated and frequent
activity with temporal and spatial disorientation that is conceptually
different from missing incidents
Definitions and management of wandering Not only
Carr et al.21 O Challenging behaviour Challenging behaviour for caregivers of individuals with dementia who may
become lost and find themselves in dangerous situations
National health policy and consequences of
wandering
Not only
Volicer et al.22 O Acts of locomotion Aimless motor activity that is not always undesiderable but sometimes has
adverse consequences, that can increase caregiver distress, and that
may be a symptom of agitation; Possible to distinguish patients with
modifiable wandering from those whose wandering is not
Relationship between wandering and
residential activities
Yes
The Task Force on the
Effect of Alzheimer’s
Disease in Arkansas23
C Motor behaviour To move about without a definite destination or purpose; less commonly
moving with a goal
National health policy and consequences of
wandering
Not only
C, clinical definition; O, operational definition.
G. Cipriani et al.
2© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society
occurs between 5 p.m. and 7 p.m.30 Variation is partly
accounted for by the variety of definitions used and
the differing time periods covered. Sink et al. studied,
the prevalence of dementia-related behaviours in
a large, multiethnic sample of community-dwelling
patients with moderate to severe dementia.31 They
observed that wandering was the most prevalent
dementia-related behaviour within each of three
ethnic groups: White (58%), Black (67%), and Latino
(63%) Americans. After multiple confounds were con-
trolled, increased risk of wandering was found for
Blacks (odds ratio =1.40; 95% confidence interval =
1.08–1.81; P=0.012) and Latinos (odds ratio =1.59;
95% confidence interval =1.21–2.26; P=0.009).
In a study performed in a long-term care service,
wandering was the second most frequently reported
behaviour problem.32 Wanderers and non-wanderers
do not differ by gender or age.33 Some consider
pacing more prevalent in men.9,27 Consistent with
some studies, use of antipsychotic medication was
also associated with greater chance of being classi-
fied as a wanderer.9,18 Colombo et al. studied an
inpatient special care dementia unit and found that
wanderers (51% of the sample) were somewhat
younger (76.4 vs. 80.5 years old) than non-
wanderers.34 Furthermore, 70% of the caretakers see
wandering as a risk for the care of the patients.35
AETIOLOGY
The aetiology of wandering is poorly understood and
it remains an unsolved riddle. Three major approaches
can be identified from the literature: biomedical, psy-
chosocial and person–environment interaction. A bio-
medical hypothesis involves right parietal dysfunction,
positing that a functionally impaired neural circuit
leads to wandering.11 Wandering might also result
from dysfunction in spatial perception and memory.11
Another approach has been to focus on impairments
in visual attention and an inability to perceive radial
motion of optic flow as the basis for wandering in
some Alzheimer’s disease (AD) patients.36,37 Lateral
asymmetric hypoperfusion is frequent during AD and
generally more pronounced on the left side, but its
consequences are not well known. However, wander-
ers have a more severely reduced regional cerebral
blood flow in the left temporalparietal region than AD
subjects without wandering behaviour.38 Based on
positron emission tomography, Meguro et al. reported
that wandering patients with AD showed decreased
frontotemporal glucose utilization and decreased
dopamine metabolism in the striatum.39 Like other
complex repetitive routines, wandering may also
result from or be facilitated by aberrant motor plans
and more elementary behaviours than disinhibited
motor programmes.40 Circadian rhythm disturbances,
particularly sleep disturbances, have also been inves-
tigated as a basis for wandering.37 Monsour and Robb
studied the lifestyle of 22 matched pairs of wanderers
and non-wanderers, and found that wanderers had a
higher motor reaction to stress and a more motor
behavioural style earlier in life than non-wanderers.41
From a psychosocial perspective, unmet needs
and environmental factors can also contribute to wan-
dering risk: the aberrant behavioural symptom can
emerge when internal discomfort, especially when
coupled with external demands (e.g. a noisy environ-
ment), exceed the individual’s threshold.42 Dementia
patients with unmet physical or psychosocial needs,
such as the need for toileting assistance or the need
to find a place of safety or someone familiar, may be
more prone to wandering. Three psychosocial factors
were identified as possibly influencing wandering: life-
long pattern of coping with stress, previous work
roles, and a need to search for people or places asso-
ciated with security.43 Clinical observations support
the inference that certain emotions and behaviours in
dementia are associated.44 According to Lee et al.,45
positive emotional expression is positively related to
wandering rates, whereas negative emotional expres-
sion and higher cognitive status were negatively
related to wandering rates after controlling for other
predictors (age, education, gender, facility type,
mobility, and time of day). They noted that one pos-
sible explanation for these results is that persons with
dementia who are sad or angry may respond by sitting
alone or staying in their rooms for periods, rather than
walking around. In contrast, demented patients who
are happy or experiencing pleasant emotions may
respond to this state by engaging in physical activity
such as walking around.
DISEASE OUTCOMES
Wandering behaviour sounds innocent enough, but it
quickly takes on special meaning: adverse outcomes
associated with this aberrant behaviour include acci-
dents, getting lost,46 malnutrition because the patients
are unable to sit down for meals and because exces-
sive wandering significantly increases their caloric
Wandering
3© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society
requirements,1weight loss,47 fatigue, sleep distur-
bance,48 social isolation,49 earlier institutionalization,42
and injury.50 Wanderers fall thrice as much as non-
wanderers, (with statistical significance according
to various statistical tools, especially non-parametric
ones); over a 3-month observation, wanders fell 1.6
times compared to non-wnaderer’s 0.6 falls.34
Wick and Zanni reported that nursing home resi-
dents who wander have double the risk of fracture
compared with residents who do not wander.26 Wan-
dering behaviour has been shown to be a key deter-
minant of patient’s death.51 For example, Kibayashi
and Shojo reported two cases of fatal accidental
hypothermia in an 89-year-old woman and a 76-year-
old man who were found dead and unclothed; in both
cases, wandering due to AD was determined as the
cause.52 In a facility, wandering may result in an activ-
ity that is undesirable (e.g. entrance into another
resident’s room) that results in resident-to-resident
violent incidents or may prevent desirable caregiving
activity (e.g. eating and toileting).22,53 Wandering may
elicit the use of restraints or excess sedation.54 It
has also been reported to require costlier care.55 Wan-
dering can lead to an increase in caregiver stress
and safety concerns that challenge care providers
responsible for managing behaviour problems.34
Furthermore, it causes problems in the hospital
environment.51
WANDERING AND DEMENTIA
CHARACTERISTICS
Wandering correlates with the severity of cognitive
impairment,56 problems in recent and remote memory,
orientation to time and place, and the ability to
respond appropriately to a given conversation topic.55
According to Hope et al.,57 wandering behaviour
occurs in patients who have scored 13 or less on the
Mini-Mental State Examination and it lasts for a period
of several years. Conversely, functional impairment,
especially as it reflects ability to walk, limits who
can wander, and relatively preserved activities of
daily living was closely associated with wandering
behaviour.58 Patients with AD are more likely to be
wanderers than those with a vascular dementia
(VaD).59 Data from a sample of 1312 patients revealed
that wanderers constituted 26% of AD patients and
18% of VaD patients.60 For both diagnoses, rates were
low (12% and 9%) in the early stages and higher (37%
and 28%) as each disease progressed to the later
stages. Klein et al. replicated this trend in the moder-
ate and severe range of dementia: of the 638
community-residing dementia patients examined, 111
(17.4%) had exhibited wandering behaviour.27 The fre-
quency of wandering varied within each severity range
of dementia for patients with AD, VaD, and other types
of dementia. Patients diagnosed with AD were overall
significantly more likely to wander than those with VaD
or other types of dementia, although this difference
did not achieve statistical significance within indi-
vidual severity ranges. The frequency of VaD did
not significantly differ between wanderers and non-
wanderers.
The close relationship between wandering and
severe cognitive dysfunction is transcultural.61 A
wide range of behavioural abnormalities have been
reported in frontotemporal dementi,a including repeti-
tive behaviours.62 They occur in the verbal domain in
the form of stereotyped use of words or phrase, and
in the motor domain as wandering and pacing.63,64
Patients with dementia with Lewy bodies (DLB) share
many clinical signs and symptoms with patients diag-
nosed with AD, but according to Knuffman et al.,65
patients with DLB have a higher incidence of wander-
ing. However, according to Chiu et al.,64 AD and DLB
patients have a similar proportion of activity distur-
bances (i.e. purposeless activity, wandering and
inappropriate activities) when considered altogether.
Despite this, to the best of our knowledge, there have
been no systematic studies about wandering in
frontotemporal dementia and in DLB.
PSYCHOPATHOLOGY AND WANDERING
Lachs et al. suggested that wandering is more
common among delusional than in non-delusional
patients.66 According to Hope et al.,57 there is a cor-
relation between persecutory ideas and increased
walking, a correlation between persecutory ideas and
attempts to leave home, a correlation between perse-
cutory ideas and aimless walking and a weaker rela-
tionship between hallucinations and increased walk-
ing. Anxious states may justify wandering behaviour:
an anxious resident may move about in an effort to
relieve anxiety, discomfort, or unsettled state, but
such motivation may be unknown to observers, so the
movement may be perceived as aimless.9
Moderate to severe depression was found more
frequently in demented wanderers.27 Lyketsos et al.
G. Cipriani et al.
4© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society
found an association between major depression
and wandering in Alzheimer’s dementia outpatients.67
Consistent with the findings of a previous study,68
Schonfeld et al. observed that being classified as
a wanderer was found to be associated with other
disruptive activities such as socially inappropriate
behaviour and resisting care.18 Wandering and delu-
sions were the only clinical predictors of aggressive
behaviour in a case mix of Alzheimer’s patients.69
Negative behaviours associated with wandering
include non-aggressive agitation, screaming and
calling out, physical aggression, and disturbed night-
time sleep.34,70 With regard to the premorbid charac-
teristics and wandering behaviour of persons with
dementia, Song and Algase’s research revealed that
premorbid extroversion and premorbid negative ver-
balization stress response are significant negative
predictors of wandering.71
ASSESSMENT AND MANAGEMENT
Of all the behavioural symptoms associated with
dementia, wandering is one of the most problematic
from the perspective of patient management and
safety. The first step in any systematic investigation of
wandering involves reliable and valid measurement of
the phenomenon. A psychometric instrument admin-
istered to caregivers, the Algase Wandering Scale,
has been developed to characterize a given patient’s
tendency to wander.72 It is a 28-item questionnaire
examining the pattern and rhythm of wandering.
Interrater reliability results were not provided but were
reported as moderately strong. To the extent possible
with current assessment strategies, clinical evaluation
is important in distinguishing wandering from similar
behavioural problems such as anxiety, agitation due
to depression, hypomania, and medication-related
mobility disorders (e.g. akathisia).18 Accurate and
prompt diagnosis of underlying psychiatric, physical,
or iatrogenic conditions that may be triggering and
maintaining wandering is essential.
Traditional management comprised physical barri-
ers and physical restraints, but a new ethos in the
management of wandering has evolved with a move
towards promoting safe walking rather than prevent-
ing wandering; this aims to balance a person with
dementia’s need for autonomy with the need to
minimize risk.73 Overall, programmes implemented to
reduce use of physical restraints have not resulted in
greater harm or injury to residents.74 A wide range of
intervention studies are reported, but these are often
weakened by poor conceptualization and design.
Robinson et al. performed a systematic review to
evaluate the effectiveness of these interventions and
to assess acceptability associated with their use.73
They concluded that there is currently no adequate,
robust evidence from controlled trials to recommend
the use of any non-pharmacological intervention to
reduce wandering in dementia; the authors added
that, from both a practical and moral perspective,
acceptable interventions included walking/exercise
and music therapy. Hermans et al. evaluated the
effectiveness and safety of non-pharmacological
interventions in reducing wandering in the domestic
setting.75 As no randomized controlled trials were
found, no results could be reported. According to
Schonfeld et al.,18 use of interventions such environ-
mental alterations and social therapeutic activities
may help create a safe and pleasant environment for
staff and residents while delivering meaningful pro-
gramming to people with dementia who wander. A
walking programme for physically active persons with
severe dementia reduced interpersonal tension on the
dementia unit of a nursing home.76
Miskelly tested a system of electronic tagging
using an electronic bracelet on patients with dementia
and wandering in three different scenarios: for 4
weeks in two wards at a large teaching hospital, 6
months in a medium-sized residential home, and 8
weeks in clients’ own homes in the community.77 The
equipment had excellent performance and demon-
strated none of the inadequacies of earlier studies.78
However, even when technology is successfully
applied, there are substantial ethical issues to be
addressed that have already generated considerable
controversy.79 The risks and restrictions of alternatives
to tagging, including the loss of privacy entailed
in benign surveillance, should be kept in mind.79
Also recently it was discussed whether patients
with dementia who wander should be electronically
tagged.80,81 Nishigaki et al. developed a support
system that employs image processing technology
based on fluorescent dye that is painted in a simple
shape on the clothes of an elderly person.82 The aim
of this technology is to prevent elderly people with
dementia from wandering. The fluorescent colour
becomes visible by irradiation with a long wavelength
of ultraviolet light. Then, a 3-D video camera was used
to acquire a 3-D image and detect the simple shape.
Wandering
5© 2014 The Authors
Psychogeriatrics © 2014 Japanese Psychogeriatric Society
Several medications are used on residents who
exhibit undesirable wandering, but strong evidence
for their effectiveness is lacking and they can produce
undesirable side-effects.84 According to Meguro
et al.,84 risperidone has some benefit over placebo in
reducing wandering, but it increases fall risk. It has
the antagonistic potency of serotonin and dopamine
receptors.
CONCLUSIONS
Although definitions vary, most researchers and
health-care providers agree that wandering refers to
seemingly aimless ambulation, often with observable
patterns such as lapping, pacing, or random
ambulation. It is one of the most frequently encoun-
tered dementia-related behavioural disturbances and
has been associated with negative consequences
such as higher morbidity and mortality. It can pose very
severe problems in caring for people with dementia.
The basis of wandering is multifactorial; biomedical,
psychosocial and person–environment factors must
be considered. These factors encompass personal
needs, both physical and emotional, and physical
and social aspects of the environment. Evidence on
the effectiveness of pharmacological interventions is
limited. High-quality studies, preferably randomized
controlled trials, are needed to determine the clinical
and cost-effectiveness of non-pharmacological inter-
ventions that allow safe wandering and that are con-
sidered practically and ethically acceptable by carers
and people with dementia.
ACKNOWLEDGMENT
None.
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... 11,12 Persons with Dementia (PwD) on antipsychotic treatment or who had comorbid depression, psychosis, or externalizing behaviors like arguing and threatening were more likely to wander. [13][14][15] The causes of wandering are elusive, though hypotheses have been proposed ranging from biomedical to biopsychosocial to person-environment interactions. 14 This includes the following: 1. ...
... 14,18 3. Wandering can be a result of person-environment interaction. 14,18,19 Other reasons can be the unfamiliar environment to the patient, recent medication changes, the severity of cognitive decline, changes in schedule, and loss while searching for things in need. 19 These are all the most important aspects of wandering as finding. ...
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... It is also rightfully suggested for senior institutional authorities and members of the society to take responsibility of at least ensuring admissions of those people who may be found wandering and in need of help. Rehabilitation of lonely patients of dementia calls for the attention, sensitivity and responsible action of institutional authorities and individuals in order to meet the needs of those may not be able to garner support otherwise (Cipriani et al., 2014). ...
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Objective: To define gender differences in noncognitive behavioral problems of patients with AD and differences in the associated treatment of those problems. Design/Methods: We performed an observational study using the Systematic Assessment and Geriatric drug use via Epidemiology (SAGE) database, which contains data collected with the Minimum Data Set on a cross- section of nursing home residents in five US states. Behavior problems were documented at the first assessment of 28,367 residents with AD. We evaluated the role of gender differences in behavior as predictors of differences in nonpharmacologic versus specific pharmacologic therapies with psychoactive medications using logistic regression. Results: Men were more likely than women to exhibit behavior problems such as wandering, abusiveness, and social impropriety (59% versus 50% for any behavior problem). Hallucinations and delusions as well as depression were equally prevalent in men and women. Nevertheless, men were more likely to receive psychoactive medications. Among the specific drug categories examined, and controlling for age and degree of cognitive impairment, men were more likely to receive antipsychotic drugs and less likely to be receiving antidepressants. Conclusion: Gender appears to play an important role in determining the frequency of behavioral problems in nursing home residents with AD, which may influence choice of treatments as well as the decision whether to treat. The use of more potent tranquilizers in men with problem behaviors has potential implications for morbidity, deserving further investigation.