Facilities that care for our aging family members have a great responsibility in assuring these loved ones are safe every moment of the day. One of the most challenging, life-threatening issues related to this care is in patients with cognitive loss and the occurrence of wandering, wherein the person strays into unsafe territories and may be harmed. The most dangerous form of wandering is an elopement through which the confused person leaves a secure area and does not return. The risk of wandering has become a growing concern of families, long-term care facilities, regulators and insurers. In addition to liability, care providers can be fined by a state regulatory agency for failure to prevent elopement. The effects upon those being cared for as well as the staff are no less traumatic. The sense of security is severely shaken and both patient and their families, and staff morale as well as the organization’s reputation sustains a devastating blow. Once we begin to understand “wandering” and the issues as they relate to patients and staff, we can then begin taking proper steps to ensure a safe and positive environment in which care can be successfully provided.
By definition wandering is: a meandering, aimless or repetitive locomotion that exposes a person to harm; frequently incongruent with boundaries, limits, or obstacles (The North American Nursing Diagnosis Association, NANDA). Common behavioral problems of a wanderer involve cognitive impairment displaying sign of difficulty in abstract thinking, language, judgement and spatial skills. Excessive pacing and/or increased motor activity can also be associated with this individual. If such patients are in an environment that is not supervised or in an area that is unnoticeable, they are in danger of entering harm’s way and ultimately at rick of an elopement.
There are many factors that cause a person in this condition to wander and potentially elope. Those who suffer from dementia experience the severe anxiety that is associated with not knowing where they are, what they are supposed to be doing, who the people are around them and perhaps not even their own name. Many institutionalized as well as community-dwelling persons, who experience this disorientation and memory loss, spend their time wandering in search of answers. Their fear is often compounded by the frustrating inability to express their feelings and needs, which provides further desire to leave (elope) in search of a more secure and meaningful place. Research shows that a physical environment that has adequate lighting, low noise levels and sufficient space to ambulate provides a positive outlet for this person. However, this requires much supervision, environmental modification, and individualized and group plans for communication approaches, exercise and activities.
All of this can be very challenging. There is no sole solution for providing the best care for these particular individuals. However, we do know that a multi-faceted approach to environmental modification is an important and necessary part of the process. Preventing a possible elopement, or potential injury, as well as creating a sense of well-being for the residents while diminishing stress for staff and administration can be a reality. Instead of preventing movement within the facility, provide a safe means by which the individual can feel a sense of comfort and familiarity. This can be achieved by creating safe walking areas that are well lit with quiet lounges that provide a place to stop and rest. Camouflaging exits could be an option. Utilizing tape to create a grid-like pattern on the floor in front of exits and restricted areas can act as a deterrent for exit-seeking behavior.
A basic and common safety intervention is the use of a wandering resident system that will safety lock doors and notify staff of a possible elopement. Many facilities employ locked or semi-locked doors to prevent the confused person from leaving the unit or facility where they are monitored. Semi-locked doors contain entry mechanisms that require cognitive skills that exceed those of most persons who wander. Electronic tagging is a system used to track residents who wander. The device may be a bracelet or may be a small lightweight device that is placed on a buckle, watch, or sewn into a piece of clothing. The doors may lock or an alarm may sound when a resident attempts to exit a door or enter a certain area. The alarm may sound at the site or a distant site that is monitored. Notification to staff by a pager, two-way radio or smart device can also be utilized. Video camera surveillance is another approach, albeit expensive. Door alarms are the most commonly used physical intervention, but can be unreliable due to staff not responding or turning the alarm off. Monitoring devices can assist the staff, but they are not fail-proof and should only be used to enhance the current careful supervision of staff.
It is estimated that 50 percent of all people over age 85 have Alzheimer’s dementia. Approximately half of all nursing home residents suffer from some form of dementia, most commonly Alzheimer’s disease. Wandering is most often associated with Alzheimer’s dementia, usually occurring two to four years after the onset of the disease. Statistics indicate that in the United States, more than 34,000 Alzheimer patients wander out of their homes or care facilities each year. Studies vary on the prevalence of wandering in institutionalized dementia patients, but is estimated that 11 % to 24 % wander. Injury or death due to unsafe wandering and/or elopement is a tragedy that requires an incisive evaluation to determine the merits as well as potential culpability of the care provider. The expected outcome of care and services is both prevention of harm as well as maximum function and dignity. The standards of care are very clear: assess risk, identify and respond to risk, assess related needs, provide care to meet needs while promoting health and safety, and evaluate the plan and revise as needed. Facilities may provide such care, consistent with standards and still have less than desirable effects. Our role is to simply assist you in providing effective, cost efficient system solutions that will enable you to achieve the highest standards possible for those that have entrusted you with their care.
