Out for a walk.Can wandering be redirected into positive activity? Here's how to quell quell
tr.v. quelled, quell·ing, quells
1. To put down forcibly; suppress: Police quelled the riot.
2. the wanderlust
IS WANDERING JUST A SYMPTOM OF DEMENTIA, or is it also symptomatic of providers' limitations?
The driving force that urges people with dementia onward often overcomes family caregivers' reluctance to seek institutional care. Before OBRA, it drove providers to chemical and physical restraints. Now it drives the installation of locks, gates, barriers, alarms, gardens, and walkways. When they fail, fatally, it's driven juries to award multimillion-dollar verdicts.
There's no simple solution, nor is there even consensus about naming it. Most providers call it wandering--and a major problem. The relentless back-and-forth can drive staff and other residents to distraction. It increases risk of falls, fractures, dehydration dehydration
Method of food preservation in which moisture (primarily water) is removed. Dehydration inhibits the growth of microorganisms and often reduces the bulk of food. , hypothermia hypothermia
Abnormally low body temperature, with slowing of physiological activity. It is artificially induced (usually with ice baths) for certain surgical procedures and cancer treatments. , hospitalizations, and death. And when residents get out (elope e·lope
intr.v. e·loped, e·lop·ing, e·lopes
1. To run away with a lover, especially with the intention of getting married.
2. To run away; abscond. ), but can't or won't return, it jeopardizes their safety as well as providers' reputations and revenues. One 1993 study (D. Kennedy, Security Journal, October) estimated one resident death weekly after eloping; another noted 70 percent of elopement Elopement
with Dombey’s wife. [Br. Lit.: Dombey and Son]
with Alvaro, rejected as suitor by her father. [Ital. claims involved deaths. Who's at risk? Any client, say experts, because inability to return is a first sign of mental impairment; any provider, say attorneys, because accepting a client implies a promise to provide care.
"When a resident not deemed capable of self-preservation departs undetected or unsupervised, it's almost always a violation of the standard of care," says Boston trial lawyer George Field of Field & Roos, LLP LLP - Lower Layer Protocol . "Day care, assisted living as·sist·ed living
A living arrangement in which people with special needs, especially older people with disabilities, reside in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication. , and other facilities' solicitations mention security, supervision, and safe environments. That assumption of responsibility carries a duty."
So many residents elope that his firm established a sub-specialty to handle plaintiff's cases. "Research shows that around 50 percent of Alzheimer's patients wander or elope, and 20 percent of nursing home residents wander into unsafe situations," says Field. "I'd be happier without these cases. Facilities can put in place very productive measures, and enroll residents in the Alzheimer's Association's Safe Return. If facilities do cost-benefit analyses, they'll conclude they're worthwhile investments."
Providers are rethinking design, staffing, and programming, putting themselves figuratively fig·u·ra·tive
a. Based on or making use of figures of speech; metaphorical: figurative language.
b. Containing many figures of speech; ornate.
2. into residents' shoes. But the first step is considering their own.
Walking in wandering shoes
Whether you wear whites or wingtips, you probably cover many miles: managing by walking around, running to meetings, even performing strenuous activity. You may pace to ponder problems. Seeking food or friendship, you go "out" to eat, even if it's to only the facility lounge. Eventually, your inner clock pushes you home, perhaps to care for kids, partners, or pets. To burn or gain energy, you may work out at the gym. Frustrated frus·trate
tr.v. frus·trat·ed, frus·trat·ing, frus·trates
a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: or bored, you might seek new scenery. Chores done, you may stroll over to neighbors, or through favorite shops.
What if you suddenly lost your memory? You'd look for someone or something to explain who you are. You'd search for your home, try to go where you belong. You might agonize about those left behind or work left undone. (Ever have nightmares about forgetting to finish homework?) And you'd panic if you couldn't get out of the small, strange, frightening place where you're trapped.
Even after "adjusting," you'd long for freedom to move around, the stimulation of change, stress release outlets, the comfort of someone who cares, the chance to do something you enjoy, the food you like, a way to connect. How can you sit and do nothing? Why should you? So you'd walk, and search--and they'd call it wandering.
"Colleagues call it sightseeing, but I prefer 'exploring,'" says Joanne Koenig-Coste, MEd, president, Alzheimer Consulting Associates, Framingham, Mass. "It's an effort to see something different, or seek emotional safety. You have to understand messages behind the behavior."
Some people flee Alzheimer's itself. In her young patients' support group, Koenig-Coste says she has a working man who says he keeps moving to get ahead of dementia. "Most people with Alzheimer's can't articulate or reason through feelings," she says. "We think of it as a disease of behaviors. It's actually a disease of emotions."
Residents rattle locked doors because they don't feel safe, not necessarily to escape, she says. "Instead of making the place secure, make the resident feel secure," she advises. She recommends providing safe places to explore, camouflaging exits (with painting or wallpaper), color-coding units, putting pictures and colors on ceilings, and providing distinctive personal room colors that become reassuringly familiar, enabling residents to find familiar havens that feel safe.
Wandering, or walking, though difficult to deal with, is not necessarily a problem to be fixed, says psychologist and former nurse Barbara Ensor, PhD, of Baltimore's multi-level Stella Maris Stella Maris (Latin for Star of the Sea) is a title of the Virgin Mary.
Stella Maris may also refer to:
A resident's history often explains behavior. At Stella Maris, the man and woman who go up and down hallways, checking doors and asking if everything is okay are a former night watchman WATCHMAN. An officer in many cities and towns, whose duty it is to watch during the night and take care of the property of the inhabitants.
2. He possesses generally the common law authority of a constable (q.v. and nursing supervisor, still enacting their jobs. At many facilities, women's afternoon agitation, often a reaction to internal alarms prompting them to begin meal preparation and after-school child care, can be relieved by allowing them to set the table or prepare meals.
At one facility, staff repeatedly redirected a new admission who went to the door each evening. One night, the nursing supervisor watched him.
He opened the door, called, "Here, kitty, kitty," then closed it, satisfied. Subsequently, he was allowed to fulfill his longtime responsibility. "Let them complete the behavior uninterrupted, then discuss it with family, so you can see pattern and meaning," says Ensor.
Counsel families so they aren't embarrassed if residents walk away during visits, says Ensor. Explain that it's part of the disease, that it may stop spontaneously, and to walk along.
"Just walking" provides pleasure, she notes. People strolled and chatted in more leisurely times.
Facilities can help by providing conversational bridges. Residents can accompany or push nourishment nour·ish·ment
Something that nourishes; food. carts, handing out items. One resident who accompanied staff delivering mail could say only, 'Good morning. How are you?' but others responded, and it kept her happy for hours, says Ensor.
Maintaining productivity helps use excessive energy that plagues some patients. Giving them dusters, mops, laundry, or rakes, regardless of how well "jobs" are done, focuses drives arising from inactivity. An Australian facility provides washing gear and a well-washed, inoperative Void; not active; ineffectual.
The term inoperative is commonly used to indicate that some force, such as a statute or contract, is no longer in effect and legally binding upon the persons who were to be, or had been, affected by it. , car.
Engaging residents in meaningful activities is eased at St. John's Lutheran Home, Billings, Mont., through "Elder Chabars," pets, and its uncommon ADL philosophy.
Chabars (Hebrew for companion) are specially trained high school and college students who offer conversation and activity. They earn hourly wages plus $1-per-hour scholarships. "We recruited the best and brightest students, who reach out to elders in friendship," says administrator David Trost, vice president of management and outreach services. "They're here during sun-downing-- what better time?"
Trost believes most wandering is searching for past homes and daily life. "if asked what you do at home, you'd say your ADLs are cooking and cleaning, not toileting, transferring, and grooming," says Trost. "It's kind, not cruel, to keep residents busy with the real activities of daily life. Instead of walking 43 feet in physical therapy, they can enjoy walking the dog. You can ask residents if they've washed their bed linens today. It may take three hours to wash, dry, and remake the bed, and you can always do it again. They feel productive, and they're comforted because it feels like home."
Men and women enjoy tasks including gardening, weeding, watering, mowing mow 1
1. The place in a barn where hay, grain, or other feed is stored.
2. A stack of hay or other feed stored in a barn. grass, raking, and pond-skimming, as well as outdoor activity groups at the 527-bed Parker Jewish Institute for Health Care and Rehabilitation rehabilitation: see physical therapy. , New Hyde Park New Hyde Park, village (1990 pop. 9,728), Nassau co., SE N.Y., on Long Island; inc. 1927. It is a residential community with some manufacturing and truck farms. Nearby is the uninc. town of North New Hyde Park (1990 pop. 14,359). , N.Y. "It's nice to get out and do what they used to do," says Martha Wolf, Alzheimer's Center manager. "Space and freedom reduce agitation from feeling penned in, and give a sense of control."
Researchers used the Pittsburgh Agitation Scale to measure behaviors before and after St. John Specialty Care Center, Mars, Pa., opened its $200,000 natural habitat. Increased outdoor access markedly decreased residents' stress and agitation. Larger than half a football field, it includes figure-8 wandering paths, color-coded handrails, herbal garden, activity areas, gazebo gazebo
Lookout in the form of a turret, cupola (small, lanternlike dome), or garden house set on a height to give an extensive view. Few late-18th- and 19th-century rustic gazebos survive, but 17th-century turrets built up in an angle of the garden wall are not uncommon. , walls in lieu of fencing, photosensitive A material that changes when exposed to light. See photoelectric. lighting (until 10 p.m., per resident vote), community concert space, and playground. "Without family, many residents have minimal chances of getting out," says neuropsychologist Neuropsychologist
A clinical psychologist who specializes in assessing psychological status caused by a brain disorder.
Mentioned in: Post-Concussion Syndrome Paul Nussbaum, PhD, neurobehavioral services director. "Playgrounds encourage grandchildren's visits."
Many internal environments, like some gardens, don't fulfill residents' needs, despite their appeal to staff.
"Even after losing other cognitive abilities, people take cues and clues from environments about how to behave," says Cornelia Hodgson, AIA AIA - Application Integration Architecture , of Dorsky, Hodgson + Partners, Cleveland. "Hospital-like environments say something's wrong. But we can also confuse people's sense of reality and cause more disorientation disorientation /dis·or·i·en·ta·tion/ (-or?e-en-ta´shun) the loss of proper bearings, or a state of mental confusion as to time, place, or identity. . Some things are infantile infantile /in·fan·tile/ (in´fin-til) pertaining to an infant or to infancy.
1. Of or relating to infants or infancy.
2. and illogical. My test is, 'Would you have it in your own home?' If not, then why do it?"
Scenic summer murals and cartoon-like, idealized i·de·al·ize
v. i·de·al·ized, i·de·al·iz·ing, i·de·al·iz·es
1. To regard as ideal.
2. To make or envision as ideal.
1. Victorian storefronts are no substitute for natural light, windows, views, and usable activity areas that invite participation. "Frankly, residents are bored. Provide interesting options, like the gift shops, lounges, and coffee shops at hotels, and wandering decreases," she says.
Indoors or out, walkers tire, so include adequate seating along walkways and corridors, she says. Placing tasks at seating areas, such as towels to fold, can also engage residents.
Despite difficulties, some providers see positive aspects to wandering. "Usually, their bowel, bladder, or legs let residents down," says Stella Henry, RN and administrator of the 84-bed Vista del Sol Vista Del Sol is a neighborhood in East El Paso, Texas which is mostly upper-middle class. nursing home and ALF ALF - Algebraic Logic Functional language in Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. . "Walking alone or with staff members helps them to stay ambulatory, sleep better, and socialize so·cial·ize
v. so·cial·ized, so·cial·iz·ing, so·cial·iz·es
1. To place under government or group ownership or control.
2. To make fit for companionship with others; make sociable. with residents in different households,"
Admission, and the change of routine, place, and unfamiliar faces compound anxieties and promote searching for something familiar.
All staff members should view wandering as physical communication, determine what residents want, learn appropriate responses, and help provide activities, say experts. But first, they must know how to introduce themselves and establish positive relationships.
"Most of us are too embarrassed to say we don't remember acquaintances we encounter, so we pretend, and wait for cues," says Walter Hoszkiewicz, NA, Sowerby Consulting Group, Lyndeborough, N.H. "When residents don't recognize you, identify yourself through body language and words as a friend who knows them. Put an arm around them, say, 'Mary, It's Walter. I'm so glad to see you. I've enjoyed our walks,'"
Providers should check the fit of shoes, and be sure they're neither slick nor sticky, he notes. Hearing and visual problems pose additional hazards. Walkers who keep their heads down heads down - [Sun] Concentrating, usually so heavily and for so long that everything outside the focus area is missed. See also hack mode and larval stage, although this mode is hardly confined to fledgling hackers. may bump into others and equipment, failing to hear warning calls. Since they're apt to trip over cords and "Wet Floor" signs, it's better to close areas during cleaning.
Pacing increases nutritional and fluid needs, and the risk of weight loss. When residents are too agitated ag·i·tate
v. ag·i·tat·ed, ag·i·tat·ing, ag·i·tates
1. To cause to move with violence or sudden force.
2. to sit for meals, provide finger foods such as vegetable sticks, fish sticks, and chicken tenders, which they can carry with them.
Residents may be used to walking long distances, particularly if they formerly lacked cars and walked extensively to work or shop.
One resident walked 12 to 16 miles daily when it was all he had to do, says researcher, author, and consultant Maggie Calkins, PhD, of Innovative Designs in Environments for Aging Societies, Kirtland, Ohio Kirtland is a city in Lake County, Ohio, USA. The population was 6,670 at the 2000 census. Kirtland is famous for being the early headquarters of the Latter Day Saint movement. Geography
Kirtland is located at (41.602581, -81. . "There's nothing therapeutic about walking in circles, unless you give goals like charting mileage, or have meaningful destinations," she says. "For radical reductions in 'aimless wandering,' provide familiar domestic, work, and community activities that make meaningful contributions."
Facilities can tap staff interests as resources for residents with lifelong pursuits. For example, Mike Wisniewski, maintenance director at The Arbors of Bedford [N.H.], a 72-bed dementia care AIF AIF Annual Information Form
AIF Apoptosis-Inducing Factor
AIF Agence Intergouvernementale de la Francophonie (French: Intergovernmental Agency for Francophony)
AIF Australian Imperial Force , laces up his running shoes to accompany residents who are avid joggers, providing male camaraderie and supervision.
Dancing, walking clubs, tracks, stairclimbers, and other exercise equipment are appealing, even to residents who lacked prior interest. "Simply being with residents makes walking purposeful and positive," Hoszkiewicz says
Providing exercise, walking, and activity areas outside Alzheimer's units benefits other residents who become agitated by the ceaseless back and forth, sometimes lashing out a striking out; also, extravagance.
See also: Lashing or deliberately tripping walkers who invade their personal space. Staff can accompany several restless residents for a snack, activity, or visit in another part of the building.
Altercations often arise when residents enter rooms of other residents, particularly those who are territorial. To decrease confrontations, staff members should avoid placing territorial residents in rooms at hallway ends, since these are most frequently investigated. Converting at least one end room into a parlor or activity space encourages residents to turn in that direction, particularly when cognitive turning functions are impaired, says Calkins.
Despite the difficulties, one thing is clear: rethinking "wandering" is a positive stride in resident care.
Fort Collins, Colo.-based freelancer Wendy Bonifazi, RN, APR APR
See: Annual Percentage Rate , is a regular contributor to CLTC CLTC Certified in Long-Term Care
CLTC Community Long Term Care
CLTC Chapter Leadership Training Conference .
When residents wander
The following six steps should be your guide to when residents are thought to be missing because of wandering:
1. Notify staff Immediately; search the vicinity thoroughly. Do NOT wait for end of meals, shifts, etc.
2. Notify 911 and the police within 15 minutes; earlier, if hazardous conditions exist, (such as traffic, water, woods, inadequate clothing, life-threatening illness, darkness, or inclement in·clem·ent
1. Stormy: inclement weather.
2. Showing no clemency; unmerciful.
in·clem weather). "Clearly state the missing person is at risk, confused, and endangered because of Alzheimer's and memory impairment," says Gerald Flaherty, Massachusetts Alzheimer's Association The Alzheimer's Association, incorportated on April 10, 1980 as the Alzheimer’s Disease and Related Disorders Association, Inc., is a non-profit American voluntary health organization which focuses on care, support and research for Alzheimer's disease. special projects director. Identify your police contact Notify family.
3. Call Safe Return's emergency line (800-572-1122), which faxes alerts to local media, hospitals, shelters, etc.
4. Notify media if the person has a life-threatening illness, it's dark, or weather is severe. They can help-and they'll hear from police, anyway.
5. When a resident is found, avoid confrontation and questions that may cause further flight Approach from the front, hold the visual focus, be calm and reassuring, use the person's name, and mention something specific that he or she enjoys, advises Flaherty.
6. Notify police, family, Safe Return, and others.
Lost and found: Safe return
Providers obviously need to purchase and maintain adequate and appropriate security systems. But even with the best of buzzers, locks, bells, mats, staff, and programs, residents get lost, including those not considered at risk.
"There's no precursor preliminary level of wandering, so people don't see the danger," notes Martha Wolf, Alzheimer's Center manager, Parker Jewish Institute for Health Care and Rehabilitation, New Hyde Park, N.Y.
Search and rescue organizations generally find lost people with dementia within 1.5 miles, usually 100 yards from roads or open fields. Typically, they "go until they get stuck" by manmade or natural barriers such as fences, walls, and waterways. Cognitively impaired people often fall into creeks, lakes, and ditches; they tend to crawl into thick brash brash (brash) heartburn.
water brash heartburn with regurgitation of sour fluid or almost tasteless saliva into the mouth. and briars. Rescuer and researcher Robert Koester found that 67 percent cross roads, and only 1 percent answer rescuers' calls. Injuries and fatalities often occur after 12 hours.
Since opening five years ago, The Wealshire, a 144-bed sheltered, intermediate and skilled dementia facility in Lincolnshire, Ill., has required families to pay $25 toward enrollment in the national Safe Return program, which provides an identification number and toll-free number on clothing labels, cards, and engraved en·grave
tr.v. en·graved, en·grav·ing, en·graves
1. To carve, cut, or etch into a material: engraved the champion's name on the trophy.
2. bracelets. The Wealshire covers the $15 balance and any replacements.
It's never needed the program's help returning or finding wanderers, nor has the 122-bed Celina [Ohio] Manor. But every admission to its dementia units gets an ankle alarm and Safe Return registration, compliments of the facility. "We know they can get lost, so we wanted to take every avenue to protect residents and help families, whether they remain here or move on," says administrator Noreen Schwieterman.
Despite keypads, bolts, hourly checks, extensive activities, and community excursions, residents can escape, says Sally Staggert, community services director at Franciscan Health Community, St. Paul St. Paul
as a missionary he fearlessly confronts the “perils of waters, of robbers, in the city, in the wilderness.” [N.T.: II Cor. 11:26]
See : Bravery , Minn., making careful screening essential. "'Marketeers' try to fill beds at all costs," she says. "It's crazy to put somebody at risk."
Man versus machine
After handling more than 750 lost patient cases, Gerald Flaherty, Massachusetts Alzheimer's Association special projects director, is appalled when providers let dementia patients go out alone.
"Supervision is better than any alarm or technology," he says. "Believing residents can find their way back is a major misconception. Research indicates getting lost is as common as memory loss, and may occur earlier. Often they haven't wandered before because they were watched." At the least, he advises, time customary walks and implement searches when residents deviate.
People with dementia go into extraordinary places, including creeks and ditches, because they don't perceive danger, Flaherty explains. Sudden noise, traffic, or confusion can trigger catastrophic reactions cat·a·stroph·ic reaction
Disorganized behavior due to a severe shock or threatening situation with which the person cannot cope. that send panicked patients crawling off-track to hide in bushes or grasses. They're frequently too afraid to answer searchers' calls. If they experience "paradoxical undressing Paradoxical undressing is the removal of clothes, blankets, or other coverings by those suffering severe hypothermia. This behavior is not fully understood, but may relate either to a malfunction in the hypothalamus, or to the exhaustion and subsequent relaxation of muscles which " in cold weather (when core body temperature falls to a critical level peripheral vasoconstriction vasoconstriction /vaso·con·stric·tion/ (-kon-strik´shun) decrease in the caliber of blood vessels.vasoconstric´tive
n. fails; the resulting sudden vasodilation vasodilation /vaso·di·la·tion/ (-di-la´shun)
1. increase in caliber of blood vessels.
2. a state of increased caliber of blood vessels. could lead to an exaggerated sensation of heat and a consequent attempt by the victim to undress), hypothermia can occur in 30 minutes.  Since police may not understand dementia behaviors and search techniques, the nationwide Safe Return program, originated by New York's Alzheimer's Association, provides training and guidance for night searches and special trackers including ground-and air-sniffing dogs.
"Trying to resolve it yourself is a big mistake," he cautions "Spending more than 15 minutes before calling Police puts people at risk."
Here are some tips recommended by the experts.
* Keep recent photos of each resident; provide copies for local police files.
* Record locations of former homes, work, worship, relatives, shopping, restaurants, adult/childhood recreation, prior wandering patterns.
* Register residents in the national Safe Return program (Information: 800-548-2111).
* Call local Alzheimer's Association for information/training on prevention, search and rescue.
* Implement policies, procedures and full-staff training.
(1.) Wedin B, Vanggaard L, Hirvonen J. "Paradoxical undressing" in fatal hypothermia, J Forensic Sci 1979; 24:543-53.