Who's watching the wanderers?

CNAs must be well trained for their critical role in dementia care

MARY, AN 81-YEAR-OLD RESIDENT OF YOUR FACIUTY'S ALZHEIMER'S unit, wanders aimlessly up and down the hail, ambling slowly, peering into other resident rooms. She enters rooms, rummages through drawers, helps herself to a few clothing items, goes back into the hall, and continues her aimless wandering as she chats with other residents along the way.

John, a 79-year-old, tries to open every closed door that he sees and attempts to get on the elevator several times. "I need to get out of here," he says frantically. "I have to get to my office." These attempts happen numerous times during the day.

How well have you prepared your CNAs to respond to such situations?

Because CNAs provide 80 to 90 percent of resident care, they are the ones most likely to encounter these situations and need to deal with them appropriately. They need to have a reasonable understanding of what the resident's behavior is communicating. They must know what types of wandering behavior are potentially harmful to the resident or others. And they must have training in skills needed to divert the resident into other courses of action.

Learning how to care for residents with cognitive impairment is a required component of the CNA training program. For any CNA who works with the cognitively impaired, the annual 12 hours of in-service education must include additional content on this specialized care.

The Alzheimer's Association estimates that 4 million Americans have Alzheimer's disease; there may be 14 million by 2050 if a cure or prevention is not found. Wandering occurs in 60 percent of these persons, according to Association estimates. Many of them will be in the nursing home setting where they will require highly skilled care from a workforce already in crisis due to staff shortages and low pay.

VIGILANCE FROM DAY ONE

The CNA's monitoring of the resident for wandering characteristics begins upon admission. Information obtained from the family regarding prior wandering patterns should be shared with the CNA, who must then observe to determine what events may trigger the wandering behavior. What is learned during staff observations will help to develop individualized care approaches.

Joan Fopma-Loy, writing in the Journal of Psychosocial Nursing (1988), suggests looking for triggers in the environment. [1] Does wandering happen at certain times of the day--for example, late afternoon or evening--when staff are busier and less available to relieve the resident's anxieties? What relationship does wandering have to daily events such as mealtime, activities, or bathing? The wandering may occur more often with changes in the weather. And the CNA should be alert to what the destination, mood, and nonverbal behavior may be communicating about the resident's motivation.

FOUR CATEGORIES

Once this information has been gathered, caregivers may be able to more specifically characterize the wandering and determine the extent to which it may be injurious to the resident or others. In Geriatric Nursing (September/October 1991), Butler and Barnett wrote that all wandering fits into one of four categories--purposeful, aimless, escapist, and critical. [2]

Purposeful wandering occurs when a resident walks with an apparent intent such as exercising, passing the time of day, or relieving boredom. The resident knows his location, and the wandering is not a problem unless he infringes on others' rights or requires excessive amounts of staff time to locate.

Butler and Barnett define the aimless wanderer as one who is "disoriented" and "moves about purposelessly looking for some unknown location." This wanderer is the one more likely to be rummaging through others' belongings. Suggested treatment strategies include placing shields over doorknobs, masking environmental sounds at night, and identifying the time of wandering so interventions may be specifically targeted toward those times.

The escapist wanderer is one who makes a conscious attempt to get to another location--such as returning home. He may leave undetected, hurrying to his destination. Knowing the resident's intentions will facilitate staff monitoring of the escapist.

"Critical wandering is the most dangerous form of wandering and has been linked to out-of-facility deaths," say the authors. This resident neither knows where he is nor understands the ramifications of his actions. Butler and Barnett suggest using identification bracelets and electronic monitoring for escapist and critical wanderers. They emphasize the importance of all staff being familiar with the facility's protocols for locating missing wanderers.

COMPOUND DEFICITS

The CNA should be aware of how neurocognitive deficits affect wandering because these will influence monitoring and treatment strategies. These deficits are described in the Journal of Gerontological Nursing (September 1999) by Donna Algase, PhD, associate professor at the University of Michigan School of Nursing. [3]

Algase says that because wanderers with memory and attention deficits may be unable to keep the destination in mind, they forget where they are going. Having possible destinations close and clearly visible (bathrooms, for example) and minimizing distractions by other stimuli along the way can be effective.

The wanderer with visual-spatial deficits may know where he wants to go but doesn't know how to get there. Algase suggests that this resident will benefit from having bathrooms, dining rooms, and other destination points clearly marked, or by being escorted or directed to the desired location.

If expressive-language deficits are present, the wanderer will probably have difficulty verbalizing needs, desires, or intentions, says Algase. She suggests anticipating their needs and intentions when ambulating or involving them in one-on-one activities.

Some wanderers may suffer from excessive motor-activity deficits. This causes them to "be more driven to walk than they would prefer if they could choose," says Algase, who suggests that alternative activities may be an effective treatment choice for this person.

FALLS AND WEIGHT LOSS

The wanderer is at higher risk for falls, and especially so in the first few weeks following admission. The CNA must constantly monitor the environment for hazards. Furniture and carts in hallways, wet floors, loose carpet, footwear with smooth soles, bare or stocking-clad feet, and not wearing prescribed eyeglasses or hearing aids are all conducive to falling. (See "They all fall down," April 2001 CLTC, page 38.)

Residents who wander are also more vulnerable to weight loss because of calories used during wandering. Close monitoring of weights, frequent offering of snacks, and regular dietary consults are important.

The CNA's use of appropriate communication techniques is very important in the monitoring and redirecting process. These include using short, simple questions with limited choices, breaking down tasks into simple steps, and repeating as necessary. Drawings and photographs give visual cues; this helps in finding one's own room, bathrooms, and activity areas.

Staff behavior and environmental distractions can exacerbate agitation in residents, who seem to sense frustration and anger, and do not respond well to being hurried. The CNA needs to be patient and use a quiet, soothing voice. Reducing the noise and sense of "busyness" on the unit is important in creating the appropriate environment for the resident who has difficulty making sense of sights and sounds.

TECHNOLOGY FOR MONITORING

Various technologies are available to assist with monitoring. Some simplified systems alarm a variety of doors; to avoid an alarm going off whenever the door is opened, the system must be decoded first. (It may or may not need resetting to re-alarm on the next opening.) The resident cannot comprehend the decoding process, and his exiting through the door will set off the alarm.

In some systems, residents wear a personal device, such as a pendant or bracelet, that triggers an alarm when the wearer approaches or opens a door. Other devices may cause a door to lock when the resident approaches it.

Occasionally, residents object to wearing a device and remove it. Disguising it as a watch face or a piece of jewelry may help. In one facility, a resident consistently removed the device no matter where it was attached. But when staff removed the wrist straps, attached a pin back, and decorated it with sequins and pearls, the resident--who loved ornate costume jewelry--proudly wore the device on her sweater with no further attempts at removing it.

In addition to alerting a central monitor or nurse-call unit, some systems communicate directly with pagers or wireless phones carried by staff. This has the advantage of notifying staff wherever they may be. Some systems can be set up to default to a series of pagers in the event of delayed staff response. Software that tracks monitor activation and staff response can assist the facility in its quality-assurance program.

Personal motion monitors may be used at night to signal when a potential wanderer is getting out of bed. These monitors sound an alarm when detached from clothing or activate a call light when a resident leans on a sensor pad while sitting up. These devices may not be advisable during the day, when the resident should be ambulatory.

When selecting monitoring technology, be aware that alarms may over-stimulate a population already having difficulty interpreting the environment. The noise may also heighten stress for staff members. Newer technology is more dependent on silent notification through pagers and less dependent on unpleasant sounds.

REGISTERING WANDERERS

Some facilities have adopted the Alzheimer's Association's Safe Return program to assist in a search for wanderers. "Numerous nursing homes across the country require wanderers to be registered for the program upon admission," says Brian Hance, director of Safe Return. "Then the program's services are available in the event a wanderer leaves the facility or escapes from staff or family during physician or home visits or other activities."

For a one-time fee of $40, the program provides identification (wallet cards, bracelets or neck pendants, clothing labels); a national photo and information database; a 24-hour toll-free emergency crisis line; local chapter support; and education and training for caregivers and family. Anyone finding a wanderer notifies the Safe Return operator. If a wanderer is reported missing, Safe Return supplies the local law-enforcement agency with database information and a photograph. Since Safe Return was initiated in 1993, 72,000 persons have joined the program. According to Hance, "Safe Return has helped locate and return more than 5,900 persons to families or caregivers."

The CNA's role in monitoring the wandering resident is frequently frustrating, occasionally exhausting, and always challenging. But providing the caregiver with ongoing and appropriate training in monitoring and interventions--and providing adequate technological support--will make a difference in maintaining the resident in a safe and secure environment.

References

(1.) Fopma-Loy J. Wandering: Causes, consequences and care. J Psychosoc Nurs Ment Health Serv. 1988;26(5):8-18.

(2.) Butler J Barnett C. Window of Wandering. Geriatr Nurs. 1991;Sep/Oct: 226-227.

(3.) Algase D. Wandering: A dementia-compromised behavior. J Gerontol Nurs. September 1999, 25(9):10-16.