Why residents wander--and what you can do about it. (Feature Article).

Few events stop long-term care staff and administrators in their tracks more quickly than discovering a resident with dementia has left their facility unescorted. No one wants to think of the people in their care shivering in the cold--afraid, alone, and very possibly in harm's way. Many effective technologies and strategies have been developed to prevent wandering and elopement. Which of these tools and methods work best? Nursing Homes/Long Term Care Management asked Bettye Rose Connell, PhD, a health research scientist with the Rehabilitation Research & Development Center at the Atlanta VA Medical Center, to share her expert views.

What design elements can be put in place in Long-term care facilities to discourage resident elopement?

Dr. Connell: First, let me emphasize that no single approach by itself is likely to work for all residents at risk. Then, how effective design elements or any other measures are at discouraging elopement depends on several factors. First, we must keep in mind what wandering and elopement are. Wandering is not a single behavior. There are several types of "wanderers"--people who have dementia and who are moving around for a variety of reasons. Some people with dementia pace endlessly in a way that may seem aimless, while others seem to be looking for something or someone, past or present. Then there are the people who are simply disoriented--for example, a woman who is trying to get to her room but can't find her way. She knows where she's trying to go, but she's lost. Her situation is different from that of the man who says he's "going to his car to look for his wife" when, in reality, his wife has been gone for years. All these different behavior patterns are called wandering and can occur with dementia.

Elopement, or as I'd prefer to call it, "unescorted exiting," isn't wandering, per se, although it can be an endpoint of wandering. It generally happens when a resident is looking for something or someone and happens to go outside in the process, or when a person with dementia is reenacting old behavior patterns--for example, saying, "It's time to go home from work now."

It's also important to remember that not everyone who leaves is really trying to get out of the facility. In fact, some residents simply happen to arrive at a door when a visitor is coming in and take the opportunity to walk out--and often the visitor graciously holds the door open!

My point is that wandering is a complex challenge, and there's no "one size fits all" solution for it. For example, an alarm system, even an excellent alarm system, by itselfwon't prevent wandering. Having a gorgeous outdoor wandering path won't do it. It requires a multidimensional approach that must involve programming and take into account staff practices, as well.

The kinds of environments that work well for people with dementia are those that present cognitive demands they can handle. For example, more open layouts and shorter or no hallways allow people to see where they are going, rather than having to recall a route to an out-of-sight destination. However, more open layouts are potentially noisier, so they are more feasible for a small, low-occupancy unit than a larger unit where a high proportion of the residents have dementia. It's also a layout you are unlikely to see undertaken as a renovation in an older facility whose long hallways define its layout.

When exits off the unit are located so that residents have to pass a location that is usually staffed, it is more likely they will be observed before they have a chance to leave. Travel routes that may look much the same to residents--such as three similar hallways leading to resident rooms from a commonly used space like a lounge--can be made more distinctive by adding readily visible landmarks. This makes it easier for residents to use their preserved abilities to find their way around.

There also is technology that can be incorporated into a facility's design, both in new construction and remodeling, to help keep residents with dementia from exiting a facility. Alarm systems are one helpful tool for alerting staff that someone is leaving or appears to be attempting to leave. The simplest exit alarms work like those devices clipped on clothing in department stores to prevent shoplifting. Residents wear tags, and if they go within a certain distance of the part of the system that can detect the tag, usually placed at doors, an alarm goes off. With the more sophisticated systems, the alarm sounds at the nurses' desk, rather than setting off a loud siren at the door, and some systems can send a message to staff pagers. Some alarm systems can be configured to operate differently during the day than at night.

A word of caution about alarms: Facilities need to communicate to alarm installers what staffs and residents' daily routine is (or will be, in new construction), so that the setup of alarm perimeters doesn't interfere. For example, I was recently in a new facility with an off-unit central dining room where the alarm system layout was planned without thinking through resident movement at mealtime. It turned out that there was no way to easily override the alarm temporarily, and all residents with alarm-system tags who went to the central dining area for meals had to go through the perimeter of the alarm system, setting it off. These false alarms are annoying to staff and expose the residents to unnecessary, meaningless noise. Worse yet, if there are too many false alarms, staff may start to ignore them. So make sure you communicate with installers.

Electromagnetic door-locking systems are available as part of many alarm systems for use when there is an exit you think is particularly hazardous--for example a stairwell door or an exit that opens close to a busy street. In addition to alerting staff, the door locks when a resident with a wanderer-system tag approaches and unlocks when the resident moves away. The locks are tied into life-safety systems so that a fire alarm will override the locking mechanism, ensuring that everyone can safely exit in the event of an emergency.

It is important to remember that no matter how good the technology or design, preventing unwanted exiting involves more than technology: It is affected by staff practices and must also involve programming.

Can you share an example of how staff practices might negatively affect wandering or unwanted exiting?

Dr. Connell: I've been in facilities where an exit to the outside happens to be a popular shortcut that staff members, and sometimes visitors, take to the parking lot, especially in bad weather. If residents see people going out that door all day, it is more likely they will recognize the door as an exit and try to go out, too. If this situation develops, the administrator needs to explain to staff and guests that saving a few steps is hardly worth risking the departure of a cognitively impaired resident.

Could you describe some programs that are helpful for deterring wandering and unwanted exiting?

Dr. Connell: Activities can help to redirect residents' attention away from the areas around exit doors. If part of what wandering is about is seeking stimulation that is meaningful to the individual, as some researchers believe, then it's good to stage activities, away from exits, that will attract and hold residents' attention--such as the smell of baking bread or the sound of period music.

We have to remember that no one approach works with everyone. A "pacer" might not be distracted by the smell of baking bread, but the person who is wandering because she's bored might follow her nose to the fragrant smell of something baking in the oven, or she might follow her ears to the sounds of swing music wafting down the hall.

Also keep in mind that the specifics involved in redirecting attention are somewhat facility-specific. For example, if most residents in your facility are women who were housewives, the activities that will appeal to them may be different from what will attract men who've had jobs outside the home.

How effective are such strategies as "disguising" exit doors to discourage residents from using them to go outside?

Dr. Connell: I'd be careful about using the word "disguise," because fire codes generally prohibit obscuring exits that are designated as fire exits. You can take measures to make these doors look less obvious to residents with dementia, but still make them readily visible to staff and others responsible for evacuating residents in the event of an emergency. For example, some facilities paint the door and trim and surrounding walls the same color.

It makes good sense, by the way, to work with your local fire officials in addressing these issues. They don't necessarily know a lot about your concerns regarding exiting, but when you help them understand what you're trying to do, you may be able to reach a mutually satisfactory solution.

Another thing I've seen done in new construction is placing exit doors on a side wall of a hallway, instead of at the end of a hall. In this configuration, the door is parallel to a resident's route of travel instead of perpendicular to it, and therefore it's less noticeable. Of course the fire code still requires a fire-exit sign above the door if it's a fire exit, which calls attention to it, but this approach might help somewhat.

All these things we've talked about--layouts and other design elements that make it easier for residents to find destinations, alarms, automatic door locks, redirecting residents' attention, making fire-exit doors less conspicuous--can help curtail unwanted exiting. But I must re-emphasize: Facilities relying upon one design solution will be disappointed. No single approach is enough, but despite that fact, I've often seen organizations lulled into thinking it is.

How much does signage help residents who tend to become disoriented?

Dr. Gonnell: For some residents, user-friendly signage can be quite helpful. You want signage that is very literal, is placed where residents are likely to see it, and uses colors and letter sizes that are easy for older people to see. You have to remember that not all residents wander because they're disoriented and not all who are disoriented will be able to comprehend signage, so signage won't help them all, but it can help reorient some of them.

What would you consider ideal in terms of the design/Layout of protected outdoor space for residents with dementia?

Dr. Connell: Several years ago we conducted a couple of small studies to examine residents' use of outdoor space. Based on earlier work we had done with elopement, we initially presumed that even if there were no staff to take residents outdoors, they would go out on their own if they had easy access to an outdoor space. Instead, we found that "if you build it they will come" is not a model that works with this population. Given the problems many residents with dementia have in initiating and sequencing tasks, it really should not have surprised us how seldom we observed residents with dementia going outside to wandering gardens and such on their own. I am no longer surprised at how often I hear about lovely, but underused, outdoor spaces. No matter how nice the space is, some level of programming must be in place to encourage and help many residents go outside and to provide at least some minimal structure for time spent there--whether that involves activities staff, volunteers, or nurses.

Another question that should be considered is how does the facility envision the outdoor space being used? In answering this, you have to keep in mind that some residents will be happy just to sit in the sun; others will enjoy walking and smelling the outdoor fragrances. Some will go out to participate in group activities, and others will prefer to be alone. There need to be sunny areas and shady areas, and you'll need a safe walking/rolling surface (that remains safe under various weather conditions) and places for people to sit, either alone or in groups. You need to provide for a variety of preferences and uses.

As is true of indoor activities, activities intended for the outdoor space need to be tailored to your residents' interests and backgrounds. Growing corn and tomatoes might be a more familiar and appealing activity for residents from a rural, farming area than those who spent their lives living in a city'.

Some researchers believe there's a correlation between agitation and wandering. What are some environmental "triggers" to these behaviors that can be avoided?

Dr. Connell: Aggression, verbal agitation, and physical agitation are all considered indicators of behavior disturbance. Wandering is one of the behaviors that falls under physical agitation. The general thinking is that people with dementia have limited ability to cope with environmental stressors or stimulation that is not particularly meaningful to them; they simply can't tolerate as much of this kind of stimulation as others, and one response is agitation, whether verbal or physical.

Stressors for this population come from being in situations where they experience aversive stimuli or more stimuli than they can process, such as the sounds of overhead paging or being in the presence of a large group of people who are all talking. Part of a multidimensional approach to wandering prevention is to eliminate meaningless stressors, as well as enhancing sources of stimulation that are meaningful. Some routines, for example, may unintentionally produce stress for residents. Bathing facilities, for example, can smell of disinfectant, and the hard surfaces can magnify noise, adding to other problems with bathing routines that make them unpleasant experiences that can trigger and escalate a whole family of behavioral problems, including wandering and actual attempts to leave the facility. I've had staff tell me that they were sure Mr. X hadleft because he knew it was time for his bath.

The ambient environment is another, major, source of stressors. If one resident is upset, calling out, and not receiving attention from staff, she may trigger agitation in her roommate or the person in the next room.

Ironically, good intentions about preventing wandering can, themselves, introduce aversive stimuli--such things as auditory wandering alarms. With the new technology available today, 100-decibel door alarms and loud paging systems really aren't necessary.

To sum up, what do you consider the most important thing for facilities to remember when dealing with wandering or unwanted exiting?

Dr. Connell: Trying to solve this complex problem with a single simple solution will not work. Wandering is not something you can simply foist off on technology and facility design. You must remember that staff and programming play important roles in wandering prevention. And it makes good sense to combine whatever tools and methods you have at your disposal in a comprehensive program to keep residents safe.

Bettye Rose Connell, PhD, is a health research scientist with the Rehabilitation Research & Development Center, at the Atlanta VA Medical Center. Her major area of research is the relationship between the nursing home environment and the behavior, functioning, and quality of Life of residents, particularly those with dementia. For more information, call [phone], ext. 6798, or e-mail [e-mail]. To comment, e-mail [e-mail].