Preventing Wanderlust in Patients
AN 81-YEAR-OLD WOMAN WITH DEMENTIA, who wandered away from the Napierville, Ohio, rehab center where she lived, was later found injured at a nearby strip mall. In another case, an elderly resident of Harrisburg Care Center in Harrisburg, Pennsylvania, slipped away on a 98º day. He was later found lying on the pavement at an intersection about a mile from the facility.
As these examples illustrate, when an elderly patient with dementia strays from caregivers, danger can be everywhere. The problem is referred to as critical wandering. It can result in hypothermia, frostbite, dehydration, or heat stroke. Or these patients may wander off and slip on treacherous ground, fall into rivers, streams, or ponds, or be hit by automobiles.
Researchers who reviewed Arkansas missing-person reports concluded that one out of every 1,000 people age 65 or older will become a critical wanderer. That translates to more than 125,000 critical wanderings annually—a number that will continue to grow as the Baby Boomer generation ages. Other studies have shown that about three percent of critical wanderers are found dead within the first day; if still missing more than 24 hours later, only about half survive. Security and medical staff must work together to establish effective programs that keep the elderly safe from this type of risk.
Size of the Problem
The best-known cause of dementia is Alzheimer’s, a disease that causes the accumulation of amyloid plaques and neurofibrillatory tangles in the central nervous system. It currently affects 4.5 million Americans; by 2050, the number could be as high as 16 million, according to the Alzheimer’s Association. Keeping patients with dementia from critical wandering will become increasingly important for security as the percentage of Alzheimer’s cases grows.
Obviously, a first step toward preventing wandering is to identify the elderly patients with dementia. Massachusetts General Hospital assesses all patients of any age for signs of memory problems, disorientation, and confusion, says John J. Driscoll, CPP, associate director of police and security for the hospital.
Within the last several years, he says, the hospital has initiated an aggressive competency identification effort during patient admission. Previously, tests were only carried out when there was the likelihood of a competency issue, “but now everyone is tested on the front end,” Driscoll states.
Medical professionals perform the competency testing. Security is alerted to those patients who are at risk. Driscoll says that the competency screening has identified a number of people who otherwise would not have been considered at-risk because their states of dementia were not evident. The emphasis on competency screenings has resulted in fewer incidents involving security because each potential wanderer is assigned a patient observer who watches for wandering attempts. “The floor is seeing more dementia cases, but security isn’t,” says Driscoll. (More on Massachusetts General’s unique program later.)
Those with dementia wander for a number of reasons, including general anxiety and disorientation. Often, the environment triggers the wandering episode. It can be something as simple as seeing their street clothes lying on a dresser top, the need to find the bathroom, or the desire to get away from unfamiliar faces and disturbing sounds. In addition, many elderly dementia patients believe they need to fulfill old obligations, such as picking their children up from school or going to work.
The Hartford Institute and Alzheimer’s
Association recommend that hospitals not place dementia patents in high-traffic, noisy areas. Exit cues, such as the elevator in plain view or street clothes left out, should also be minimized, and all exit routes should lead past the nursing station. Access to areas that the patient can use, such as the bathroom or common room, should be accented.
The environment should be as stress-free as possible, providing a sense of safety and security. Some techniques include installing non-glare lighting and playing soothing music. Room changes should be avoided, and physical restraints, which greatly enhance dementia patients’ agitation, should be used only as a last resort.
Many smaller facilities with limited staff rely on anti-wandering technology to enhance supervision. Most of these systems use radio frequency (RF) to transmit a signal to an electronic door monitor. Patients wear the transmitter, usually as a bracelet or anklet, and their proximity to the monitored door triggers an alarm.
One such facility is Centennial Park Retirement Village in North Platt, Nebraska, which includes 31 independent-living apartments, 39 assisted-living rooms, and a 68-bed full-time care unit. It has a staff of less than a dozen.
Most of the patients in the fulltime care unit have some form of dementia, says Nicole Beel, manager of medical records and supplies. Often, “They don’t understand that they are there to live—that this is their home now,” she adds.
Last summer, Beel recalls, one full-timecare patient announced that he was going home and walked out of the building. Another patient with dementia snuck out through the laundry room. In both cases, staff intercepted the wanderers, who were wearing bracelets that set off alarmed exit doors.
Centennial Park uses WanderGuard by Stanley Security Solutions. All exit doors are alarmed in the building that houses the assisted living and full-time-care units, as are the main interior doors to the fulltime-care unit (around the clock) and the interior doors of the assisted-living area (after hours). The alarms are monitored from a panel at the central nursing station.
Incoming residents at Centennial Park are tested for competency, and the families of those with dementia are interviewed to ascertain whether wandering has previously occurred and under what conditions. All patients in the full-time-care unit, and any others considered at high risk of wandering, receive a monitoring device. Residents can wear the regular hospital-type bands with the transmitter boxes attached on their wrists or ankles, or the devices can be placed on their walkers or wheelchairs. Once the band is attached, it cannot easily be removed; it must be cut off.
Beel says that wearers seem comfortable with the bands. “They really don’t notice them. I’ve never had a complaint,” she states.
The transmitter boxes need no programming to begin working, and they function for about three years. The cost is approximately $120 per replacement. Staff test each patient’s transmitter daily to make sure that it is functioning.
“Since we got the system, once we hear the alarm, we start looking. We have had patients who have tried to wander, but they don’t get very far,” Beel says.
Centennial Park’s technological efforts to prevent wandering have been enhanced in the last few years by the additions of TABS Disposable Patient Safety (DPS) Sensor Pads, also by Stanley Security Solutions. Made to help medical facilities prevent falls, these large battery-operated sensor pads can be placed on the seat of a wheelchair or used as a mattress pad on a patient’s bed.
At the end of the pad is a jack that plugs into a speaker box. If a dementia patient tries to leave the bed or chair, a prerecorded calming message from a staff member tells them to sit or lie down and that someone will be there to help them momentarily.
Recycle. In hospitals where budgets are tight, other extant security systems can be modified for reuse. For example, New York Presbyterian Hospital’s Weill Cornell branch at Cornell University has a small 20-bed unit for Alzheimer’s and other dementia patients. Bernard J. Scaglione, CPP, director of security, says that when the hospital upgraded its infant abduction prevention technology to a supervised system, the previous system was adapted for use in the dementia unit.
All patients in the dementia unit now wear an anklet with an RF transmitter that will trigger an alarm at the nursing station when alarmed doors are approached. If a patient with the device lingers too near a door, a buzzer sounds an alarm. The unit is also physically set up so that the nurses at their station can see almost every patient room.
Says Scaglione, “Our number of elopements because of dementia has been reduced. There weren’t a lot of them before, but now it is even rarer.”
Massachusetts General sees many cases of dementia, but has chosen a different approach to dealing with those affected by it. “We don’t have a patient wandering system,” says Driscoll. The hospital has instead chosen to hire patient observers.
“These are paid nonclinical, nonsecurity persons, but they do have general training,” he explains. “Essentially, they try to dissuade the patients from trying to leave. If they can’t, they notify clinical staffers, and if there is an issue of safety, they call security.”
The decision to use patient observers instead of antiwandering technology was made by the hospital’s Patient at Risk Committee, of which Driscoll is a member. The committee has also developed an educational program on dementia for medical staff, pieces of which are incorporated into security staff restraint and use-of-force training.
“We bring people from the mental health side to discuss psychiatric issues, dementia, and withdrawal from alcohol,” Driscoll says. “But we don’t want our security staff to be clinicians. It isn’t our role to find out if someone is bipolar rather than schizophrenic, but they do have the general things to look for.”
One aspect of the training is on how officers can use gentle persuasion to get the patient’s compliance. “If a security officer sees someone who appears to be wandering, we train them to engage the patient and try to find out if there is a competency issue. If it appears so, the officer tries to talk to the patient and give the reasons why it’s better to go back to the room,” Driscoll states. By avoiding a hard line, he says that security staff can almost always get the wanderer to comply.
Security personnel conduct more frequent checks on patients with competency issues. Security and other staff will also work with a patient’s family members on ways to help lessen the patient’s anxiety by making sure they are surrounded by what they perceive as safe objects, such as family pictures. “Usually, they are glad to partner with us on that,” he says.
As the number of elderly increases, hospitals and care facilities may struggle to deal with the number of dementia patients. But with security as an educated, fully participating partner, critical wanderings can be reduced.
Ann Longmore-Etheridge is an associate editor of Security Management and editor of Dynamics.