An interview with Bettye Rose Connell, PhD
AN INTERVIEW WITH BETTYE ROSE CONNELL, PhD 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 re-enacting 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 itself won'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 staff's 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.
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