Alzheimer's Disease and Related Disorders
Escape from the Nursing Home
VY, a 74 year-old male suffering from severe Alzheimer’s disease is a resident in a nursing home located in a rural county with rolling hills. VY retired as a watch repairer several years ago and fought in the Battle of the Bulge. He had wandered off on two previous occasions. On the first occasion he was found in a horse pasture across from the nursing home, while the second time he was located in the back yard. On a particularly warm October day he wandered off again. After having an argument with his "girlfriend" he was last seen sitting on the sun porch at 3:45 P.M. The nursing home staff noticed him missing between 4:00-4:30 P.M. In the first 45 minutes they checked the building, looked in the yard, checked the horse pasture, searched a barn, contacted neighbors, and then called the sheriff’s office. State SAR resources were contacted at 11:50 P.M. Searching continued throughout the night with tracking dogs, air-scent dogs, mantrackers, ground searchers, and helicopters. During the day over two hundred searchers became involved. The detection of a footprint gave a general direction of travel. | Case Conclusion | Case Study Discussion |
In emergency management and the disaster business focusing on only the actual response, while important, represents a short-sighted approach. Historically, additional emphasis was placed on preparing for disasters through disaster planning and then carefully working on a coordinated recovery effort. In recent years additional, and much needed, emphasis as been placed on prevention. Since it is impossible to totally prevent damage from hurricanes, tornadoes, and floods the consulting lawyers decided mitigation might be a better term than prevention. The cycle of mitigation > preparedness > response > recovery which then leads back to mitigation allows a comprehensive approach of planning for, and responding to disasters.
When a loved one wanders away it quickly becomes a personal disaster to the caregiver. The numbers and types of resources required to conduct a professional search may also quickly overwhelm a local community. Searches may last longer and require more personnel than a typical multi-casualty incident, which activates almost all of a communities public safety resources. These pages will look at suggestions on how caregivers and skilled care facilities can prevent (or mitigate) cases of critical wandering. Despite best efforts, especially in the home environment, critical wandering may still occur. Therefore, several steps should be taken to prepare a response plan. Attempting to decide what to do in the middle of a crisis seldom results in the best actions. An important part of any preparedness' actions will be enrolling mobile Alzheimer's patients in the Alzheimer's Association's Safe Return program. If the Alzheimer's subject should happen to wander off the quick actions on the part of the caregiver or skilled care provider, and local law enforcement are critical in returning the subject to safety. Finally, once the wanderer has been found, the story is not over. Caregivers need to understand they will undergo some critical incident stress. It is also a time to look back at prevention, preparedness, and response plans and determine if they can be improved.
Wandering itself does not harm the Alzheimer's patient. In fact, wandering may help alleviate anxiety and provides some often needed exercise. However, critical wandering is a life threatening problem that must be prevented. The prevention of critical wandering may be broken into three major categories; behavioral, inside environment, and exit control. Each preventative measure can be implemented in the person's residence or in a skilled care facility.
Behavioral measures to control critical wandering.
The first step is to recognizes common causes that often trigger critical wandering. Two studies have been conducted that gave similar but slightly different results. The results from Silverstein and Salomns (n=239) are given first and the results from O'Connor, Rosewarne & Bruce) study (n=15) are given second in blue. It is expected that differences in results are largely due to differences in the sample sizes. Percentages do not total 100% because of some multiple causes.
- Placed in unfamiliar environment (28%)(20%)
- Saw coat and hat and decided to leave (27%) (13%)
- Argumentative or confronting situation (23%)(47%)
- Change in schedule or routine. Often first week of moving to a new care facility (23%)(27%)
- Spent the day in day care (23%)
- Had a change in medication (21%)
- Was left alone in car (18%)
Next look for the underlying cause of each of these trigger factors. These might include:
- Confusion related to time
- Becoming disoriented to landmarks, familiar people, and objects
- Misinterpretation of sights and sounds resulting in increased anxiety or fear
- Past experience pattern; going to work, looking after a child
- Memory links; seeing coat > going outside, seeing doorknob > something to turn
If unable to recognize an underlying cause or pattern to the wandering begin keep a log of the wanderers pattern. The log should list the time, date, and events surrounding each wandering event. Over time it should assist in identifying the underlying cause. Once the cause of potential wandering has been identified then steps may be taken to reduce the wandering behavior.
- Consult with physician regarding medication side effects
- Make sure person's basic needs (hunger, thirst, temperature, toileting, fear, boredom, etc) are met.
- Encourage exercise to reduce anxiety, agitation, and restlessness. Exercises may include activities such as long vigorous walks, circular walking, rocking chairs, playing with beach balls, dancing, or group exercises.
- Empower the person and give them a sense of control by involving them in productive daily activities
- If the person is wandering or becoming agitated, redirect the person's attention. Offer the person a favorite food or drink. Avoid arguing or confrontation. Instead, focus on a distracting activity.
- Place interesting items the person may play with near exits.
- If possible, allow person some control over aspects of their life, such as activities or food selection.
- Orient the person to people and place by reminding the person that he or she is in the right place. This should also include frequently repeating the name of the patient, name or caregiver or staff, and locations of places in the facility. Skilled facilities may consider having staff wear extra-large name tags.
- Let person look out windows to stay oriented to time of day and season
- Make sure the person has properly fitted glasses and hearing aids (if required) on a frequent basis.
- Reassure the person If the person feels lost, abandoned, or disoriented provide reassurance. Talk with the person by speaking in a low tone of voice, using short words, and simple phrases. Gently touch the person if words are not understood. It provides reassurance and communicates warmth. Make sure you approach the person from the front and make eye contact first. Repeating words of reassurance, directions, and gentle touch often has a calming effect.
- Schedule short-term interesting activities
- Provide comfortable rocking chairs
- Provide companionship and one-on-one attention
- Avoid extended interactions with a large group of people.
- Avoid physical or chemical restraint unless absolutely necessary!
- Help the person stay oriented to time by placing clocks and calendars in various spots around the facility
- Remove "trigger" items such as hat, coat, keys, etc that signal to the person it is time to leave the structure.
- Place large signs on the bathroom door to reduce wandering in a search to find the toilet. Place a night light in the bathroom.
- Place a picture of themselves or a collage of significant pictures on their bedroom door.
- Reduce environmental distractions such as noise levels from television or loud music.
- Provide continuity with same room assignments, and same furnishings in the room.
- Design a walking path that allows safe wandering with interesting destinations and objects along the way.
- Making environment more home-like
- Designing a quiet and comfortable place for the person to sit if they become agitated
- Assigning staff responsibility regarding the location of each person
- Regularly checking that doors and gates are securely locked.
- Ensure staff vigilance and observation
- Assign a non-demented companion resident
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