Some years ago, I was supervising a group of nurse practitioner students in the health care center of a continuing care retirement community where I had previously been employed. While I was in a room with a resident and student, I heard a knock and saw a familiar face: a resident I had cared for two years earlier in the ambulatory care center.
She smiled and explained to me that she had come to the center to visit a friend and needed help exiting the unit — the door was locked, and the nursing staff were busy getting the other residents into the dining room for lunch. I walked with her down the hall, punched in the code to the keypad on the wall, and held the door open for her. To my surprise, a loud alarm sounded, and staff members quickly converged in the hall. I had inadvertently assisted their new resident with eloping from their unit.
I found out later that in the two years since I had last encountered her, she had developed dementia. She had been moved to the locked health care center after she had made several attempts to leave the building unaccompanied in the middle of the night.
I then followed her off the unit and spent 20 minutes walking with her around the community grounds before we were able to return through an alternative door. I have never lived down this error in judgment, and my friends who know of my misadventure like to tease me about it to this day. My pride was injured, but the resident remained accompanied and safe, and the weather cooperated with us during our stroll.
Modifications were made to her care plan for regular, accompanied walks outside, structured daytime activities, and more alerts to staff about her propensity for exit seeking. But the outcome could have been worse if the alarm hadn’t sounded: elopement from post-acute and long-term care settings have been associated with injury due to falls and deaths due to exposure, drowning, or motor vehicle accidents.
Wandering and Elopement
Donna Algase, PhD, RN, FAAN, and colleagues, who have published extensively on wandering and wayfinding in the context of dementia, define wandering as “a syndrome of dementia-related locomotion behavior having a frequent, repetitive, temporally-disordered, and/or spatially disordered nature that is manifested in lapping, random, and/or pacing patterns, some of which are associated with eloping, eloping attempts, or getting lost unless accompanied” (Aging Ment Health 2007;11:686–698).
Wandering is often considered a component of the behavioral and psychological symptoms of dementia, and it is estimated to occur in 20% to 30% of nursing home residents living with dementia (Ann Longterm Care 2012;20(3):1-6). The beneficial effects of wandering include increased physical activity, strengthening of muscles, promotion of sleep and appetite, and minimization of infection and skin breakdown. However, wandering can also lead to fatigue, falls and injury, weight loss, elopement, and death.
In PALTC settings, elopement is defined in F-tag F689 in the surveyor guidance (42 CFR § 483.25(d)) as “a resident leaving the premises without the facility’s knowledge and (if necessary) supervision.” The surveyor guidance explains that when a resident who has decision-making capacity intentionally exits a PALTC facility, this would only be considered an episode of elopement if the facility’s staff were unaware that the resident had left.
Risk Factor Identification and Assessment of Elopement
The first step in minimizing the risk of elopement in PALTC is to identify individual risk factors. The resident risk factors include older age, male sex, dementia, a recent history of substance use disorder, and insomnia (Annals of Long-Term Care 2012; 20(3):1-6). Individuals who are newly admitted to a facility and those who have made past attempts to leave unaccompanied are more likely to successfully elope.
The common behavioral precursors to elopement from PALTC settings include verbalizing the intent to leave, positioning near and tampering with doors and exits, preparing to go outside, packing up belongings, frequent calling of family, friends, or the police, and being overly observant of outside stimuli, such as the movement of cars and people (Neurodegener Dis Manag 2020;10:125–135).
Use of a psychometrically sound instrument may be helpful in monitoring a resident’s response to changes in the care plan to address the frequency and severity of wandering and elopement behaviors. There are several instruments designed to measure the behavioral and psychological symptoms of dementia that include wandering and elopement as single items. Version 2 of the Algase Wandering Scale (AWS-V2), the long-term care version, includes 19 items that are specific to wandering, elopement, and spatial orientation (Aging Ment Health 2004;8:133–142).
Management of Wandering and Elopement
The management of wandering and decreasing the risk of elopement require a team approach to care that must balance the autonomy and safety of our residents. The following are a few suggestions from my experience.
Identify and resolve unmet needs. As the old saying goes, “all who wander are not lost.” Wandering and elopement behaviors may be the resident’s way of trying to tell us something. Accompany the resident to the bathroom, provide a snack or drink, and engage the resident in an activity that is meaningful. Take the resident outside for walks in a secure area to provide some fresh air and a change of scenery. Virtual simulation techniques, such as a video or audio recording of someone they trust, can be used to reassure individuals and redirect them. There is no medication to treat wandering or elopement; we must identify and use nonpharmacological and pharmacological interventions to treat the anxiety, depression, insomnia, or psychosis that may be contributing to the elopement behaviors.
Use technology to help you. Secured doors, wander and elopement alarms, and sensor-based technology can be helpful tools in keeping our residents safe, but they cannot be the only management strategies that are used. The newer sensor-based monitoring symptoms have become better at identifying unassisted bed-leaving events, with notifications that go directly to caregivers and are increasingly sensitive and specific (Int J Environ Res Public Health 2022;19:2103).
Engage the interdisciplinary team. When a resident is at high risk of elopement, it requires an all-hands-on-deck approach. Residents who successfully elope from secured units often do so with a visitor. Educate your visitors about exiting-support from staff, and encourage them to ask the staff whenever they aren’t certain whether an individual is a resident or visitor. Also enlist the watchful eyes of reception, security personnel, and building and grounds staff.
In case the worst happens, make sure that your facility already has a search-and-rescue plan and that all staff have been trained to implement it.
Dr. Galik is editor in chief of Caring for the Ages and a professor at the University of Maryland School of Nursing. The views the editor expresses are her own.
November 30, 2022
In this episode, Dr. Karl Steinberg and Dr. Elizabeth Galik discuss our November-December issue, including the oral COVID-19 outpatient treatment known as Paxlovid, the role of professional social workers in the nursing home, the assessment and management of wandering and elopement in nursing homes, and what to do with spousal disagreements impact individuals, other patients, and staff.