During an outbreak, the priority is to keep residents and employees safe while implementing infection control protocols. Wandering can be a common symptom for residents who have a cognitive impairment, e.g., unwell, dementia, pain, etc. and caring for these residents can be challenging for the healthcare team. Wandering can pose a major risk of spreading infectious organisms to other residents and employees.

It is important to remember the following   

Majority of these residents are usually redirectable and manageable

There are multiple contributing factors to restlessness and wandering

Agitation may result in emotional distress and/or wandering

Behaviours may be worse in the evening hours

A balance is needed to provide quality care and infection control considerations to contain transmission and spread.

Ethical Considerations

It is important to provide for the health, safety and welfare of all while maintaining independence and choice when managing an outbreak, so careful consideration of the ethical values at stake is needed. To maintain trusting relationships with residents and families, all employees should be able to explain the reasons for restrictions in transparent communication and provide clarification to facilitate understanding. A balanced approach is needed in order to prevent resident abandonment or isolation, and the following values should be upheld 

Common good

Respect for individuals

Proportionality (risk/benefit)

Duty to care

Fairness

Trust

Transparency

Collaboration and reciprocity

Management Begins with Assessment

Assess: the individual resident. Are there any

Modifiable factors: unmet needs, acute medical problems, knowledge about the condition, distress, over/under stimulation, lack of routine, caregiving quality, quantity, and knowledge, family dynamics,

Unmodifiable factors: medical comorbidities, stage of dementia, type of dementia, brain changes, personality, life history, infrastructure of care facility

Describe: Measure and document the assessment of wandering and restlessness, for example

When and how severe

Associated with depression

Emotional dysregulation and insomnia

Safety issues

Any identifiable triggers

Family dynamics

Analyse: what we know about the resident and whether there are any medical, psychological, or social contributing factors

Rule out delirium as a contributing factor to agitation and wandering

Consider and assess triggers such as pain, hunger, toileting and medications

Identification of Triggers: What event(s) are creating anxiety and/or wandering behaviour?

Is toileting required?

Is the patient experiencing pain?

Is there withdrawal from substances e.g. nicotine?

Have any medications been stopped or started in the past 2 - 4 weeks?

Have any medication dosages been changed in the past 2 - 4 weeks?

Are there sensory barriers or losses to consider – vision, hearing?

Is there social isolation without family presence?

Is PPE worn by employees creating fear and worry?

Employ all Relevant Interventions: Create a resident-specific care plan that is reviewed and revised as required and contains information on the following

How to attend to responsive behaviours

How to reduce external stimulation if possible

How to use redirection strategies 

Capitalise on positive relationships with some employees

Maintenance of the right of a resident to continue to connect with their family, e.g., Partner in Care/Named Visitor/essential visitor

Advice from Geriatric Medicine, Geriatric Psychiatry, Behavioural Therapist

Any medication adjustments or rapid behavioural interventions that are available

Non-pharmacological approaches should be considered the mainstay of therapy, complemented by psychotropic medications only when unavoidable.

Clinical Considerations

Consider pharmacologic restraint if the resident cannot comply with isolation

Physical restraint is a last resort if the resident cannot adhere to outbreak requirements