Home Evaluation of Exit Barriers in Wandering
Home Evaluation of Exit Barriers in Wandering
Main hypothesis. Floor and door visual exit barriers will decrease exit-seeking wandering
 (exit door approaches) proximal to exit doorways by persons with dementia who wander.
Introduction: Wandering behavior is manifested in ways that include lingering near exit doors
 and/or mimicking or "shadowing" the exiting behavior of others who depart through this door.
 Referenced as "exit-seeking," such behavior is a common mobility pattern that places persons
 with dementia who wander (PDW) at high risk of wandering away or eloping. PDW who wander away
 from a care setting unattended are at risk of death from exposure or accidents if lost and
 not quickly found, and those that do not wander away but persist in such behaviors are at
 risk for falls, fractures and other injuries, weight loss, fatigue and sleep disturbances.
 Traditional methods to manage PDW exit-seeking and wandering away include physical restraints
 and pharmacology, but these can be harmful. Subjective or "visual exit barriers" to deter
 exit-seeking offer an attractive alternative because these interventions are non-invasive,
 low-cost and simple to use. Nursing home tests of visual exit barriers such as plain cloth
 door covers and stripped floor covers have demonstrated positive results in reducing or
 completely exit-seeking behaviors. Confirmation of these results in a well designed,
 home-based trial is warranted.

 Research Questions/Hypotheses: The research questions and hypotheses of this 2-year,
 cross-over assignment with randomized allocation design with two intervention and two
 no-intervention periods (at baseline and after the first intervention) are: Q1. Will
 installation of visual barrier interventions change exit-seeking wandering patters,
 controlling for cognitive impairment? H1. Compared to baseline, installation of a visual exit
 barrier will lower the frequency and duration of exit-seeking behaviors. Q2. Of the two
 visual barriers (door and floor), which will result in the greater reduction of wandering
 (frequency and duration of lingering and shadowing)? H2. Door covers will reduce exit seeking
 more than floor covers.

 Five secondary questions are proposed for descriptive purposes and to generate hypotheses for
 future studies on wandering management interventions. These include: Q3. What are the
 baseline characteristics of exit-seeking (predominant loci, durations and variability of
 durations during waking hours)? Q4. Will the introduction of a visual barrier on one exit
 doorway alter exit-seeking behaviors occurring in proximity to other potential exit doors and
 windows within the same area? Q5. Will the introduction of visual exit barriers reduce CG
 (caregiver) burden? Q6. Will the introduction of visual exit barriers increase PDW agitation?
 and Q7. How do CG rate visual barrier effectiveness and acceptability for in-home use?

 Methods: A crossover assignment with randomized order of allocation design was used. One main
 exit doorway was sequentially protected with the two types (door, floor) of visual barriers.
 Data related to exit-seeking of subjects was collected via ultrawide radio frequency
 identification devices on a continuous basis for four 14-day periods: Entry into a monitored
 zone 6-feet in front of exit doorways will be considered exit-seeking behavior; PDW
 locomotion in tandem with CG locomotion will be considered shadowing. Caregiver-reported PDW
 agitation and CG burden will be collected at baseline and immediate post-interventions. Prior
 to all statistical analysis, all variables will be reviewed for valid data points and
 normalcy for continuous data. Should erroneous data points exist, data will be verified to
 ensure accuracy. Should data not be normally distributed, processes such as transformations
 or truncations will be completed. Prior to conducting formal hypothesis testing, an order of
 allocation analysis will be completed to determine if carry-over effects occurred in the
 study. Analysis (Pocock) will be completed, which in essence examines the mean of differences
 by use of t-statistics. In addition, intent to treat analysis will be completed. Given we
 have incorporated a second baseline phase into the study, frequency and duration will be
 compared between the two baseline phases to ensure consistency. Descriptive statistics
 (frequency distributions for categorical variables, means and standard deviations for
 continuous variables) will be calculated for all baseline variables including the covariates.
Inclusion Criteria:

 -  veterans age 60 and over with an Alzheimer's-like dementia diagnosis, documented in
 medical record with International Codes for Diagnosis (ICD-9) codes that include all
 290 diagnoses and 331.0

 -  Mini Mental State Examination (MMSE) 24 or less

 -  evidence of pre-elopement behaviors operationalized as scoring 1 standard deviation
 (SD) above mean on any one of the three items that comprise the Revised Algase
 Wandering Scale-Community Version (RAWS-CV) eloping subscale (#16 - He/she attempts to
 get outside; #27- He/she stands at the out door wanting to go out; #30- He/she
 attempts to find or go to familiar locations, even unrealistic ones)

 -  living in a non-institutional private family home or foster home

 -  independently ambulatory (with or without canes, walkers or wheelchairs to assist)

 -  living within a 60-mile radius of the James A. Haley Veterans Administration Medical
 Center (VAMC), Tampa, Florida

 -  living with a caregiver (CG) who is willing and able to serve as a study partner and
 provide informant reports, and who intends to be with the PDW for three months
 (allowing for being away for seven days or less during the three-month study period)

 -  English speaking.

 Exclusion Criteria:

 -  living in a nursing home, group home or assisted living facility at point of entry
 (foster homes allowed)

 -  previous exposure to any visual exit barrier for wandering management

 -  no live-in CG

 -  bilaterally deaf or blind

 -  currently taking anti-psychotic medications

 -  current use of any visual exit barrier on any main exit doorway. CG will be allowed to
 use other wandering management interventions that are not specific to the exit
 doorways. For example, they may use a stop sign at the entrance to the kitchen, but
 may not use a stop sign on an experimentally monitored door.