Schlaudecker JD, Moore I. Reducing wandering through improved waiting room design. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(1):30-31.
We no longer have problems with wandering patients. For a geriatrician, or for any geriatric care provider, a patient wandering away from your office is not a good thing. Wandering patients used to be a major problem in our dementia consultation office. Clerical staff proactively distracted our cognitively impaired patients to prevent them from leaving the waiting room, often sitting beside patients while their family members were in concurrent consultation. Thankfully, patients were never actually lost, but they sometimes made it as far as the elevator or down the hall to the next office. These patients, who had varying degrees of cognitive impairment, were apparently not comfortable in the traditional waiting room within the offices of a continuous care retirement community (CCRC). While the office had comfortable chairs, magazines appropriate for older adults, and a pleasant watercolor painting hanging on the wall, the fluorescent lighting reinforced an impersonal clinical setting. Patients were also seated facing a busy hallway, which added to overstimulation and anxiety, and a trip to the restroom necessitated them leaving the immediate area. In addition, the clerical staff sat at an uninviting counter behind a sliding glass window.
This environment seemed to worsen patients’ behaviors, and families often made comments like: “Dad does much better at home.” Something about this space made our cognitively impaired patients feel restless and uncomfortable, and they appeared to be powerfully motivated to leave. A construction project led to that office being torn down, and we relocated to a two-bedroom cottage within the CCRC. Upon parking in the driveway and entering through the front porch, families encounter bright white woodwork, soft and indirect lamplight, and large windows bordered by flowing floral-patterned curtains. Patients admire the marble-top tables or the assembled antiques, often making comments like: “This is like my grandmother’s.” Families and patients share mutual memories, enabling everyone to relax.
The primary wish for older adults is often to stay in their own home. We surmise our home-like waiting room reassures cognitively impaired persons by tapping into this wish, thereby reducing their anxiety and curtailing wandering. A more welcoming, comfortable, and familiar atmosphere is the perfect environment for these patients. They no longer have to sit anxiously in a traditional doctor’s waiting room; instead, they contentedly lounge with dignity in an upholstered armchair formally grouped around a coffee table in a sunny living room. This enables us to take all the time that is needed to talk to their caregivers in the consultation room, which was previously a bedroom. Clerical staff now work in what was once the breakfast nook, and they have the ability to keep an indirect eye on patients, fostering a sense of dignity throughout the appointment. What follows is a quick overview of wandering and how waiting rooms can be improved to curtail this problem.
Wandering and the Waiting Room
Wandering is a highly common and potentially injurious behavior in adults with cognitive impairment, whether they reside in the community or in long-term care settings. Several evidence-based theories have been suggested as to why wandering occurs in these settings, with many of these theories reporting stress, discomfort, and unmet needs as common triggers.1 In a report by Inouye,2 a familiar environment was noted to be an effective way to prevent delirium and decrease agitation, and there is no more familiar environment than that of home. In addition to providing patients with a cozy, home-like environment, the move to a cottage enabled us to facilitate greater partnerships with patients and their families, thereby improving patient care.
Currently, there are approximately 15 million caregivers in the United States taking care of the estimated 5.4 million Americans with Alzheimer’s disease.3 If asked for input, we suspect many of these caregivers would support the idea that a physician’s office or care facility that feels like a home, instead of an institutional space, would help decrease agitation and wandering, improving patient care. Our office fortuitously landed in a “homey” space. A move like this is not feasible for most practices, but enhancements to existing spaces to give them a home-like feel are possible.
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Many useful recommendations are made in Geriatric Care by Design: A Clinician’s Handbook to Meet the Needs of Older Adults Through Environmental and Practice Redesign, which was published in 2011 by the American Medical Association.4 While these are general recommendations for practices caring for all older adults (≥65 years), they can be particularly beneficial for practices caring for persons with dementia, who have a greater number of sensory deficits to contend with and are more sensitive to environmental issues than cognitively intact persons. What follows are just a few of the recommendations that are outlined in the Handbook with regard to waiting rooms4:
• Ensure the reception desk is accessible to patients in wheelchairs (countertop area should be 30 inches high and at least 36 inches wide).
• Use light to medium floor colors with no or simple patterns with low color contrast to improve perception.
• If using carpets, use low-pile types to improve mobility.
• Have sturdy furniture that can’t be tipped and that has rounded corners to prevent injuries when bumped into. Avoid glass tabletops.
• Reduce background noise by using sound-absorbing materials, such as drapes, carpeting, and wall and ceiling panels.
• Offer a variety of seating areas that use firm or medium-firm cushions, ensuring comfort and easing repositioning and the ability to move between seating and other areas.
• Use glare-free lighting and ensure that all light sources are shaded, including lamps and windows.
• Use light to medium wall colors in warm rich tones, such as yellows and blue/greens.
• Ensure that the foreground is always distinct from the background. For example, patients should be able to distinguish the couch from the floor, door handles from the door, and walls from the floor intersection.
• Signage should be easy to read and placed at appropriate intervals to prevent patients from getting lost.
In designing interprofessional faculty. These individuals designed the new space, and if you look at the Figure, which provides a glimpse of our office, you’ll see many of the recommendations outlined in Geriatric Care by Design put into practice. We have multiple seating areas, low-pile carpeting, shaded lamps, white trim to delineate the walls from the floor, soft yellow paint, and rounded corners on our furniture. our new office space, we benefitted from more than 30 years of practical experience among our inter profession faculty. These individuals designed the new space, and if you look at the Figure, which provides a glimpse of our ofﬁce, you’ll see many of the recommendations outlined in Geriatric Care by Design put into practice. We have multiple seating areas, low-pile carpeting, shaded lamps, white trim to delineate the walls from the ﬂoor, soft yellow paint, and rounded corners on our furniture.
Geriatricians recognize that optimal care must involve a partnership between an individual patient, their family support system, and the healthcare provider. This care philosophy, known as
patient- and family-centered care, emphasizes a dignified, mutually beneficial partnership of shared medical decision-making.5 The current healthcare debate has renewed societal interest in improving the care of older adults. An office environment that increases safety and fosters a sense of dignity among cognitively impaired older adults through familiar environments enables improved partnerships and outcomes.
1. Lester PE, Garite A, Kohen I. Wandering and elopement in nursing homes. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(3):32-36.
2. Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165.
3. Alzheimer’s Association. 2012 Alzheimer’s Disease Facts and Figures. www.alz.org/ documents_custom/2012_facts_figures_fact_sheet.pdf. Published March 2012. Accessed December 13, 2012.
4. Bakker R. Environmental design. In: Geriatric Care by Design: A Clinician’s Handbook to Meet the Needs of Older Adults Through Environmental and Practice Redesign. Chicago, IL: American Medical Association; 2011:1-14.
5. Johnson B, Abraham M. Partnering with Patients, Residents, and Families: A Resource for Leaders of Hospitals, Ambulatory Care Settings, and Long-Term Care Communities. Bethesda, MD: Institute for Patientand Family-Centered Care; 2012:4-11, 26-39.
The author reports no relevant financial relationships.
Address correspondence to:
Jeffrey D. Schlaudecker, MD
2123 Auburn Ave, #340
Cincinnati, OH 45219