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Confining questions

People with Alzheimer's disease are often restless, and safety can be a major factor in their care. Left alone, they may wander off outdoors, oblivious to their current surroundings and bound for destinations that can never be attained. They may be looking for loved ones who died years ago, or trying to be punctual for jobs from which they have long since retired. Despite their frailty, they can display great energy and persistence. Frustrated in their efforts, they sometimes become agitated, making their behavior even more difficult to manage. One obvious solution is to keep the mentally confused elderly behind locked doors, in secured wings of nursing homes, for instance. Some Florida nursing homes do just that.

Last year, however, state rules changed in response to federal reforms that addressed patients' rights. Connie Cheren, former director of the Office of Licensure and Certification, which handles such matters in Florida, explained the shift this way: "It's like we locked up mentally retarded people in the 1950s. The families wanted it, everybody wanted it. But you won't find the mentally retarded locked up now without a court order that proves them dangerous. There was a time we thought it was okay. Now we look at it as archaic."

Cheren was fired in February, and her replacement, Lumarie Polivka-West, inherited a complex problem. While Cheren had cited and fined nursing homes that locked patients in, many continued the practice. The rule was not easy to enforce, and the nursing homes were not equal with regard to services. Some devoted special staff and facilities to caring for the mentally confused in segregated units. Others, unfortunately, simply locked the doors for convenience.

In late May, Polivka-West decided to stop the fines. "This is not a blanket approval of locked units," she explained. "But we are not going to be giving out citations just because a unit is locked."

Instead, a committee of experts will take three weeks to decide when and how the mentally confused should be locked up. The committee includes members of the nursing home industry, physicians, advocates and state officials.

Such standards cannot be drafted without addressing two underlying issues. First, does the practice violate patients' rights? These nursing home residents have committed no crimes, and most have not been granted formal competency hearings. Should a private institution be given the power of judge and jury over individual freedoms, even though the individuals clearly require constant supervision to protect them from harm?

Second, does confining patients address their therapeutic needs? Federal studies show that more than half of nursing home residents are labeled as mentally confused. Confusion can stem from many causes other than Alzheimer's disease, and many problems respond dramatically to the proper diagnosis and treatment. Should it become too easy to lock people away, those with treatable conditions will be robbed of their potential for recovery.

Alzheimer's itself is not fully understood, and there is some evidence to suggest that patients can benefit from increased freedom of movement. Many nursing homes have found humane ways to manage them without resorting to locked doors.

Three weeks seems a brutally short time to settle such questions and also fashion a workable standard for maintaining the highest quality of care. At stake is the issue of confining ill and elderly citizens _ for life.