A nurse is caring for an 82-year-old client with moderate Alzheimer's disease who has been experiencing increased agitation and wandering behavior during evening hours. Which nursing intervention should be the priority to manage this client's sundown syndrome?

Non-pharmacological interventions like structured activities and consistent lighting (option 2) are first-line for sundown syndrome. Options 1, 3, and 4 are inappropriate due to risks of sedation, restriction, or increased agitation.

Understanding Sundown Syndrome and Priority Nursing Intervention

The correct answer is 2. Implement structured evening activities and maintain consistent lighting in the environment. This approach directly addresses the underlying pathophysiology of sundown syndrome and aligns with the highest standard of evidence for managing behavioral and psychological symptoms of dementia (BPSD).

Why This Is the Priority: Pathophysiology and Evidence

Sundown syndrome is characterized by increased agitation, confusion, and wandering in the late afternoon and evening. Its primary driver is a disruption in the circadian rhythm, the internal biological clock that regulates the sleep-wake cycle. In Alzheimer's disease and related dementias (ADRD), neurodegenerative changes in the suprachiasmatic nucleus (SCN) impair this clock, leading to fragmented sleep and increased evening behavioral disturbances ^[1].

The priority intervention is nonpharmacological and targets the root cause: the dysregulated circadian rhythm. The provided evidence strongly supports two key components of this option:

- Consistent Lighting: Light is the most potent external cue for synchronizing the circadian rhythm. Research demonstrates that timed light exposure can consolidate nighttime sleep, increase daytime wakefulness, and directly reduce evening agitation ^[1]. A systematic overview of reviews confirms that environmental interventions, including light therapy, are effective nonpharmacological approaches for BPSD ^[3]. Maintaining consistent, adequate lighting during the evening helps reinforce the natural circadian signal, reducing confusion and agitation without the risks of medication ^[1].
- Structured Evening Activities: Providing meaningful, structured activities offers cognitive engagement and a predictable routine. This serves as a positive external zeitgeber (time-giver), reinforcing the day-night cycle and reducing the restlessness and boredom that often manifest as wandering and agitation. This approach is a core component of behavioral interventions, which are recommended as a first-line strategy for managing BPSD ^[3].

Analysis of Incorrect Options

- Option 1: Administer prescribed PRN lorazepam to reduce anxiety and agitation. While a PRN order exists, pharmacological intervention is not the priority here. Evidence explicitly highlights that nonpharmacological treatments like light therapy can reduce evening agitation "without the adverse effects of pharmacological solutions" ^[1]. In older adults with dementia, benzodiazepines like lorazepam are associated with a high risk of adverse effects, including excessive sedation, falls, paradoxical agitation, and further cognitive decline. The systematic review emphasizes that nonpharmacological interventions should be the first line of treatment for BPSD ^[3]. Medication should only be considered after environmental and behavioral strategies have failed.

- Option 3: Restrict the client to their room during evening hours to prevent wandering. This intervention is restrictive and counterproductive. Confinement can increase anxiety, frustration, and agitation, potentially escalating the very behavior it aims to control. It does not address the underlying circadian disruption and can be considered a form of restraint, violating the principle of least restrictive care. The goal is to manage wandering safely and address its cause, not to simply prevent it through confinement.

- Option 4: Increase caffeine intake during afternoon hours to promote alertness. This is contraindicated. Caffeine is a central nervous system stimulant that interferes with sleep onset and quality. Administering it in the afternoon would further disrupt the already fragile sleep-wake cycle, worsening fragmented sleep and nighttime awakenings, which are core features of sleep abnormalities in AD . This action would likely exacerbate sundowning symptoms.

Clinical Reasoning and NCLEX Application

For a client with moderate Alzheimer's disease exhibiting sundown syndrome, the nurse's priority is to implement a safe, evidence-based, nonpharmacological care plan. The intervention of structured evening activity and consistent lighting is a multicomponent strategy that directly targets the disrupted circadian rhythm, is supported by systematic reviews as a first-line treatment for BPSD ^[3], and avoids the significant risks associated with pharmacological or restrictive measures ^[1]. This reflects the NCLEX principle of prioritizing the least restrictive and most physiologically supportive intervention.