# A nurse is caring for a 78-year-old client with moderate Alzheimer's disease who has been exhibiting increased agitation and wandering behavior during the evening hours. The client's family reports that these behaviors have worsened over the past week. What is the most appropriate initial nursing intervention?

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> subject: Mental Health

## 문제

A nurse is caring for a 78-year-old client with moderate Alzheimer's disease who has been exhibiting increased agitation and wandering behavior during the evening hours. The client's family reports that these behaviors have worsened over the past week. What is the most appropriate initial nursing intervention?

## 보기

1. Administer prescribed PRN lorazepam to reduce agitation
2. Restrict the client to their room during evening hours
3. Increase environmental stimulation with television and music
4. Establish a consistent evening routine with calming activities **✔ 정답**

**정답: 4**

## 해설

Establishing a consistent evening routine with calming activities is the most appropriate initial intervention for sundowning in Alzheimer's disease, as it addresses underlying causes non-pharmacologically. Other options involve restrictive measures or medications that are not first-line.

## 심화 해설

Clinical Reasoning and Core Mechanism

The client is exhibiting a classic pattern of sundowning, a circadian rhythm disturbance common in Alzheimer's disease and related dementias (ADRD) where agitation, confusion, and wandering intensify during the late afternoon and evening hours. The underlying pathophysiology involves degeneration of the suprachiasmatic nucleus (SCN), the brain's master clock, which disrupts the sleep-wake cycle and leads to a misalignment between internal biological rhythms and external environmental cues [3]. Nonpharmacological interventions that target this disrupted circadian system by providing structured, predictable external cues are the first-line approach to managing behavioral and psychological symptoms of dementia (BPSD) [1,3].

A consistent evening routine with calming activities directly addresses the root cause by reinforcing the natural circadian drive for sleep and reducing the sensory confusion that can trigger agitation. This aligns with evidence that timed, predictable environmental stimuli can consolidate sleep and reduce evening agitation without the risks associated with pharmacological solutions [3]. In contrast, pharmacological restraint with lorazepam (Option 1) carries significant risks in older adults, including paradoxical agitation, oversedation, and increased fall risk, and does not correct the underlying circadian dysregulation. Physical restriction (Option 2) is a form of restraint that violates client rights, can escalate fear and agitation, and is never an appropriate initial intervention. Increasing environmental stimulation (Option 3) is contraindicated because excessive or unpredictable noise and light can act as an environmental trigger for specific subtypes of agitation in people with dementia, overwhelming their already compromised sensory processing [2].

The scoping review by Au-Yeung et al. confirms that indoor environmental quality parameters, such as light and noise, are directly associated with BPSD and that controlling these parameters is a key management strategy [1]. Specifically, a structured routine helps modulate the timing of light exposure, which is a critical zeitgeber (time-giver) for the circadian system. Figueiro's work further supports that timed light exposure and consistent daily patterns can improve nighttime sleep efficiency and reduce evening agitation in ADRD patients [3]. By establishing a predictable sequence of calming activities, the nurse is essentially providing a nonpharmacological, environmental intervention that reduces the sensory triggers for agitation [2] while strengthening the client's weakened circadian signaling [3].

References (research sources)

- [1]Examining the Relationships Between Indoor Environmental Quality Parameters Pertaining to Light, Noise, Temperature, and Humidity and the Behavioral and Psychological Symptoms of People Living With Dementia: Scoping Review.Research articleAu-Yeung WM, Miller L, Wu CY, Beattie Z, Nunnerley M, Hanna R, Gothard S, Wild K, Kaye J. (2024) · DOI: 10.2196/56452

- [2]Environmental Triggers of Specific Subtypes of Agitation in People With Dementia: Observational Study.Research articleDavidoff H, Van Kraaij A, Lutin E, Van den Bulcke L, Vandenbulcke M, Van Helleputte N, De Vos M, Van Hoof C, Van Den Bossche M. (2025) · DOI: 10.2196/60274

- [3]Light, sleep and circadian rhythms in older adults with Alzheimer's disease and related dementias.Research articleFigueiro MG. (2017) · DOI: 10.2217/nmt-2016-0060

## 임상 시나리오

Managing Sundowning in DementiaEstablishing a Consistent Evening Routine
The primary intervention for sundowning is a nonpharmacological approach that reinforces the circadian rhythm. Initiate a predictable, calming routine 1-2 hours before symptoms typically begin.

Structure the routine with low-stimulation activities like listening to soft music, folding laundry, or a hand massage. Ensure consistent timing and a quiet environment to provide external cues that counteract the degeneration of the suprachiasmatic nucleus (SCN).

CautionAvoid pharmacological restraints like lorazepam as a first-line choice due to risks of paradoxical agitation, oversedation, and falls. Never restrict the patient to their room as this can escalate fear and agitation.

## 핵심 개념

- **Sundowning (일몰 증후군)** — A syndrome in dementia patients where confusion, agitation, anxiety, and wandering behavior increase in the evening or at night. It results from a combination of circadian rhythm disturbances and environmental factors.
- **Non-Pharmacological Intervention (비약물적 중재)** — Methods to manage symptoms through behavioral, environmental, and psychosocial approaches without using medication. This is the first-line choice in managing behavioral symptoms of dementia patients.
- **Circadian Rhythm (일주기 리듬)** — A biological process that repeats approximately every 24 hours (sleep-wake cycle, hormone secretion, etc.). In Alzheimer's disease, the brain region that regulates this rhythm (hypothalamus) is damaged, which is associated with sundowning.
- **Agitation (초조/동요)** — Non-specific behavioral symptoms manifesting as anxiety, agitation, excessive movement, aggression, etc. In dementia patients, these occur due to various causes such as pain, discomfort, fear, and environmental changes.
- **Person-Centered Care (개인 중심 돌봄)** — A care philosophy that places the patient's personal history, preferences, needs, and values at the center of nursing. It is essential in dementia care for strengthening the patient's remaining abilities and maintaining dignity.

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