# Situation: A 78-year-old woman with Alzheimer disease diagnosed 3 years ago lives with her daughter, who is her main caregiver. She is admitted to the medical ward for dehydration after 2 days of poor oral intake. She has no known drug allergies. On her first night she repeatedly tries to climb out of bed. She is not in pain, and her bladder is not distended. Which action is BEST?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 78-year-old woman with Alzheimer disease diagnosed 3 years ago lives with her daughter, who is her main caregiver. She is admitted to the medical ward for dehydration after 2 days of poor oral intake. She has no known drug allergies.

On her first night she repeatedly tries to climb out of bed. She is not in pain, and her bladder is not distended. Which action is BEST?

## 보기

1. Raise all four side rails so she cannot leave the bed
2. Apply soft wrist restraints until she falls asleep
3. Keep the bed low and toilet her on a set schedule **✔ 정답**
4. Ask the physician for a sedative so she sleeps all night

**정답: 3**

## 해설

For a confused older adult at risk of falls, the bed is kept in its lowest position, toileting is scheduled, and rounding is frequent, with nonslip footwear and night lights. Raising all rails and applying restraints increase injury from climbing or struggling, and sedatives worsen confusion and falls in dementia.

## 심화 해설

Clinical context

A 78-year-old woman with Alzheimer disease is admitted for dehydration and, on the first night, repeatedly attempts to climb out of bed. She is not in pain and has no bladder distention. The priority is to protect her from fall-related injury without using measures that increase agitation or worsen confusion.

Why option 3 is the best action

Keeping the bed in the lowest position and providing scheduled toileting addresses the two most common drivers of nighttime wandering and bed-exit attempts in hospitalized older adults with dementia: disorientation and unmet elimination needs. A low bed reduces the distance to the floor and the severity of injury if she does get out of bed, while scheduled toileting prevents urgency, discomfort, and the urge to climb out to find a bathroom. This approach is consistent with a person-centred, least-restrictive falls-prevention strategy for older adults with cognitive impairment.

Why the other options are unsafe

Raising all four side rails is classified as a form of physical restraint when used to prevent a confused patient from leaving bed. A patient who is determined to get out will climb over the rails, and the fall from a higher point produces more serious injuries such as fractures or head trauma. The scoping review on dementia care in acute hospitals identifies restraint use as a risk-management strategy that can paradoxically increase harm by triggering distress and challenging behavior [1]. The night-monitoring study reports that physical restraint can provoke challenging behavior in approximately 80% of older adults with dementia, which then leads to more vigorous struggling and a higher fall risk [2].

Soft wrist restraints carry the same problem. They do not treat the underlying confusion or need, and they increase agitation, skin injury, and the risk of entrapment or asphyxia. In a patient with Alzheimer disease, restraint-induced struggling also raises intracranial pressure and energy expenditure, which is especially dangerous when she is already dehydrated.

Requesting a sedative to make her sleep all night is also inappropriate. Sedatives and hypnotics worsen confusion, impair balance, and are strongly associated with falls in older adults with dementia. The World Falls Guidelines emphasize that medications with sedative properties should be reviewed and minimized as part of falls prevention in older adults . Sedation may stop the bed-exit attempts temporarily, but it does not address the reason for the behavior and increases the risk of a more dangerous fall if she wakes disoriented during the night.

Nursing process application

The immediate nursing diagnosis is Risk for Falls related to cognitive impairment and unfamiliar environment. The best interventions are environmental modification and structured routines rather than physical or chemical restriction. A low bed, scheduled toileting, frequent rounding, nonslip footwear, and a night light are all low-risk, high-yield measures. Key point! In a confused older adult who tries to get out of bed, the first-line response is to modify the environment and meet basic needs, not to restrain or sedate. Watch out! Four side rails raised together is a restraint and increases fall injury severity; it is not a safety measure for a patient who is actively trying to leave the bed.

| Intervention | Effect on fall risk in dementia | Safety concern |
| --- | --- | --- |
| Low bed position | Reduces fall distance and injury severity | Minimal; may need a floor mat |
| Scheduled toileting | Removes a common trigger for bed-exit attempts | None; promotes comfort and orientation |
| Four raised side rails | Increases fall height when patient climbs over | Acts as physical restraint; entrapment and agitation risk |
| Wrist restraints | Does not reduce falls; increases struggling | Challenging behavior in about 80% of dementia patients [2] |
| Nighttime sedation | Impairs balance and worsens confusion | Higher fall risk; medication should be minimized |

The best action is therefore to keep the bed low and toilet her on a set schedule, which protects her from injury while preserving mobility and dignity in a way that aligns with current falls-prevention guidance for older adults with cognitive impairment [1][2].References (research sources)

- [1]Understanding Risks in the Care of People With Dementia in Acute Hospital Settings: Definitions, Types and Management Strategies-A Scoping Review.Research articleBhaskaran A, Irving K, Courtney E, Gordijn B, Cantwell M. (2026) · DOI: 10.1111/jocn.70433

- [2]Night-Time Monitoring System (eNightLog) for Elderly Wandering Behavior.Research articleCheung JC, Tam EW, Mak AH, Chan TT, Lai WP, Zheng YP. (2021) · DOI: 10.3390/s21030704

## 임상 시나리오

Nighttime Bed-Exit in Hospitalized DementiaLeast-restrictive fall prevention for confused older adults
For a confused older adult attempting to climb out of bed, keep the bed in the lowest position and provide scheduled toileting with frequent rounding. Add nonslip footwear and night lights to reduce disorientation and fall risk.

A low bed shortens the fall distance and lessens injury severity if the patient gets out. Scheduled toileting addresses unmet elimination needs, a common driver of nighttime wandering in dementia.

CautionAvoid raising all four side rails or applying wrist restraints; a determined patient may climb over rails and fall from a greater height, and restraints increase agitation and injury. Sedatives worsen confusion and fall risk in dementia.

## 핵심 개념

- **Least-restrictive intervention** — Use of the least confining or controlling measure that effectively protects patient safety, preferred over restraints or sedation
- **Scheduled toileting** — Providing toileting at regular intervals to prevent urgency, discomfort, and wandering related to unmet elimination needs
- **Physical restraint** — Any method that restricts freedom of movement, including full side rails when used to prevent bed exit
- **Low bed position** — Keeping the bed at its lowest height to reduce fall distance and injury severity
- **Sundowning** — Increased confusion, agitation, or wandering in late afternoon or evening, common in dementia

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