Sundowning and Wandering on the NCLEX
Dementia behavioral care: environment, routine, redirection, safety devices over restraints.
Two dementia behaviors NCLEX tests hard. The correct answers are environmental, never chemical or physical restraint.
Sundowning
Increased confusion, agitation, and restlessness in the late afternoon and evening. Triggers: fatigue, low light and shadows, overstimulation, unmet needs (pain, hunger, full bladder), disrupted sleep-wake cycle. First nursing move: look for a physical trigger before treating the behavior.
Environment and routine
Consistent daily routine, same caregivers where possible. Bright light during the day, soft lighting before dark (shadows fuel misperception). Reduce evening noise and traffic. Cluster care earlier in the day. Limit caffeine and daytime napping. Familiar objects and photos at the bedside. Toilet, feed, and manage pain on a schedule so unmet needs never drive behavior.
Redirection beats reality orientation
In moderate-to-late dementia, arguing facts increases agitation. If the patient wants to 'go home to mother,' do not announce that mother died. Validate the feeling, then redirect: 'You miss her. Tell me about her while we fold these towels.' Reality orientation is for delirium and early dementia; validation and redirection for established dementia. NCLEX rewards the response that preserves dignity and de-escalates.
Wandering
Often purposeful to the patient: searching, boredom, discomfort, old routines (leaving for work). Interventions: secured or alarmed exits, door alarms, wander-management bracelets, ID bracelet, MedicAlert-type enrollment, camouflaged doors, safe walking paths or supervised walks to spend the energy. Alert the whole team and family. A recent move or new environment raises risk.
Safety devices over restraints
Restraints are the last resort and worsen dementia behavior: more agitation, deconditioning, injury, delirium. Same for sedatives as a convenience. The tested hierarchy: assess for cause → environmental change → redirection → increased supervision → alarms and low beds. Chemical or physical restraint only for immediate danger, with an order, time-limited, with monitoring.
Frequently asked
Patient insists on leaving to 'pick up the kids.' Best response?
Validate and redirect: 'The kids are safe. Walk with me and tell me about them.' Never argue, never bar the door with your body.
Are bed alarms restraints?
No. Alarms, low beds, and floor mats are safety devices. A device the patient cannot remove that restricts movement is a restraint.
Why not a PRN benzodiazepine for sundowning?
Benzos worsen confusion and fall risk in dementia and can cause paradoxical agitation. Nonpharmacologic measures first.
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