Which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer's disease who has night time wandering?

According to a study published by NCBI, sundowning, which increases the risk of wandering, is more common in Alzheimer's patients at night. To manage this, a nurse must develop a specific plan of care. So, which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer's disease who has night time wandering?

Quick Summary

A nursing care plan for an older adult with Alzheimer's disease experiencing night time wandering focuses on ensuring a safe environment and establishing a consistent routine. Key strategies include enhancing sleep hygiene, utilizing non-pharmacological methods to reduce agitation, and managing environmental factors to prevent wandering and reduce fall risks.

Key Points

• Structured Routine: Maintain consistent sleep and wake schedules to regulate circadian rhythms and minimize confusion.

• Safe Environment: Ensure pathways are clear, use night lights, and consider bed alarms to prevent falls and injury.

• Address Triggers: Proactively check for underlying causes like pain, hunger, or need for the bathroom to address the root cause of the wandering behavior.

• Redirect and Distract: Instead of arguing or confronting, use distraction techniques like soothing music or looking at pictures to manage agitation.

• Personal Comfort: Keep familiar, comforting items nearby to provide a sense of security and reduce anxiety.

• Team Collaboration: Educate family members and work closely with the care team to ensure a consistent and effective approach.

• Ongoing Evaluation: Continuously monitor and document wandering episodes and the patient's response to interventions to adjust the care plan as needed.

Implementing a Structured Routine to Manage Sundowning

For an older adult with Alzheimer's disease who experiences night time wandering, a structured daily routine is one of the most effective non-pharmacological interventions. This helps to re-establish a more normal circadian rhythm, which can be disrupted by dementia, leading to 'sundowning'—a state of increased confusion and agitation in the evening. By providing consistent schedules for meals, activities, and bedtime, the nurse helps to create predictability and reduce the patient's anxiety and disorientation.

Steps for Developing a Routine

• Maintain Consistent Wake-Up and Bedtimes: Ensuring the patient wakes up and goes to bed at the same time every day can help regulate their internal clock.
• Schedule Daytime Activities: Include engaging and physically stimulating activities throughout the day. This might involve walking, gardening, or simple exercises to promote a healthy energy expenditure that encourages nighttime sleep.
• Provide Adequate Light Exposure: During the daytime, it is beneficial to expose the patient to natural light by opening blinds and encouraging time outdoors. This reinforces the day-night cycle.
• Wind-Down Routine: In the evening, a calm, relaxing routine should be established. This might include listening to soothing music, looking at family photos, or a warm bath, to signal that it is time to prepare for sleep.

Environmental Modifications for Safety and Prevention

Creating a safe and secure environment is a top priority for patients with night time wandering. Environmental interventions are practical and can prevent injury without resorting to restraints or sedatives, which can increase agitation and confusion. A thoughtful approach to the physical space can make a significant difference.

Comparison of Interventions

Intervention Category	Specific Example	Benefits	Risks/Considerations
Environmental Control	Installation of bed/chair alarms	Notifies staff of patient movement; improves supervision.	Can be frightening or distressing for some patients; must be used appropriately to avoid startling the individual.
Environmental Control	Use of night lights in hallways and bathrooms	Reduces disorientation and risk of falls in the dark; helps guide the patient.	Bright lights may disrupt sleep for some; lighting needs to be subtle and not too harsh.
Behavioral Management	Redirection and distraction techniques	De-escalates agitated behavior; avoids confrontation.	Requires skilled staff training; may not work for all individuals at all times.
Behavioral Management	Providing a security object	Offers comfort and familiarity; reduces anxiety.	Effectiveness varies by individual; patient may still wander for other reasons.
Medication (Pharmacologic)	Sedatives or sleep medication (last resort)	May induce sleep for some patients.	Can increase confusion, disorienting effects, and risk of falls; can be a chemical restraint.

Managing Behavioral Triggers and Sensory Needs

Night time wandering can be triggered by various factors, including pain, discomfort, the need to use the bathroom, or sensory overload. A comprehensive nursing plan will address these potential triggers proactively. It is crucial to monitor the patient's non-verbal cues and attempt to interpret their needs, as their ability to communicate effectively may be impaired.

Addressing Triggers Through Nursing Action

• Assess for Discomfort: Regularly check for signs of pain, hunger, thirst, or a full bladder. A simple offer of a snack, drink, or a bathroom visit can sometimes prevent the urge to wander.
• Provide a Familiar Environment: Keeping personal items, like photos or a favorite blanket, within reach can provide a sense of security and familiarity. Maintaining a consistent room layout also reduces confusion.
• Reduce Excess Noise: Minimize disruptive noises during the night. A quiet environment is crucial for promoting restful sleep. Avoid leaving televisions or radios on unless used as a specific, calming technique.
• Use Visual Cues: Simple signage or contrasting colors can help guide the patient. For example, using a different color for the bathroom door or a dark mat outside the room entrance can sometimes be a visual deterrent.

Conclusion: A Holistic Approach to Care

The most effective nursing home plan of care for an older adult with Alzheimer's who has night time wandering is a multifaceted and individualized approach. The plan must prioritize patient safety by managing the environment and providing close supervision, without resorting to physical or chemical restraints. Establishing and maintaining a consistent daily routine, particularly with regard to sleep hygiene and daytime activity, helps to regulate the patient's internal clock and reduce 'sundowning' symptoms. By addressing both the behavioral triggers and the environmental factors that contribute to wandering, the nurse can significantly improve the patient's well-being and safety, ensuring a higher quality of life for the individual with Alzheimer's disease.

Visit the Alzheimer's Association website for more information on managing dementia-related behaviors.

Nursing Communication and Collaboration

Finally, effective communication and collaboration are essential components of the nursing plan. This includes not only communicating with the patient but also involving their family and other members of the healthcare team. Educating the family on the nature of wandering and the strategies being implemented can help them understand and support the care plan. Regular updates and a collaborative approach ensure consistency and the best possible outcomes for the patient.

• Family Education: Teach family members about distraction techniques and how to avoid frustrating “why” questions.
• Team Huddles: Regular meetings with nursing assistants, therapists, and other staff members ensure everyone is on the same page regarding the patient's care plan and any recent behavioral changes.

Monitoring and Evaluation

A critical part of the nursing process is continuous monitoring and evaluation of the implemented interventions. The nurse must document the frequency, timing, and possible triggers of the wandering episodes to assess the effectiveness of the care plan. This ongoing assessment allows for adjustments to be made, ensuring the plan remains relevant and effective as the patient's condition progresses.

• Track Wandering Incidents: Keep a log of when wandering occurs, where the patient goes, and what might have triggered it.
• Assess Patient Response: Document how the patient responds to interventions like redirection or distraction.

This continuous loop of assessment, intervention, and evaluation is fundamental to providing high-quality, person-centered care for an individual with Alzheimer's disease and night time wandering.

Frequently Asked Questions

What is sundowning and how does it relate to night time wandering?

Sundowning is a state of increased confusion, agitation, and disorientation that occurs in the late afternoon and evening in individuals with dementia. It is a common trigger for night time wandering, as the patient's disrupted circadian rhythm can cause restlessness and a desire to walk around when they should be sleeping.

Should a nurse physically restrain a patient who is wandering at night?

No, physical restraints are not recommended and are generally contraindicated. Restraints can increase agitation, frustration, and the risk of injury. Nursing interventions focus on non-restrictive methods like environmental modification, behavioral management, and redirection to ensure patient safety.

What is a simple environmental change that can help with wandering?

A simple but effective change is to use night lights in the patient's room, bathroom, and hallways. This can help prevent falls and reduce disorientation by providing enough light to see clearly without disrupting the sleep-wake cycle with harsh lighting.

How can music help a wandering Alzheimer's patient?

Music can be a powerful tool for distraction and relaxation. Playing familiar, soothing music during the evening can help calm the patient and signal that it's time to wind down for bed, which can help prevent wandering episodes.

Is it helpful to orient the patient to the time and place frequently?

Attempting to reorient a patient with advanced dementia and memory loss can be frustrating for them and is generally not effective. The nurse should instead use validation and distraction techniques to manage behavior, as repeatedly correcting the patient can increase anxiety.

What role does the family play in managing night time wandering?

The family can provide valuable insights into the patient's habits and preferences. Educating them on the care plan, providing strategies for communication, and involving them in activities can help create a consistent and supportive environment, which is crucial for managing wandering.

When should medication be considered for night time wandering?

Medication, such as sedatives, should generally be considered a last resort after non-pharmacological interventions have been explored. These drugs can cause increased confusion, disorientation, and a higher risk of falls. They may be used in severe cases under strict medical supervision and when absolutely necessary.