How to Prepare for and Manage Sundowning Patients

Rachelle Klein

This article discusses sundowning, also known as late-day confusion, in patients with Alzheimer’s and other forms of Dementia and the best way to plan for and manage it.

As a nurse caring for a patient with delirium or dementia, the late afternoon can be a difficult time of your shift, and for some patients, it can lead to changes in emotions and behaviors ranging from one person to another. This is a phenomenon called sundown syndrome. There is no exact reason to explain why this happens, but research has suggested it can be caused by a disruption in the circadian rhythms. Nurses must be equipped to handle all types of scenarios that present themselves during a shift, but in the case of a sundowning patient, things can go from bad to worse quickly. Now that we know what sundowning is, what behaviors do we look for in our patients?

Signs of Sundowning

Patients can experience sundowning at any stage of dementia, but most commonly in the middle to late stage. The most common changes in behavior are:

Agitation or irritability
Restlessness or pacing
Crying or sadness
Yelling or shouting
Increased confusion
Hallucinations or delusions
Wandering
Sleep disturbances
Violence

Interventions to Prepare and Manage

1- Start to remove stimulating factors

Take notice of things that may aggravate the patient, such as noise, lights, too many people/disturbances, soiled clothing, etc. Minimizing physical, visual, and auditory clutter, which can be sundowning triggers. Also, if the patient normally wears glasses or hearing aids, it is a good idea to make sure they have them to avoid unnecessary frustrations.

2 - Keep the patient in a consistent routine

New changes to routines may cause anxieties in your patient that they cannot articulate, so they act out instead. Habitual routines can be comforting when a patient is in a hospital setting. It is also important to try and maintain a regular sleep/nap schedule, as being overly tired can contribute to a possible cause of sundowning.

3 - Monitor the patient’s diet

The patient may be sensitive to missing meals which may affect blood sugar and mood. Keeping adequately hydrated and nourished throughout the day will help to avoid nutritional triggers. Reduce the amount of caffeine and sugar, especially later in the day, as they can be overstimulating.

4- Nonmedication therapies

Promoting a calming environment for the patient can work wonders to ease into the sundowning areas. Playing soothing music and sounds is helpful as well as keeping photos of loved ones in sight for comfort. If they are restless, try a simple game or activity for distraction or read a book to the patient.

5- Plan for sleep and night-time disturbances

It can be very likely that a patient experiencing sundowning may continue into the night. Keep the lighting bright during the day and dark at bedtime, and make bedtime at the same time each night. Keep the room temperature in a comfortable setting. Check for medication side effects that may cause sleep disturbances.

6- Prepare for both nurse and patient safety

The patient may begin to wander or attempt to leave the room as confusion sets in, so it is important to remove all fall or tripping risks, such as electrical cords or objects on the floor. A bed alarm is sometimes necessary in certain cases. Some patients will require medications or restraints for violent behavior to protect the patient, other patients, and staff. Keep a safe distance to avoid injury if the behavior is escalating. Only use restraints, if necessary and provider-ordered, as this will further aggravate the patient.

Conclusion

At some point or another, you may have to care for a patient experiencing sundowning. Knowing important triggers and interventions can make your job as a nurse much more effective. Verbal communication is key with coworkers in working together to care for the patient during this time. Discussing your sundowning care plan with the oncoming nurse at shift report can help make this transition easier for all involved. The next shift will thank you for it!

References/Resources

Tips for Coping with Sundowning

Sundowning and dementia

Sundown Syndrome