If you were to ask any professional about the phenomenon of geriatric sundowning-a burst of energy some residents experience at sundown-most could define and describe it without hesitation. It occurs in every nursing home across the country and can create serious resident-care challenges for staff.
Some of the consequences of this burst of energy are risks of wandering, falls and aggressive outbursts, all of which could cause serious injury. Our ongoing safety analysis revealed that a high number of such incidents involving our cognitively impaired residents occurred between 6:30 and 8:00 p.m. As a result of this data analysis, our continuous quality improvement team (CQIT) set forth to analyze and prevent this trend from continuing.
Initially, we evaluated all incidents occurring within this time period. Commonalities were identified and care plans modified for several residents, but it was clear that a large group of residents involved were experiencing a type of sundowners' phenomenon, characterized by:
- getting up unassisted
- wandering into the wrong room
- showing increased confusion with elevated agitation
- exhibiting increasingly repetitive actions or speaking patterns
- engaging in combative behaviors
The CQIT reviewed the incidents and the times of their occurrence and concluded that these residents could be sundowning. The team developed a program designed to occupy the attention of these particularly fragile residents at their most vulnerable time of the evening. The program was named, affectionately, "The Safety Program."
All departments were invited to participate in developing program guidelines. Social services assisted with managing behaviors, an experience that provided insight for all staff into management techniques that would promote residents' dignity and provide them with meaningful life activities. The restorative department provided physical exercise and activities appropriate to the residents' physical and functional abilities. The activity department was consulted regarding activities and equipment that might be beneficial for cog-nitively impaired individuals. Figure 1. Incidents during 1st quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m. Figure 2. Incidents during 2nd quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m. Figure 3. Incidents during 3rd quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m. Figure 4. Incidents during 4th quarters of 2000 and 2001 that occurred between 6:30 and 8:00 p.m. Figure 5. Incidents during 1st quarters of 2000 and 2002 that occurred between 6:30 and 8:00 p.m. Goals
The goals of The Safety Program were:
- to reduce incidents and accidents involving a fragile geriatric population during a recognized high-risk, high-incident time period;
- to provide appropriate therapeutic activities to enhance residents' quality of life;
- to incorporate Edenization into our safety programming; and
- to recognize the need for budgetary compliance. This program had to be implemented without additional cost to the nursing department or the facility.
Based on review of the incidents, the following criteria were developed to identify those residents who would be appropriate for this type of programming:
- residents with cognitive impairments
- residents with high safety risks, particularly falls and elopement
- residents with serious behavioral issues
- residents who were experiencing recognizable sundowning symptoms
The Safety Program Activities
The Safety Program incorporates a variety of games and activities designed to stimulate and entertain the selected residents during this high-risk daily period, under direct supervision of our qualified staff. Some examples of these activities include ball toss, reading out loud, reminiscing and/or validation, coloring, tactile stimulation and music.
We chose a competency-evaluated nursing assistant (CENA) as the hands-on leader, under the supervision of a licensed nurse.
Qualifications of the person for directing the program included: