Preventing and managing sundowning
Distressing to the resident and difficult for caregivers to manage, sundowning typically occurs between 4:30 and 11:00 p.m. This state of increased agitation and restlessness has been observed in up to 20 percent of persons with moderate to moderately severe dementia.1 It resembles delirium because there is a rapid change in behavior. Unlike delirium, it happens every evening at the same time for the same resident without a change in physiological condition. Manifestations present as disordered cognition, attention, sleep-wake pattern or psychomotor behavior and include visual hallucinations, resistance to care or redirection, disoriented verbalization, wandering, aggression and reversed sleep-wake cycle.2 Sundowning, like delirium, may contribute to falls, injury to others, attempted elopement and removal of medical devices.
SUNDOWNING OR DELIRIUM?
Evidence suggests contributing factors for sundowning may be sensory deprivation or overload, unmet physical needs (fatigue, hunger, pain, elimination), altered levels of light, inadequate orienting cues, altered mobility, increased stress, decreased sense of security, social isolation, anxiety or fear, unfamiliar environment and/or prevailing or disrupted circadian rhythm.3 These contributing factors may differ for each patient, making it important to individualize the plan of care based on thorough assessment data that includes lifelong preferences and patterns.
It is important to distinguish between sundowning and delirium because treatment differs. Interventions for delirium are supported by strong evidence. Evidence for the treatment of sundowning is limited and often contradictory. Delirium is caused by the direct physiological consequences of a general medical condition and resolves as the medical condition stabilizes and normalcy returns. If the behavior differs from the resident’s usual evening behavior, evaluation and treatment of altered physiological condition (usually infection or new medication) are appropriate. If the same behavior occurs every evening for the same resident(s) and is a rapid change from his/her usual daytime behavior, interventions for prevention and management of sundowning are required.
These interventions fall into three categories: (1) general approaches to prevent the contributing factors, (2) individualized approaches to prevent the onset of sundowning, and (3) specific approaches to manage or eliminate problematic behaviors. The focus for all interventions is “What are the resident’s feelings and perceptions? What is the resident experiencing?”
General interventions include meeting physical and psychological needs, structuring the environment, using effective communication techniques and providing behavioral cues and appropriate social activities. Scheduled eating, toileting, pain medication, mobility, activity and rest all assist in meeting physical needs. Social activities of interest to the person, family involvement and enjoyable communication demonstrating honor and respect for the resident may prevent boredom, loneliness, fear and perceived threats, thus addressing psychological needs.
To decrease feelings of anxiety and fear, reduce chaos in the environment, listen to the resident, comply with requests, allow autonomy and don’t force or argue. A restraint-free environment with consistent lighting, sound and sensory stimulation levels helps prevent sundowning.
Behavioral interventions include redirection, cueing, companionship, gentleness and empathy. Effective communication requires nonconfrontational statements, responses consistent with the person’s reality, reassurance, one-to-one interactions and positive facial expressions.
Additional general management strategies include providing bright light during morning hours; low-carbohydrate foods and less or no caffeine during evening hours; activities, including games or pacing, during the day; a late-morning nap, if needed; calmer evening activities; family visits or simulated presence; and soft music in the late afternoon and early evening. Keep the resident’s bedtime routine as close as possible to lifetime preferences. Interventions are most effective when started about 15 minutes before sundowning symptoms begin and continued until a “tucking in” at bedtime. If agitation begins, back off and return to the resident in two to five minutes using different verbal and nonverbal communication.
Base individualized approaches to prevent the onset of sundowning on the resident’s preferences or past routines. The most effective approach incorporates multiple interventions: Take the resident to an area or room where sensory stimulation (lighting, sound, odors, etc.) is controlled, where a person who interacts effectively is present and favorite activities (including food) are available. A Snoezelen room is effective for some residents, while being outdoors (perhaps watching the sun go down) works better for others.4
The most effective specific approach to manage or eliminate problematic behaviors associated with sundowning is to have a person present with whom the resident associates positive emotions. The resident might not know his or her name, but positive feelings associated with the face and previous experiences will be perceived. This may be a relative, friend or favorite staff person. When others bring out agitation or aggression, the approach of the favored person will elicit a positive response and cooperation.
The following examples were described by participants in continuing education programs:
Jenny started going door to door, banging on them and trying to get out. Then she grabbed a wire hanger and lashed out at everyone nearby. We had to hold her down and give her an injection of Haldol. We knew next time we needed to intervene earlier and try to redirect. When she again began going door to door, I tried to talk to her about family and home and tried to get her to go to the Snoezelen room without positive outcome.
Other aides also tried. The CNA who usually cared for Jenny was called to the floor. She approached Jenny and called her by a pet name. They hugged and Jenny agreed to go with her to the Snoezelen room. The CNA listened attentively while Jenny cried and talked about her family and feelings. After about 30 minutes, they went to Jenny’s room where the CNA got her comfortable in bed, held her hand and sang to her until she fell asleep.
Just before the evening meal, Jim would enter any accessible room, take small objects and put them in his pockets. Since Jim could no longer communicate verbally, the RN talked to his sibling who said that when they were young, the entire family would play music before dinner. The children were the rhythm section using spoons, lids, pencils and other small objects. Jim was attempting to re-create that activity. When staff provided small rhythm instruments to residents and organized a “band” to play before the evening meal, Jim no longer went into rooms or took small objects.
Challenges to the recommended approaches include difficulty obtaining information about resident preferences and staff time required to implement individualized plans.5 Resident interviews, part of the MDS 3.0, should help overcome the first challenge, and information can also be obtained through interactions as care is provided. Providing enjoyable experiences during care (smiling, talking, touching gently, singing and laughing together) does not increase the time needed to complete many tasks. Educating staff about effective interventions and giving them permission to modify care based on what is effective may decrease frustration, challenging behaviors and time requirements. Although upfront time may be increased by implementing recommended interventions, time will eventually be saved by preventing challenging behaviors related to sundowning. As the quality of life for residents improves, quality of work experience for staff will improve too.
Martha Sparks, PhD, GCNS-BC, NGNA Fellow, teaches gerontology courses at the University of Southern Indiana and practices independently as a Gerontological Clinical Nurse Specialist. To contact Dr. Sparks, email
- Alzheimer’s Association. Sleeplessness and sundowning.Available at: www.alz.org/living_with_alzheimers_sleeplessness_and_sundowning.asp.
- Nowak L, Davis JE. A qualitative examination of the phenomenon of sundowing. Journal of Nursing Scholarship 2007:39:256-8.
- Wu Y, Swaab DF. The human pineal gland and melatonin in aging and Alzheimer’s disease. Journal of Pineal Research 2005:38 (3): 145-52.
- Robbins RA, Norton ES. The effects of Snoezelen intervention: How treatment impacted agitation, depression, and socialization.Available at: www.iadvanceseniorcare.com/EffectsOfSnoezelenIntervention.
- Kolanowski A, Fick D, Frazer C, Penrod J. It’s about time: Use of nonpharmacological interventions in the nursing home. Journal of Nursing Scholarship 2010:42:214-22.
Long-Term Living 2011 October;60(10):58-61