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