Main image courtesy of Hospimedica.

Around 5.8 million people in the U.S. have Alzheimer's or a dementia-related condition. Many of those who are diagnosed are dealing with a specific set of behaviors physician’s refer to as sundowner syndrome. These symptoms are difficult for both family caregivers as well as nursing staff who work in long term care facilities. 

When senior residents are in hospital settings getting essential care, they may also be at risk of developing sundowner syndrome. This condition develops for a variety of reasons, which we’ll discuss, as well as some ways staff can help prevent and support these challenging behaviors. 

Although each person who experiences dementia is a unique case, training on how to effectively deal with behaviors associated with sundowner syndrome is absolutely necessary. Mariposa Training offers a variety of classes for nursing staff so they can learn how to recognize these behaviors, and provide the best care possible for their patients.  

In this article, we’re going to discuss:

• What sundowner syndrome is
• What hospital induced delirium is
• Ways to prevent sundowner syndrome in the hospital 
• Whether or not hospital induced delirium and sundowner syndrome symptoms can be treated

What is sundowner syndrome?

What type of behavior is associated with sundowner syndrome? 

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Sundowner syndrome gets its name from the time of day when the symptoms of the condition present themselves. As the sun goes down and it starts to get darker outside, people with dementia can experience a state of confusion that seems to occur daily in the late afternoon and early evening. It is not a separate condition from dementia (or delirium), but rather classified as a series of behaviors. Although typically a result of another condition, sundowning can also be induced by medication, pain, or another undiagnosed medical condition. 

The reason seniors with dementia experience sundowning is not yet fully understood, although it seems to be correlated to a disruption with the body’s internal clock, as well as changes to other biological functions.

Typical sundowning symptoms can include aggression, confusion, and anxiety, which can all be difficult to manage in dementia patients. Patients may pace or become restless at this time of day, or they could become confused when they see staff leaving and think that they are supposed to leave as well. 

 It’s important to know some of the common factors that can influence whether or not a senior dementia resident is exhibiting sundowning symptoms.

• They could be exhausted. Some dementia residents could be experiencing these types of symptoms because they’re tired. Their sleep could be interrupted, preventing them from getting the crucial amount of hours they need. Patients with sundowner syndrome could also be exhausted from being in a new and unfamiliar place. 

• The lighting is low.  As the sun sets, it gets dimmer outside as dusk approaches. If there is low lighting in their facility, it may confuse them. Lower levels of lighting may mean that they cannot see as well. It could also cause an increase in the amount of shadows that they see, which could be misinterpreted as something confusing or scary. This leads to further agitation. 

• Their biological clock is disrupted. Sundowning seems to be connected to the body’s internal clock. When the circadian rhythm is disrupted, dementia patients may have trouble deciphering between what is daytime and what is supposed to be nighttime. 

• They are disoriented and have trouble separating dreams and reality. Separating dreams from reality can become increasingly difficult as their condition progresses. This can add to the feelings of confusion and agitation. 

• They’re in pain or have an unmet need. Sometimes patients will experience confusion or aggression when they’re in pain, or they’re hungry, thirsty, need to use the bathroom, or are constipated. They could also be bored or are dealing with another underlying condition that has not yet been diagnosed such as a urinary tract infection. 

While it may be difficult to precisely determine the reason for this behavior, there are ways to help reduce the severity of these kinds of challenging behaviors.

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What is hospital induced delirium?

Seniors can experience hospital induced delirium

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If you’re in the geriatric nursing community, you’re probably already aware of delirium. This occurs when a patient experiences:

• Mood swings that appear to be sudden or out of nowhere
• They engage in behavior that seems to be contrary to their personality
• They lose initiative in their daily actions or activities that used to bring them pleasure
• There are issues surrounding their judgment or safety awareness
• They engage in attention seeking or isolating behavior

Delirium seems to overcome a patient over a short amount of time, either within a few hours, days, or weeks. This condition is typically the result of a change in the environment or a change in the patient’s body, and can be due to an underlying condition or an unmet need.

Staff typically see delirium manifest in patients when their room or roommate has been changed, and the environment is no longer the way they prefer it to be. It can also occur after a traumatic experience or while they’re enduring something that is out of their normal routine—such as a stay in the hospital. These unfamiliar surroundings can trigger feelings of confusion or aggression that are common with delirium. In addition, isolation or naturally occurring events such as a thunderstorm may also cause this condition to present itself.

Sometimes the cause can be tied to a change in the bodily experience. This can happen when they're over/under medicated, a new medication is introduced, or they’re experiencing depression due to social isolation or other circumstances. Delirium can also be the result of an unmet need such as being hungry, thirsty, bored, or dealing with an underlying condition.

Difference between delirium and dementia

Although the behaviors at times may look similar, it is crucial to point out the difference between dementia and delirium. Dementia is a disease that gradually occurs over the course of months and years. It is an irreversible condition that occurs because of the gradual degradation of brain cells. Delirium on the other hand can be reversible because it is the result of changes that are either internal or external. Once the cause of the problem is diagnosed, a solution can be found that will allow the patient experiencing delirium to return to their normal state of being. 

It is important for staff at long term care facilities as well as hospitals to be aware of the difference between the two conditions, as many seniors due to their age are misdiagnosed with dementia—when in reality they are experiencing delirium. This is especially common when they are exhibiting symptoms of sundowner syndrome when they are in the hospital. 

Ways to prevent sundowner syndrome in the hospital 

It is common for seniors to experience sundowner syndrome in the hospital, but what causes it?

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The behaviors associated with sundowner syndrome are not isolated to those patients with dementia. Seniors who are admitted to the hospital or are required to stay in short term nursing facilities can also experience this type of behavior, which can result in confusion, aggression, and anxiety. Sundowner syndrome in the hospital can be the result of hospital induced delirium. We’ve already discussed that changes in the environment, such as being admitted to the hospital, or changes to their condition, such as an increase in medications, can cause seniors to experience delirium. 

Many times the staff at hospitals do not even notice the change in the behavior of the patient because they are so busy. Delirium unchecked can cause the patient to worsen. This is why it’s important for staff to know and recognize delirium, as it can affect many seniors staying in the hospital. 

Delirium and sundowning symptoms in hospitals:

• Is common
• Can be treated
• Is often missed completely or misdiagnosed
• Can lead to worse health outcomes if it is not treated
• There is not typically just one cause for the onset of delirium

However, there are ways for staff to limit or even prevent the onset of delirium and sundowner syndrome in hospitals. 

Keep sleep disturbances minimal

It is essential for our bodies to maintain a proper circadian rhythm to keep all of our mental and physical processes functioning properly. If a patient is experiencing trouble sleeping, or something is keeping them up during the night, they may have a greater risk of developing sundowner syndrome. Staff can work to limit the amount of nightly interruptions (blood pressure checks, etc.) as well as ensure the room is a quiet place with little to no disturbances.

If the room can be kept dark, that would also be helpful, although leaving a small night light on may help the patient relax before bed knowing they can see their environment.  If it is their roommate that is causing the wakefulness during sleep hours, this may require that the patient is moved to a quieter room. 

Encourage the patient to get up

As much as they are physically able to, encourage the patient to get up and walk or move around during the daytime. They may not be tired during the night because they are not getting any movement during the day. The room should be kept brightly lit and the curtains open to allow as much light as possible in. This encourages their body’s internal clock to associate daytime with movement, and the absence of the daylight as the time to rest and sleep. 

Although they may be in the hospital due to a fall or another physical issue, it’s still important to help them move as safely as possible. Limiting the use of catheters and encouraging physical therapy as soon as they’re ready are great ways to encourage movement.  

Provide companionship

Hospital staff are busy, and there are different people on shifts at different times of day. However it can be very comforting to a senior to have someone spend a little time asking how they are or engaging in some conversation. Having someone to speak to while they’re in a new environment can help calm and reassure seniors who may be confused or anxious to get back to their familiar environment. Staff can also help patients understand what’s going on, and tell them why they need to be in the hospital.

Avoid overstimulation

Try to avoid overstimulation, especially in the late afternoon and early evening. If necessary, see if the TV can be turned off (or turned down), or if it’s possible for their roommate to use headphones instead. If they have family or friends visiting, ask if they can make their visits earlier in the day if possible, allowing the patient to wind down slowly as dusk approaches. 

Avoid sedatives and try to minimize pain

Sedatives (including sleeping pills) should be avoided when it comes to patients who experience sundowning due to hospital induced delirium. Their side effects and interactions with other drugs could potentially make things worse, and they may not help the quality of the patient’s sleep at night.

Sometimes delirium can be brought on because the patient is in pain, or is having trouble interrupting the actions of staff. This can cause them to become confused or agitated. Ask patients if they’re experiencing pain and try to explain calmly and clearly what procedures or tests are conducted on them. 

Can you treat hospital induced delirium?

Remember, delirium is treatable and can be prevented

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The elderly are more vulnerable to hospital induced delirium and sundowning symptoms. However, it can be treated. Although there can be many causes to the delirium, it’s important for staff to:

• Find and eradicate as many triggers as possible, whether it’s environmental or conditional
• Ensure that the patient is receiving supportive care
• Keep the patient mentally and physically active
• Encourage family/friends to be involved

Staff can support seniors with hospital induced delirium, but it all starts with recognizing the signs. Once the root causes are determined, staff can help minimize the problems, which will allow patients to return to their baseline. Proper training is essential for staff to give senior patients the care that they need to recover from hospital induced delirium. 

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