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What Is Sundowners In The Hospital In Elderly Patients?

senior lady lying in hospital bed and looking out the window

Recently, we wrote an explanatory guide to sundowning, which is characterized by confusion and other symptoms in dementia and Alzheimer’s patients later in the day. However, this doesn’t only happen at home but can happen in the hospital.

What is sundowner’s syndrome in the elderly in the hospital?

Sundowning can occur in the elderly in the hospital, with symptoms such as mood changes, restlessness, confusion, anxiety, sleeplessness, and possible physical aggression.

Creating a comfortable environment, revising medications, and avoiding stimulants can alleviate sundowning in the elderly.

This guide to hospital sundowning will explain when the onset of symptoms begins, what to expect when it happens, and how to differentiate sundowning from hospital delirium. 

Let’s get started. 

What Is Hospital Sundowning?

Sundowning syndrome, also known as sundowner’s syndrome, occurs in roughly 20 percent of people who have dementia and Alzheimer’s disease. 

Hospital sundowning is when the symptoms of this syndrome take place in a hospital setting such as hospice or a nursing home. 

To recap our last post, sundowning is characterized by symptoms such as:

  • Disorientation or late-day confusion
  • Pacing or restlessness
  • Wandering
  • Hallucinations
  • Agitation
  • Anxiety or fear
  • Depression or deep upset (sometimes to the point of crying)
  • Potential physical aggression
  • Trouble sleeping

It’s named after the time of day when symptoms begin, which is late into the afternoon or early evening as the sun starts setting. However, the symptoms may occur in the morning hours in a small subset of people. 

Sundowning can occur in those who have certain forms of dementia, but it also happens in older adults who may not have a dementia diagnosis. Sundowning can also happen towards the end of life, as it did for both of my parents.

Sundowners syndrome isn’t a disease, per se. It’s a group of symptoms and behaviors.

Adult children, caretakers, and hospital staff will notice that the patient may seem like themselves in the morning and afternoon. However, as daylight wanes, the symptoms will typically begin.

The symptoms of sundowner syndrome usually continue into the evening but will not last all night.

However, the sleep struggles that these experiences can leave dementia patients exhausted, even if they eventually get some shuteye. 

The next day, the same schedule resumes, so the patient’s needs are very up and down.  

What Is An Example Of Sundowning?

Here is an example of how sundowning might affect older people during or for awhile after hospital stays so you can get a clearer picture.

It’s a typical day with an elderly patient in the hospital. They wake up, eat breakfast, and receive their first dose of medication.

Depending on their health and mobility, they might spend the rest of the morning resting or participating in light, engaging activities such as arts and crafts.

Throughout the morning, their disposition remains the same as usual. They could be more agitated if they’re in a lot of pain or frustrated with their progress, but their mood is stable and mostly predictable.

Around noon, the patient will have lunch and take more medication if necessary. They might take a nap if they haven’t already. The afternoon could be spent resting or perhaps visiting with loved ones. They might also take up more activities if allowed. 

The patient’s mood should remain about the same throughout the afternoon. If anything, the patient might be even happier if they received a visit from family. 

As the afternoon wears on is when the behavior changes begin.

The patient might begin seeing things that aren’t there as the end of the day approaches. Their confusion begins to spike.

While they might have been cognizant of where they were and what they were doing all day, that changes at night. 

The decrease in light and increase in shadows can worsen the hallucinations and visions, driving fear into the patient’s heart. Their confusion, agitation, and anxiety will spike into the evening. 

They might not want to eat or take their medication and calming them down might prove difficult.

It may be next to impossible for professional caregivers or family members to calm down the dementia patient or get the person to go to bed, much less to get a good night’s sleep.

After several arduous hours of this behavior, the patient will begin to calm down enough to get some rest.

However, by this point, they might have missed meals and medication and lost the hours of sleep they needed.  

What Causes Sundowning In Patients?

Sundowning is difficult for elderly people, as it causes a lot of panic that can leave them fatigued. It’s also strenuous on family caregivers, as they often need a break just when sundowning hits its peak.

What is the exact reason for sundowner’s syndrome so that caregivers might lessen its effects?

Experts haven’t pinpointed a clear cause yet. Some think it’s tied to a disruption in the person’s circadian rhythms.

There may be one underlying cause or several, but here are some risk factors that researchers and medical professionals believe could contribute to this state of confusion.

Boredom

Sitting around in the hospital can get boring for a patient, as their life follows the same routine day in and day out throughout their stay.

The lack of stimulation could set the stage for sundowning syndrome. However, overstimulation can also worsen it.  

Pain

Older patients with dementia or Alzheimer’s patient who live with recurring pain are good candidates for experiencing sundowning.

The pain can make them more agitated and depressed, possibly even causing aggressive behavior. 

Depression

Sundowning can significantly affect the elderly person’s mood, causing extreme distress to the point of crying in some patients.

Patients with diagnosed depression should be monitored for sundowning, as depression could cause the onset of the symptoms of sundown syndrome.

Thirst, Hunger, Or Other Needs

Unmet needs can cause discomfort in a patient, triggering sundowning symptoms, especially if their needs go unmet later in the day. 

Exhaustion

A tired hospital patient is likelier to see things that aren’t there, including shadows growing in the diminishing natural light as daylight fades. 

Biological Clock Changes 

The most likely cause of sundowner’s syndrome is changes to one’s circadian rhythm.

Older adults frequently don’t sleep as soundly as younger adults, and a lack of sleep could leave them agitated and more susceptible to experiencing sundowning. 

Medication Side Effect

According to an article on A Place For Mom, “Side effects of both prescription and over-the-counter medications may cause rapid behavioral changes in people with dementia. Medications used to treat incontinence, depression, or insomnia should all be used cautiously and may produce sundowning-like behaviors or worsen sundowning symptoms.”

What Is The Difference Between Hospital Delirium And Sundowning?

Hospitalized elderly can experience another condition that mimics sundowning, known as hospital delirium. Let’s explore, then compare it to sundowner’s syndrome.

Hospital delirium is known as hospital-induced or hospital-acquired delirium.

This mental impairment can affect “a third of patients 70 years old and above,” according to the National Library of Medicine.

The symptoms of hospital delirium include the following:

  • Restlessness 
  • Rambling
  • Personality changes
  • Mood swings
  • Sleep difficulties
  • Difficulties with eating, reading, speech, and memory
  • Disorientation and confusion 
  • Hallucinations and paranoia
  • Agitation
  • Withdrawing
  • Distractions
  • Lack of focus 

It sounds a lot like sundowning, so how do you tell the difference? Here are some methods you can rely on.

The Time Of Day The Symptoms Occur

To reiterate, sundowning symptoms typically begin in the late afternoon into the evening. You’ll recall it can occur in the morning, but this is uncommon. Hospital delirium can happen at any time, day or night.

An Alzheimer’s or dementia patient experiencing confusion, agitation, and hallucinations in the morning or late into the evening likely has hospital delirium, not sundowner’s syndrome. 

The Suddenness Of Symptoms

Hospital delirium can come on suddenly, and since it can occur anytime, it’s much more unpredictable.

Caretakers overseeing the elderly with sundowners will notice the onset of symptoms is more foreseeable by comparison.

The Duration Of Symptoms

Another difference between sundowning and hospital delirium is how long the symptoms last.

Sundowning traditionally affects a patient between the late afternoon and evening hours, whereas hospital delirium will come and go in shorter bursts. 

The Setting The Symptoms Occur In 

Where the symptoms occur can also be an indicator.

If a patient experiences mood changes and concentration difficulties in a hospital setting only, it’s likely due to hospital delirium.

Sundowning can happen anywhere, including an elderly patient’s home. 

How To Manage Sundowning

No one thing will magically stop sundowning, but trying a combination of some of the following suggestions may help.

  • The Alzheimer’s Association recommends you “reduce stimulation during the evening hours. For example, avoid watching TV, doing chores or listening to loud music. These distractions may add to the person’s confusion.”
  • They also say you should try to limit any napping during the day in those people who have a hard time sleeping at night.
  • The AARP reports that bright lights may help: “As it gets dark outside, increase indoor and even outdoor lighting.” My father went through sundowning after a hospital stay near the end of his life. He saw the shadows of night approaching, but to him it was the shadowing you see at dawn. When the lights were all turned on in his apartment, it seemed to help him better comprehend the time of day.
  • They also recommend trying some soothing music as a distraction.
  • WebMD says to limit caffeine and sweets to only the morning hours.
  • They also suggest that you “Make a big lunch, and keep their evening meal smaller and simple.”
  • The National Institute on Aging says getting physical exercise can help. They also say, “Go outside or at least sit by the window—exposure to bright light can help reset the person’s body clock.”
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