Sundowning in elderly patients is a common and distressing condition that often worsens during hospital stays. It refers to increased confusion, agitation, or anxiety that appears in the late afternoon or evening.
For families, it can be heartbreaking to watch a loved one’s symptoms intensify when they’re already vulnerable.
Hospitals can make sundowning worse because of bright lights, unfamiliar surroundings, and constant disruptions. It’s natural to feel worried about how to handle these episodes and what can help calm your loved one.
The encouraging news is that there are proven strategies to ease sundowners in hospital settings and restore a sense of calm.
Quick Rundown
- Sundowning causes confusion, agitation, and restlessness in elderly patients, especially in hospitals.
- Unfamiliar environments, poor sleep, and medical routines often trigger symptoms.
- Simple interventions like consistent routines, soft lighting, and familiar objects can help.
- Caregiver support and communication with staff make a big difference in outcomes.
- Knowing what to expect helps families reduce fear and stress during hospital stays.
With this understanding in place, let’s look closer at what sundowning in the hospital means, why it happens, and what you can do to help.
What Is Hospital Sundowning?
Sundowning syndrome occurs in approximately 20% of people with dementia and Alzheimer’s disease
1. It is characterized by a cluster of symptoms that typically emerge in the late afternoon or early evening, including:
- Disorientation and confusion
- Restlessness and agitation
- Anxiety and fear
- Hallucinations
- Mood swings and emotional distress
- Potential physical aggression
- Sleep disturbances
While sundowning can occur in various settings, hospital sundowning specifically refers to the manifestation of these symptoms in a hospital, hospice, or nursing home environment
Causes and Risk Factors
The exact cause of sundowning remains unclear, but researchers believe it may be linked to disruptions in the circadian rhythm.
Several factors may contribute to or exacerbate sundowning symptoms in hospitalized elderly patients:
- Circadian rhythm disruptions: Changes in sleep-wake cycles due to hospitalization can trigger sundowning.
- Unfamiliar environment: The hospital setting can be disorienting and stressful for elderly patients.
- Medication side effects: Certain medications, particularly those used to treat incontinence, depression, or insomnia, may worsen sundowning symptoms.
- Pain and discomfort: Unmanaged pain can increase agitation and confusion.
- Sensory overload or deprivation: Both lack of stimulation and overstimulation can contribute to sundowning.
- Dehydration and malnutrition: Unmet physical needs can exacerbate symptoms.
Sundowning vs. Hospital Delirium
It’s crucial to differentiate between sundowning and hospital delirium, as they require different management approaches. Here’s a comparison:
| Characteristic | Sundowning | Hospital Delirium |
|---|---|---|
| Onset timing | Late afternoon/evening | Any time of day or night |
| Duration | Several hours | Can last for days or weeks |
| Predictability | More predictable | Often sudden and unpredictable |
| Setting | Can occur in various settings | Primarily in hospital settings |
Hospital delirium affects approximately one-third of patients over 70 years old and requires immediate medical attention, according to the National Library of Medicine.
Management Strategies
While there’s no single cure for sundowning, a combination of environmental, behavioral, and medical interventions can help alleviate symptoms:
Maintain a consistent routine: Stick to regular meal times, activities, and sleep schedules.
Optimize the environment:
- Increase lighting in the evening to reduce shadows and confusion. 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 sun is rising. When the lights were all turned on in his apartment, it seemed to help him better comprehend the time of day.
- Minimize noise and distractions during the evening hours. Also, minimize TV watching and other stimulating activities as bedtime approaches.
- Ensure comfortable room temperature and familiar objects from home if possible.
Consider assistive technology:
- Use motion sensors, bed alarms, or monitoring systems to alert caregivers of nighttime wandering or other potentially dangerous behavior.
Address physical needs:
- Manage pain effectively
- Ensure proper nutrition and hydration
- Encourage regular physical activity during the day
Medication management:
- Work with healthcare providers to review and adjust medications that may contribute to confusion or sleep disturbances.
- Consider melatonin supplements under medical supervision to help regulate sleep-wake cycles.
Non-pharmacological interventions:
- Help to calm the person by using soothing music or nature sounds to create a relaxing atmosphere, especially during the evening hours.
- Implement relaxation techniques such as gentle massage or aromatherapy.
- Engage in familiar, comforting activities during high-risk periods.
- Try to limit any napping during the day in those people who have a hard time sleeping at night.
- 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.”
Emerging Technologies That May Help With Sundowning
There are several emerging technologies and tools that show promise for monitoring and managing sundowning symptoms in hospital settings. Some could potentially be used in the home, as well:
Bright light therapy: While not a new technology, advanced light therapy devices delivering specific intensities (e.g., 10,000 lux) have shown positive effects on motor restlessness in dementia patients experiencing sundowning.
Digital symptom diaries: Mobile apps or tablet-based tools for caregivers to log daily observations of sundowning symptoms and potential triggers can help identify patterns and inform personalized management strategies.
Circadian lighting systems: Advanced lighting systems that automatically adjust light intensity and spectrum throughout the day to mimic natural daylight patterns may help regulate patients’ circadian rhythms and reduce sundowning symptoms.
Medication management systems: Smart pill dispensers or reminder systems can help ensure patients receive the right medications at the right times, potentially reducing medication-related triggers for sundowning.
Final Thoughts
Sundowning syndrome can be challenging for both elderly patients and their caregivers, especially in hospital settings.
By understanding the causes, recognizing the symptoms, and implementing appropriate management strategies, healthcare providers and family members can work together to improve the quality of life for seniors experiencing sundowning.
If you suspect your loved one is experiencing sundowning in the hospital, don’t hesitate to discuss your concerns with the healthcare team.
With proper management and support, the impact of sundowning can be significantly reduced, leading to better outcomes for hospitalized elderly patients.
