What is Sundowner Syndrome?

• Patients with delirium or dementia can have Sundown Syndrome, a diagnosis in which emotional and behavioral changes occur beginning in the late afternoon. 
• Mood swings, restlessness, and hallucinations can be symptoms of Sundown Syndrome, along with screaming, disorientation, and resistance. 
• Sundown Syndrome can occur at any stage of dementia, although many nurses observe the behaviors primarily in the middle stages. 

As a nurse caring for a patient with delirium or dementia, the late afternoon can be a challenging time of your shift. And for some patients, it can lead to changes in emotions and behaviors ranging from one person to another.

This is a phenomenon called Sundown Syndrome. There’s no single explanation as to why this happens, but research has suggested it can be caused by a disruption in the circadian rhythms.

As a new nurse working in long-term care, I remember how unequipped I felt during my first experience in managing a resident experiencing Sundown Syndrome, which inspired me to write this article for other nurses. Nurses must be equipped to handle all types of scenarios that present themselves during a shift, but in the case of a sundowning patient, things can go from bad to worse quickly

Now that we know what Sundown Syndrome is, what behaviors should we look for in our patients? What are some nursing inventions that can be implemented? By the end of this article, I hope you have the answers to those questions.

Symptoms of Sundown Syndrome

Patients who have dementia, and some other conditions, can undergo “sudden emotional, behavioral, or cognitive changes” as sundown approaches, according to AARP. Those can include: 

• Mood swings 
• Anxiety 
• Sadness 
• Restlessness 
• Energy surges 
• Increased confusion 
• Hallucinations 
• Delusions

These changes may also lead to challenging behaviors such as:

• Pacing 
• Rocking 
• Screaming 
• Crying 
• Disorientation 
• Resistance  
• Anger 
• Aggression 
• Violence

Many patients experiencing Sundown Syndrome feel the urgent need to go somewhere or do something, but they can’t always explain why. For some patients, the behavior doesn’t last long, while for others it continues for hours. Some patients alter their sleep schedule to be awake at night and sleep during the day. 

Causes of Sundown Syndrome

There are many theories about why Sundown Syndrome happens, and the triggers vary among patients who have dementia. Some might be triggered by dimming light, an indicator that it’s time to change activities or go home. Evening and darkness might bring up fears of being unsafe and insecure. Whatever the cause, seeing a patient with these symptoms can be distressing for nurses and other caregivers. 

In Which Stage of Dementia Does Sundown Syndrome Occur?

Sundown Syndrome can occur at any stage of dementia, although many nurses have seen the behaviors heighten in the middle of the diagnosis and then subside as the disease progresses. 

Nursing Interventions to Reduce Sundown Syndrome

1. Observe and minimize triggers

Be aware of actions or emotions that could prompt Sundown Syndrome behaviors. Among those are seemingly normal events and activities like transitioning to the afternoon. For example, does the unit get chaotic and noisy as people get ready for bed? Are there loud noises or cross talk during mealtimes? Is there a caregiver shift change? 

Observe for possible nutritional triggers and adjust eating and drinking schedules as needed. Caffeine and sugar can also be too stimulating. Having liquids later in the day can cause increased toileting needs in these patients, making them more restless at night. Try to limit the amount of liquids they have close to bedtime.  

2. Maintain routines and structured activities

Increased activity earlier in the day and limited naps can be part of a standard routine, according to AARP, along with limiting the number of stressful tasks in evening hours. 

3. Keep a regular daily routine

There’s security in the familiar. Keeping a regular routine will help the patient feel secure and decrease anxiety as they will know what to expect daily.  

 4. Simplify surroundings

Environmental chaos can be difficult for dementia patients.

“Too much sensory stimulation can cause anxiety and confusion, worsened by changing light,” according to AARP. “Remember their brain is being damaged by dementia and it can be very challenging for the brain to view and process visual information.” 

5. Modify the environment for sleep

Minimize clutter in the patient’s room and ensure their living area is calm and comfortable. Use dark curtains or dim night lights for safe navigation. Evaluate patients for any sleep disturbances such as sleep apnea. 

6. Validate and distract

Simply trying to reason with a patient in the middle of a Sundowner Syndrome episode will not work. Instead, validate your patient’s feelings even if they don’t make sense to you. Redirect their attention to activities or people they enjoy. 

7. Play music and calming sounds

Playing music the patient enjoys, nature sounds, or white noise can help patients who have dementia fall asleep faster and stay asleep through the night.

8. Stay calm

Your patients will notice even subtle nonverbal behaviors and may respond unpleasantly. This can quickly escalate, so it’s imperative that you’re aware of your own stress and that you present a calm demeanor. 

Risks of Sundown Syndrome

Wandering is the most critical concern for those who have Sundown Syndrome. Dementia patients who wander might not be able to find their way back, “especially when they are experiencing several other symptoms that may be frustrating or confusing,” according to CenTrak. Long-term care facilities know this can be a danger for patients. They try to keep patients with dementia in closely monitored areas, but they do not want these patients to feel as though they are on lockdown or alarm their families.  

How to Manage Patient Wandering

Many long-term care communities use patient security platforms to keep patients safe without the patients feeling as though they have less freedom. These devices, or tags, provide certain access points within a designated area. Patients are provided with the appropriate level of protection from wandering into dangerous areas. Frequent safety checks can also be incorporated into a patient’s care plan. Frequent checks are typical, however, patients who struggle with dementia and other cognitive declines might benefit from even more frequent checks to ensure safety. 

The Bottom Line

At some point, you might have to care for a patient experiencing Sundown Syndrome. Knowing important triggers and interventions can make your job as a nurse much more effective and keep the patient calm. Verbal communication is key in working with coworkers to safely care for the patient during this time. Discussing the care plan with the oncoming nurse at shift report can help make the transition easier for all involved and help keep your patients safe. 

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