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Managing the sundowning patient.


Sundowning or nocturnal delirium can be defined as a marked increase in confusion, disorientation and possibly agitation in an elderly or severely cognitively impaired subject at sunset or when daylight is reduced. Other clinical manifestations associated with sundowning are screaming, paranoidal/delusional thinking, moaning and wandering (Prinz and Raskind, 1978).

Although there are no prevalency studies of sundowning, it would appear to be endemic to the residential treatment of the cognitively impaired adult. Evans in her study at a nursing home facility working with elderly subjects found that approximately one in eight (12.4%) of her patients exhibited some form of marked change in their cognitive status at sunset. The experience of this rehabilitation program would suggest that its prevalence will depend largely on the diagnostic group within which the patient falls. Furthermore, as a general rule, the degree to which a patient is cognitively compromised may be a significant factor in determining predisposition towards sundowning.(1) Nevertheless, as can be seen from Table 1, irrespective of overall percentage of patients affected, sundowning would appear to touch virtually all groups in which there is some degree of cognitive involvement.

In view of the increased demand on resources that sundowning will present, it will be essential for the rehabilitation team to have developed a policy which will insure a comprehensive evaluation and intervention. The following article attempts to assist the reader with this goal by outlining a treatment strategy that will address both the patient's needs as well as insure appropriate use of team resources.


A number of studies have looked to account for nocturnal delirium in various ways including in terms of disturbance in circadian rhythm and/or changes in sleep cycles. For instance, TABULAR DATA OMITTED Feinberg, Koresko, and Shaffner (1965) examined differences in sleep cycles between a group of young adults and cognitively impaired elderly subjects. They reported that the elderly subjects experienced an earlier onset of dream periods along with more frequent and abrupt awakenings. On the basis of this, they speculated that nocturnal delirium might be seen as a product of an abrupt transition from dreaming to wakefulness and consequent intrusion of dreams into a waking state. Other studies have looked to broaden their search of precipitating factors by examining a number of other physiological indices. As an example, Evans (1987) reviewed the medical charts of a large group of elderly institutionalized subjects who were experiencing sundowning. She demonstrated a significant relationship with a number of physiological variables including disturbed circadian rhythms. Evans nevertheless noted that those physiological factors alone cannot fully account for sundowning since a number of non-sundowning patients shared a similar medical status. Evans therefore suggested that we consider psychological variables such as the role of stress as crucial in understanding sundowning. Wolanin and Phillips (1981) while acknowledging the physiological correlates of confusion emphasize the interaction with staff as crucial in assessing more broadly confusion with the cognitively impaired. Kral (1975) with greater specificity stressed the importance of psycho-social stressors such as bereavement and loss of independence as precipitants to confusion in the cognitively impaired subject. Other authors besides looking at psychological and physiological variables have looked at environmental factors as crucial (Cameron, 1941). In an often cited study Cameron placed a group of

elderly subjects suffering from nocturnal delirium in a darkened room and found that without repeated visualization they would not be able to preserve the orientation of objects (i.e. exits, windows, etc.). His subjects consequently experienced difficulty in orienting themselves and became easily confused.

In summary, most studies that have attempted to explain sundowning or nocturnal delirium have tended to fall into one of three groups (psychological, environmental, and physiological) according to the specialty of the author. Recommendations for both assessment and intervention have as a consequence tended to follow the author's discipline as noted above. This paper offers an interdisciplinary strategy for assessment and intervention of a sundowning patient by culling the recommendations provided from various sources. As will be seen in reviewing these recommendations, a strategy has been developed with the multidisciplinary inpatient rehabilitation team in mind. We do not here attempt to review modifications to this approach as it might apply to numerous other residential settings to which sundowning may be an issue but rather have left our suggestions sufficiently broad so that certain aspects of the procedure may be addressed in a multi-disciplinary fashion. For instance, an assessment of staff/patient conflict need not be assessed by the psychologist but may, in fact, be most advantageously accomplished by any team member in a supervisory role to the individuals most immediately involved in the conflict, i.e., unit nurse manager. Other aspects of the assessment and intervention procedure are of course restricted to certain disciplines and although not specified will be quite apparent to the rehab team, i.e., determining whether the patient is suffering from a reversible medical condition will need to be addressed by the medical staff of the rehabilitation team.

Assessment and Intervention

1. Evaluation.

The evaluation of sundowning will follow essentially in all details the criterion for the diagnosis of delirium.

A cardinal difference for sundowning when contrasted with delirium will be that delirium tends to be relatively brief (a matter of hours or days) and furthermore although delirium may fluctuate during the course of the day it will not share the marked onset and exacerbation instigated by changes brought on by late afternoon or early evening hours. Whether the pathophysiological mechanisms involved with the demented patient in the onset of sundowning are the same or similar to delirium is not known at present (Lipowski as cited by Evans 1981), therefore the differentiation between sundowning and delirium will be made essentially on the basis of the time of onset and cessation as noted above.

2. Medical Status: Reversible medical condition?

Whether as a product of a traumatic or nontraumatic degenerative process, the sundowning patient will be to some degree cognitively and medically compromised prior to the onset of sundowning. In the case of the demented patient, the dementia does not preclude the possibility for delirium but may in fact be a pre-condition for nocturnal delirium to take place(2). Therefore, staff should not rule out the possibility for intervention on the basis of the presence of dementia. Close scrutiny will need to be paid to the possible causative factors acting as precipitants to the delirium.

As a rule deliriums are, when contrasted with dementia, more than symptomatically treatable and may in fact be reversible. This will, therefore, need to be the treatment team's most immediate objective in attempting to negotiate a patient's sundowning. An example of this was with a 67-year-old male patient who was suffering from severe myoclonus secondary to a non-traumatic head injury. The patient was treated, in part, with L-5-hydroxytryptophan in an attempt to control the myoclonus, but was found to be delusional with an exacerbation in his disorientation by late afternoon, early evening. A simple reduction in dosage resolved both the delusional thinking as well as the temporal disorientation.

3. Staff/patient conflict.

Wolanin (Wolanin & Phillips, 1981) reviewed a series of patients' charts on an inpatient geriatric unit in which the patients were identified as confused. What she found was a lack of uniformity in the definition of confusion. Furthermore, it appeared that patients experiencing a conflict with treatment agenda were identified as confused or disoriented. Insofar as Wolanin's observations were directed towards all patients labeled as confused, they will similarly apply to the sundowning patient. Questions that will therefore follow and need to be addressed by the treatment team are the potential sources for such conflict that may include:

1) Does the patient's cognitive status allow for an understanding of the rationale and need for treatment?

2) Patients may be cognitively intact, but given diminished sensory abilities with an environmental change, may not be able to comprehend what is being communicated to them.

3) Is appropriate sensitivity being shown for the needs and concerns of this particular patient, i.e., as it applies to the patient's need for privacy for instance.

Lastly, it is important in dealing with staff/patient conflicts to secure full communication between staff to insure that the patient is not splitting staff as a product of the patient's characterological pathology or feelings of extreme or profound distress engendered by diminished physical independence.

4. Physical environment.

As has been noted above, central to the concept of sundowning and what, in fact, in the treatment of this syndrome will differentiate one's intervention in response to other forms of delirium is its onset with diminished light. Loss of visual acuity in particular which may follow as a product of aging and/or a neurologically compromised brain, may with inadequate lighting fail to allow the patient to orient themselves and thus confusion and possibly agitation will follow. One recommendation may be to review the available ambient light in the patient's room. Increased lighting may significantly assist the patient in re-orienting. Our own experience here has suggested considerable differences in available light in various portions of the hospital that may not be immediately apparent to the healthy eye. One suggestion might be to attempt to modify ambient light by matching light readings attained from the day and evening hours.

A full sensory evaluation, audiological as well as ophthalmological, may be appropriate to determine whether orthoses are adequate or functioning. Such an evaluation may require further consultations outside of the immediate rehabilitation treatment team.

5. Social environment.

Much of what follows will in fact be familiar to the rehabilitation specialists in assisting the cognitively impaired patient who may be disoriented but must nevertheless not be overlooked for the sundowning patient. The implementation of these recommendations will be made in conjunction with all other recommendations.

Is the patient being appropriately stimulated by his environment? For instance, does the patient's room open onto the nursing station resulting in excessive noise or activity? A consistent schedule along with extended periods of uninterrupted sleep are essential. This may be difficult to insure in a large hospital-based rehabilitation unit. Just as with too much stimulation, too little may prove to contribute to disorientation. Patients should not be allowed to socially isolate themselves and placement in a room with an interactive and oriented room-mate should be considered when appropriate.

It is important that the patient be provided with constant visual and verbal cueing, i.e., a calendar or date board to which his or her attention can be directed. Cueing the patient should include place, time and person. When appropriate, individuals should be identified by age and the relationship they may bear to the patient. Photographs may be used to assist staff in orienting patients. Sundowning patients along with other disoriented patients experience severe short-term memory deficits and may therefore benefit from a structured and consistent environment. Assessing the patient's environment for continuity of care including the times at which he or she receives meals, medications, as well as sleep will be of importance. Both Wolanin and Phillips (1981) and Feinberg, et al. (1965) have noted that a disturbed sleep may be a common experience particularly for the hospitalized geriatric patients. The chronic fatigue that follows a disturbed sleep cycle may contribute significantly to the patient's confusion. Since a number of authors (Evans 1981, Kral 1975) have noted that a recent change in living circumstances appears to be related to disorientation in general and sundowning in particular, a review of the patient's previous regimen and an attempt to accommodate this in terms of the patient's schedule of activities in particular may be, when feasible, beneficial.

6. Psychological

Traumatic psychological events play a significant role in the patient's current experienced confusion (Wolanin, Phillips 1981; Kral, 1975). Some of the most salient issues noted by these authors are listed below and will need to be identified by the treatment team.

1. Was the patient relocated within the past five months?

2. Has the patient experienced a significant crisis within the past 6 months?

3. Has the patient experienced loss of a significant other within the past year?

4. Has the patient experienced a loss of functioning within the past year?

5. Has the patient experienced a significant loss of independence within the past 9 months?

Wolanin and Phillips in particular have emphasized the role of depression in contributing significantly to a patient's confusion. Again this will need to be assessed by the treatment team and the appropriateness of some form of psychotherapeutic intervention will need to be considered. A psychiatric consultation should be considered to explore pharmacological interventions once over-medication as the precipitant to the patient's delirium has been ruled out.

As was noted earlier, in investigating the possibility for staff/patient conflict it is essential to insure that the patient has the cognitive capacity to comprehend what is being asked of him or her as well as at least a marginal grasp of the purposefulness of the activities he or she is being subjected to. A number of cognitive assessment tools are available and will be familiar to the rehabilitation team. Nevertheless, according to the resources available to this team in question, a neuropsychological consultation may prove beneficial in understanding the patient's cognitive abilities.


Multi-disciplinary teams within the rehabilitation setting are unquestionably the most appropriate vehicle for addressing the multiple treatment concerns presenting staff with the sundowning patient. In this article we have attempted to outline key issues in evaluating and confronting sundowning. As noted earlier, prevalence may be comparatively low for some diagnostic groups but when this issue does arise may prove to be a significant challenge to the available resources of the treatment team. Previous studies have tended to focus their recommendations on one or other aspect of treatment which in and of itself may not prove sufficient to address the problematic nature of sundowning. Although our recommendations for intervention are presented sequentially, they clearly will not need to be executed sequentially but rather will need to be tailored to the particular needs of the individual patient. Nevertheless, certain considerations will need to be given precedence, for instance as to whether the patient's condition is a reversible medical condition, such as dehydration, etc. Secondly, it is important to insure that appropriate communication is established between both the staff and patient to in turn insure that there is not a staff/patient conflict over agenda. Lastly, in intervening with a sundowning patient, consideration will need to be given to both physical and social environment as well as psychological factors. Such issues will include amongst others, insuring that the patients' physical environment is adequate or is adequately tailored to their limitations. Furthermore consideration will need to be given to the patient's ability to cognitively comprehend what is being asked of him or her as well as to insure that it is appropriately structured and allows for continuity with the patient's scheduled activities. Finally, consideration needs to be given to the patient's emotional adjustment following what may in fact be a traumatic change of lifestyle or loss of independence. Intervention in such cases may need to include supportive counseling.

Recommendations that are included in this article are a product of both a review of the literature as well as clinical experience. Therefore, a systematic study to assess the effectiveness of some of the specific recommendations may be appropriate. For instance, to what extent does increased lighting mitigate an episode of confusion for a sundowning patient during sunset? Secondly, it is not clear at all whether all possible precipitants to delirium noted above in fact apply to sundowning. Further study could allow us to more precisely define what may be seen as potentially contributing to or precipitating and what will not. This issue in turn leads into the question left open by Lipowski in which he asks whether the patho-physiological processes at play with sundowning are in fact the same as delirium. Clarification on this issue may carry certain consequences for our response to Sundown Syndrome. Finally, prevalency studies will need to be done with various populations in various settings for us to be able to understand the full impact of this syndrome as well as potentially assist in identifying precipitants to sundowning.

Stephane Duckett, Bryn Mawr Rehab Hospital, Malvern, PA 19355

1 Upon reviewing table 1, it will be apparent to the reader that the relationship between degree of cognitive impairment and prevalence of sundowning is not linear for this group of patients, but rather that there appears to be an optimal range within which a patient may be susceptible to Sundown Syndrome, i.e. with the head injured patient Rancho Los Amigos levels IV - VI.

2 The criterion for dementia as provided in the DSM III-R is sufficiently broad so as to allow for virtually all globally cognitively compromised patients. In this respect, it may be that relative to the sundowning patient, dementia may in fact be a necessary but not a sufficient condition, i.e., not all demented patients sundown, but all sundowning patients will be demented, as well as delirious at the time of their sundowning episode.


Armstrong-Esther, C. (1978). Day for night. Nursing Times, 78(30), 1263-1265.

Burnside, I. (1981). Nursing and the Aged. New York: McGraw-Hill.

Cahn, A., Folk, G., Huston, P. Age comparison of human daynight physiological differences. Aerospace Medicine, 39(6), 608-610.

Cameron, O. (1941). Studies in senile nocturnal delirium. Psychiatric Q, 15, 47-53.

Campbell, S.S., Kripke, D.F., Gillin, J.C., Hrubovcak, J.C. (1988). Exposure to light in healthy elderly subjects and Alzheimer's patients. Physiology & Behavior, 42(2), 141-144.

Castleberry, K., Seither, F. (1982). Disorientation, C.M. Norris (ed). Concept Clarification in Nursing. Rockville, MD, Aspen.

Czeisler, C., Richardson, G., Zimmerman, J. et al. (1981). Entrainment of human circadian rhythms by light-dark cycles: A reassessment. Photochemical & Photobiological Reviews, 34(1), 239-247.

Duckett, S., Scotto, M. (1992). A case study - an unusual case of sundowne syndrome subsequent to a traumatic head injury. Brain Injury, 6, no 2, 189-191.

Evans, L.K. (1987). Sundown Syndrome in Institutionalized Elderly. Journal of the American Geriatrics Society, 35(2), 101-108.

Feinberg, I., Koreski, R., Shaffner, L. (1965). Sleep electro-encephalographic and eye movement patterns in patients with chronic brain syndrome. Journal of Psychiatric Research, 3, 11-24.

Ginsburg, K., Weintraub, M. (1976). Caffeine in the "sundown syndrome": Report of negative results. Journal of Gerontology, 31(4), 419-420.

Hoch, C.C., Reynolds, C.F. 3d, Houck, P.R. (June 1988). Sleep patterns in Alzheimer, depressed, and healthy elderly. Western Journal of Nursing Research, 10(3), 239-256.

Kral, V.A. (1975). Confusional States/Descriptions and Management. In Modern Perspectives in the Psychiatry of Old Age, J.G. Howells, (ed.). New York: Brunner & Magee.

Leishman, D., Ancill, R., Nacewan, W. (Aug 1989). Sleep disturbance in cognitively impaired elderly person |letter~, American Journal of Psychiatry, 146(8), 1078-1079.

Lipowski, Z. (1980). Delirium. Springfield, IL: Charles C. Thomas.

Lipowski, Z. (1983). Transient cognitive disorders (delirium, acute confusional states) in the elderly. American Journal of Psychiatry, 140(11), 1426-1436.

Loevenstein, R.J., Weingartner, H., Gillin, J.C., Kaye, W., Ebert, M., Mendelson, W.B. (Winter 1982). Disturbances of sleep and cognitive functioning in patients with dementia. Neurobiology of Aging, 3,(4), 371-377.

Moody, L., Baron, V., Monk, G. (1970). Moving the past into the present. American Journal of Nursing, 70(11), 2353-2356.

Pablo, R. (1977). Intra-institutional relocation: Its impact on long-term care patients. Gerontologist, 17(5), 426-435.

Phillips, P. Phil, D., Rolls, B. et al. (1984). Reduced thirst after water deprivation in healthy elderly men. New England Journal of Medicine, 311, 753-759.

Prinz, P., Raskind, M. (1978). Aging and sleep disorders, Williams, R., Karacan, I. (eds): Sleep Disorders: Diagnosis and Treatment. New York: Wiley and Sons.

Reynolds, C.F. 3d, Hoch, C.C., Stack, J., Campbell, D. (1988). The nature and management of sleep/wake disturbance in Alzheimer's dementia. |Review~. Psychopharmacology Bulletin, 24(1), 43-48.

Rosan, Robert C., (1987). Physical complications of Alzheimer's disease. Special Issue: The physician's guide to counseling the elderly. University of Texas Mental Science Institute, Texas Medical Center of Houston, Medical-Aspects-of-Human-Sexuality. March Vol 21(3), 77-88.

Seymour, D., Henscheke, P., Cape, R., et al. (1980). Acute confusional states and dementia in the elderly: The role of dehydration/volume depletion. physical illness, and old age. Age Aging, 9(3), 137-146.

Slater, R., Lipman, A. (1977). Staff assessments of confusion and the situation of confused residents in homes for old people. Gerontologist, 17(6), 523-530,

Smallwood, Robert G., Vitiello, Michael V., Biglin, Elizabeth C., Prinz, Patricia N. (Spring 1983). Sleep apnea: Relationship to age, sex, and Alzheimer's dementia. University of Washington, Seattle, Vol 6(1), 16-22.

Wolanin, M.O. & Phillips, L.R.F. (1981). Confusion. St. Louis: Mosbey.

Table 2

Diagnostic Criteria for Delirium

A. Reduced ability to maintain attention to external stimuli (e.g. questions must be repeated because attention wanders) and to appropriately shift attention to new external stimuli (e.g. perseverates answer to a previous question).

B. Disorganized thinking, as indicated by rambling, irrelevant, incoherent speech.

C. At least two of the following:

1. reduced level of consciousness, e.g. difficulty keeping awake during examination.

2. perceptual disturbances: misinterpretations, illusions, or hallucinations.

3. disturbance of sleep-wake cycle with insomnia or daytime sleepiness.

4. increased or decreased psychomotor activity.

5. disorientation to time, place, or person

6. memory impairment, e.g. inability to learn new material, such as the names of several unrelated objects after five minutes, or to remember past events, such as history of current episode of illness.

D. Clinical features develop over a short period of time (usually hours to days) and tend to fluctuate over the course of a day.

E. Either 1, or 2:

1. evidence from the history, physical examination, or laboratory tests of a specific organic factor (or factors) judged to be etiologically related to the disturbance.

2. in the absence of such evidence, an etiologic organic factor can be presumed if the disturbance cannot be accounted for by any non-organic mental disorder, e.g. Manic Episode accounting for agitation and sleep disturbance.

Diagnostic Criteria for Dementia

A. Demonstrate evidence of impairment in short and long-term memory. Impairment in short-term memory (inability to learn new information) may be indicated by inability to remember three objects after five minutes. Long-term memory impairment (inability to remember information that was known in the past) may be indicated by inability to remember past personal information (e.g. what happened yesterday, birthplace, occupation) or facts of common knowledge (e.g. past Presidents, well-known dates).

B. At least one of the following:

1. impairment in abstract thinking, as indicated by inability to find similarities and differences between related words, difficulty in defining words and concepts, and other similar tasks.

2. impaired judgment, as indicated by inability to make reasonable plans to deal with interpersonal, family, and job-related problems and issues.

3. other disturbances of higher cortical function, such as aphasia (disorder of language), apraxia (inability to carry out motor activities despite intact comprehension and motor function), agnosia (failure to recognize or identify objects despite intact sensory function), and "constructional difficulty" (e.g. inability to copy three-dimensional figures, assemble blocks, or arrange sticks in specific designs).

4. personality change, i.e. alteration or accentuation of premorbid traits.

C. The disturbance in A and B significantly interferes with work or usual social activities or relationships with others.

D. Not occurring exclusively during the course of Delirium.

E. Either 1, or 2:

1. there is evidence from the history, physical examination, or laboratory tests of a specific organic factor (or factors) judged to be etiologically related to the disturbance.

2. in the absence of such evidence, an etiologic organic factor can be presumed if the disturbance cannot be accounted for by a non-organic mental disorder, e.g. Major Depression accounting for cognitive impairment.

Criteria for Severity of Dementia:

Mild: Although work for social activities are significantly impaired, the capacity for independent living remains, with adequate personal hygiene and relatively intact judgment.

Moderate: Independent living is hazardous, and some degree of supervision is necessary.

Severe: Activities of daily living are so impaired that continual supervision is required, e.g. unable to maintain minimal personal hygiene: largely incoherent or mute.

Reproduced from the Diagnosis & Statistical Manual of Mental Disorders, American Psychiatric Association, 1987.

Table 3

Disorders Causing Dementia:

Degenerative disease:

Alzheimer's disease Pick's disease Huntington's disease Progressive supranuclear palsy Parkinson's disease (not all cases) Cerebellar degenerations Amyotrophic lateral sclerosis (ALS) (not all cases) Parkinson -- ALS-dementia complex of Guam and other island areas Rare genetic and metabolis disease (Hallervorden-Sparz, Kufs', Wilson's, late-onset metachromatic leukodystrophy, adrenoleukdystrophy)

Vascular dementia:

Multi-infarct dementia Cortical micro-infarcts Lacunar demential (larger infarcts) Binswanter disease Cerebral embolic disease (fat, air, thrombus fragments)

Anoxic dementia:

Cardiac arrest Cardiac failure (severe) Carbon monoxide

Traumatic dementia:

Dementia pugillistica (boxer's dementia) Head injuries (open or closed)

Infectious dementia:

Acquired immune deficiency syndrome (AIDS) Opportunistic infections Creutzfeldt-Jakob disease (subacute sponfiform encephalopathy) Progressive multifocal leukoencephalopathy Post-encephalitic dementia Bechet's syndrome Herpes encephalitis Fungal meningitis or encephalitis Parasitic encephalitis Brain abcess Neurosyphilis (general paresis) Normal pressure hydrocephalus (communicating hydrocephalus of adults)

Disorders that can cause delirium:


Sedatives Hypnotics Anti-anxiety agents Anti-depressants Anti-arrhythmics Anti-hypertensives Anti-convulsants Anti-psychotics Digitalis and derivatives Drugs with anti-cholinergic side effects Others (mechanism unknown)

Nutritional disorders:

Dehydration Pellagra (B-6 deficiency) Thiamine deficiency (Wernicke-Korsakoff syndrome) Cobalamin deficiency (B-12) or ernicious anemia Folate deficiency Marchiafave-Bignami disease

Metabolic disorders (usually cause delirium, but can be difficult to differentiate from dementia):

Hyper- and hypo-thyroidism (thyroid hormones) Hypercalcemia (calcium) Hyper- and hyponatremia (sodium) Hypoglycemia (glucose) Hyperlipidemia (lipids) Hypercapnia (carbon dioxide) Kidney failure Liver failure Cushing syndrome Addison's disease Hypopituitarism Remote effect of carcinoma

SOURCE: Adapted from R. Katzman, B. Lasker, and N. Bernstein, "Accuracy of Diagnosis and Consequences of Misdiagnosis of Disorders Causing Dementia", contract report prepared for the Office of Technology Assessment, U.S. Congress, 1986.
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Author:Duckett, Stephane
Publication:The Journal of Rehabilitation
Date:Jan 1, 1993
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