Managing the Sundowning Patient

Abstract

Introduction 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. Background 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. …