ADvancing Care Newsletter  

  January/February 2012
The Hard End of the Day:
Shedding New Light on Sundowning

"Sundowning” is a term used to describe the agitation, pacing, irritability and disorientation that many people with Alzheimer’s experience during the late afternoon, evening or night. For those who work or live with older adults who have dementia, Sundown Syndrome or “sundowning” is one of the most challenging situations they encounter on a daily basis. Several years ago, staff at the nursing home on the Beatitudes Campus in Phoenix, Arizona determined they had a serious problem with sundowning and set about finding some solutions.

As Tena Alonzo, Director of Research and Dementia Programs at Beatitudes, describes it, “In the dementia unit, everyday at the evening shift change, the chorus would start: a few people would call out and then everyone in the vicinity would join in. You could hear ‘help me, help me’ and ‘oh, shut up’ continuously. Perhaps it wouldn’t have been so bad if that’s where the challenging behavior stopped, but this was just the beginning of the evening! People who were easy to get along with the rest of day would suddenly want to fight with anyone who crossed their path. Others would pace the floor looking for an exit to escape. Dinner was disastrous as no one could hear themselves think. Visiting families and friends were distressed and upset. After several hours dealing with agitated residents and family visitors who were sometimes inconsolable, the exhausted staff would finally get everyone in bed so the whole process could begin again the next day.”

As the staff looked at the frequency and severity of residents experiencing sundowning, they thought there must be something that can be done about this situation. Is sundowning just a part of the disease? Why do some older adults with dementia act so differently in the afternoon? Isn’t there something we can do to help everyone be more comfortable? The answers to these questions didn’t come all at once, but over time some valuable lessons were learned about older adults with dementia.

In considering possible solutions to sundowning, the Beatitudes staff had something in their favor. They had recently begun implementing a philosophy where achieving comfort was the overall staff goal. This comfort philosophy was not about an end-of-life hospice focus, but rather about meeting the needs of people with dementia the way they would do for themselves if they were able. This was a big change as it meant stepping away from the schedules and routines that had been established to embrace the routine of the person with dementia.

To begin, the team decided to observe everyone residing on the dementia unit between the hours of 2:30 PM and 9:00 PM. This observation, which occurred over several days, shed light on some interesting scenarios. The staff saw that many residents looked tired and frazzled and wondered if they would be more comfortable if they were to lie down and rest. Much of the time these rest periods were not necessarily convenient for the staff, and it was a little challenging at first to envision the perspective of the resident for some staff members. The team decided if someone looked tired, no matter when that occurred, they would assist him or her to rest either in a comfortable chair or on the bed (some prefer a chair or the couch, some may only lay on top of their bed, with a throw, while others prefer to change and get back into bed--the decision is based on the resident’s comfort). After some discussion, the staff also agreed that it didn’t matter if the rest period was during a meal or an activity. After a few months, everyone accepted the “rest when tired philosophy.” As residents started to sleep when they were tired and wake when they were rested, the change was obvious. They were happier and didn’t seem to need so much psychotropic medication. The nurses didn’t give PRN medication for agitation any longer and felt comfortable asking the physicians to begin tapering the medications. They started with the anti-anxiety medications because almost every resident was receiving one, and then worked on tapering the anti-psychotics. While not every resident was comfortable without psychotropic medication, most were.

This first phase of addressing the issues with sundowning had been very successful, but staff felt there was more work to do. Next, they observed the overall unit environment (or milieu as they prefer to call it). What was seen and heard was appalling. At the evening shift change, the commotion increased significantly. Staff were used to speaking all at once and rushing around trying to complete tasks before end of shift or gearing up to begin their work. This cacophony and disruption were compounded by a television in the common area and general noise on the unit. Watching the residents respond to the din was enlightening. Sometimes people covered their ears or tried to get away from it. Some just looked scared and bewildered. It became clear to the staff that they needed to stop talking so loudly and slow down. The television that had been so prominently displayed in the common area, but never really used by residents, was moved. The milieu became quiet, and everyone responded positively to the change in the environment.

It can be easy to forget that being confused and unable to make sense out of the environment can be extremely tiring for the person with Alzheimer’s, and overstimulation only makes this worse.

The staff was amazed that making comfort the goal of everything had such a positive impact on the residents and on themselves. Once the changes were in place, no one called out, became angry or upset or tried to leave the unit. Staff members became sane again, and many reported they enjoyed their jobs more since the changes were implemented. Families and friends increased their visits in the afternoon and evening. Dining became a wonderful event which resembled a restaurant setting rather than a nursing home dining room.

As Ms. Alonzo relates, “It’s been almost 14 years since we’ve experienced the pain of sundowning here. We still do the same things, still make comfort the goal of everything, and both the residents and the staff are better for it.”

Our thanks to the Herman Goldman Foundation for their generous support of this newsletter.

Beatitudes Campus
For more information, contact Tena Alonzo at or call 602-433-6182.

Free Comfort Care Guide
Comfort Care: A Guide for Families of People with Dementia Living in Care Facilities.

16th Annual Symposium The Comprehensive Approach to Dementia

Thursday, March 8, 2012
A Practical Update for Practitioners in Mental Health, Primary Care and Long Term Care Settings.
Sponsored by Albert Einstein College of Medicine and Montefiore Medical Center, jointly with the Geriatric Mental Health Alliance of New York and the Alzheimer’s Association, NYC Chapter.