Loddon Mallee Regional Dementia Management Strategy

Specific strategies to manage sundowner syndrome

Identify the A (activating) trigger. Always assume there is a purpose to the behaviour.

Late afternoon and early evening can produce confused, restless and agitated behaviour in people with dementia. The lack of sensory stimulation after dark with fewer environmental cues available to the person and the fact that people with dementia tire more easily and become more restless when they are tired, contribute to sundowner syndrome.e.g.

Other factors can also impact on the behaviours produced when the sun goes down and the person should be assessed for:

• Fatigue – assess the person’s sleep pattern.
• Hunger –they may be wanting tea or think they need to go and prepare tea.
• Infection – eg urinary tract infection causes constant pressure to urinate. Has the behaviour had recent sudden onset?
• Pain may be caused through acute or chronic illnesses, such conditions as shingles, neuralgia etc. Pain can get progressively worse through the day.
• Trauma - Has there been a recent event that may have resulted in trauma, eg falls, knocking into furniture, altercation with another resident; medication changes resulting in unsteadiness, scalding from food / fluids being too hot.
• Medication - consider whether restlessness is due to medication eg medication may be causing ‘restless’ legs or cramps; diuretics may be causing incontinence, some medications may cause agitation.
• Constipation and/or dehydration can significantly affect behaviour.

The person’s psychological and mental health should also be examined. Factors to consider include:

• Mental illness - restlessness and agitation may be symptoms of such illnesses as depression, anxiety or psychosis. Does the person with dementia or their family have a previous history of psychiatric illness? Has the person with dementia been assessed recently?
• Recent or past life events (eg anniversary of loss, post traumatic stress disorder, abuse (physical/financial/ sexual), may also contribute to behavioural disturbance and may be triggered when activities are not there to distract the person.
• Becoming more anxious late in the day about ‘going home’ or ‘finding mother’ may indicate a need for security and protection.
• Whose problem is it? Why is it a problem? Rule out staff culture and regimented routine as a causative factor. Refer to strategies for wandering behaviour.

Strategies related to the above factors:

• Try to keep the person active in the morning and encourage a rest after lunch.
• Provide snacks and finger food, especially if the person is unable or unwilling to eat at regular mealtimes.
• Physical health - assess current medical state. Do not assume the condition is related to a chronic condition or to the person’s dementia. Check for infection. Take temperature, pulse and blood pressure. The person with dementia may not be able to communicate a feeling of illness/pain.
• Always check for delirium (please refer to the Confusion Assessment Method [CAM]).
• Pain may be caused through acute or chronic illnesses. Ensure adequate analgesia. Consider such conditions as shingles, neuralgia etc that may not be getting pain relief due to the person’s inability to communicate.
• Trauma - Review the nursing notes to identify episodes when trauma may have occurred eg Betty Bloggs has been restless and intrusive for approximately the last week. Investigations (blood tests and physical investigations) have failed to identify a cause. A review of the notes reveals that Betty was found sitting on the ground nine days ago with no apparent injuries. An x-ray reveals a fractured neck of femur.
• Medication - All medications have side effects and many medications interact adversely with each other. Consider whether restlessness is due to medication & check the drug information for possible side effects or drug interactions. Has the medication impacted significantly on the behaviour?
• Constipation and/or dehydration can significantly effect behaviour. Use bowel charts to keep track of the bowel motions of the person with dementia. Consider ways (prunes, adequate fibre, exercise) to promote normal bowel actions. If the person is using aperients/enemas, document the results to ensure constipation does not go unnoticed. Communication problems may mean the person may not be able to communicate thirst. Give plenty of fluids to prevent dehydration. If the person is restless, walk with them and offer them small drinks.

Psychological and mental health

• Mental Illness - Restlessness and agitation may be symptoms of depression, anxiety or psychosis. Observe behaviour and communicate to identify symptoms of sadness, fear etc. Discuss your concerns with the person with dementia and their family. Identify any recent or past life events (eg anniversary of loss, post traumatic stress disorder, abuse (physical/financial/sexual) that may be contributing to the behaviour.

Environment

• Don’t physically restrain the person. Let them pace somewhere safe.
• Avoid staff changes, changing of the layout of the room unnecessarily or relocating from usual environment. Recent admission of the person with dementia will usually take an initial settling in period of a few days.
• Climate - Avoid extreme temperatures. Check that the temperature is not too hot or too cold for the person with dementia. Check that their clothing is appropriate to the setting eg John Smith has poor circulation and always feels cold, even on summer days.
• Stimulation - Check for excessive noise/too much stimulation both internal & external to the building. Avoid loud, noisy activities in the afternoon. Is there a lack of stimulation or appropriate activity or opportunity for social interaction?
• Identify times when the person with dementia is likely to become restless and engage them in one-to-one activity specifically designed to meet their cognitive capacity, eg walking in the garden, foot massage.
• Are there any restrictions in the environment? The restless person needs to have safe areas to wander to avoid frustration. Utilise keypad locks, alarms or family involvement etc to encourage light exercise in a purposeful way. Disguise the exit doors eg curtaining, full length mirror, paint the same colour as the walls and use discreet handles, locate key pad away from the door to prevent frustration at not being able to exit the door.
• Are there enough cues and light to orientate the resident or do they wander into someone’s room through disorientation/confusion.
• Remove things from the environment that may stimulate ‘going home or going out’ behaviour. e.g. suitcases, hats, coats.
• Use large signs to provide some simple orientation. Do not add the confusion by having multiple signs.
• Ensure the person’s room contains familiar belongings.
• Drawing the curtains to remove external cues regarding decreasing daylight can often reduce agitation caused through the need to go home.
• Stuffed toys, pets, familiar music or a favourite activity can help comfort and distract the person.

Mrs Dogood (a previous member of the hospital auxiliary) wanders about the ward ‘chatting’ to various residents. At 4.00pm she begins hovering at the door waiting to go home. The activities worker reminisces with Mrs Dogood during staff changeover to minimise the ‘going home’ message. Removing her hat and gloves also reduces the belief that she is on an outing.

References and recommended reading

Alzheimer's Association Australia (2000). Help Sheets for people with dementia and their families and carers. Alzheimer's Association Australia. [available online] http://www.alzheimers.org.au/.

Lees, C. Hecht, H. & Hall, K. (1998). Behaviour & Dementia. The Caulfield Behaviour Support Team.

Lovestone, S. & Gauthier, S. (2001). Management of Dementia. Martin Dunitz Ltd, London.

McCurry S.M. Logsdon, R.G. Teri, L. Gibbons, L.E. Kukall, W.A. Bowen, M.D. McCormick, W.C. & Larson, E.B. (1999). Characteristics of sleep disturbance in community-dwelling Alzheimer’s disease patients. Journal of Geriatric Psychiatry & Neurology. Vol. 12:No.2.pp.53-59.

Vitiello, M.V. & Borson, S. (2001). Sleep disturbances in patients with Alzheimer’s disease: epidemiology, pathophysiology and treatment. CNS Drugs. Vol.15: No.10., pp.777-796.

Satlin, A. (1994). Sleep disorders in dementia. Psychiatric Annals. Vol.24.No.4.pp.186-191