The hospital is a great place to go to get better, Dr. Amy Greminger likes to say. It’s not a great place to feel better.
“They’re not at home,” she said. “They are not sleeping well, because things are buzzing and bumping at night. They’re loaded up with a whole bunch of medicines. … It’s not a restful place to be.”
That disorientating, sleep-depriving atmosphere likely is the reason that hospitals — and intensive care units in particular — are common places for the phenomenon known as sundowners syndrome, said Greminger, an Essentia Health internist and faculty member at the University of Minnesota Medical School’s Duluth campus.
Also known as sundown syndrome, sundowning syndrome or just plain sundowning, it’s “the emergence or worsening of agitation (or) other types of potentially problematic, challenging behaviors that occur in the late afternoon or early evening,” said Joseph Gaugler, director of the School of Public Health Center on Aging at the University of Minnesota.
Some of the behaviors can include confusion, anxiety, aggression, ignoring directions and pacing or wandering, according to Dr. Jonathan Graff-Radford, a neurologist at the Mayo Clinic in Rochester whose specialties include Alzheimer’s disease and dementia.
The News Tribune turned to Greminger, Gaugler and Graff-Radford for a primer on sundowning and how it can be counteracted.
Who gets it?
Sundowning is by far most common among people who have forms of cognitive impairment or dementia, the experts said, although it doesn’t necessarily accompany dementia.
“Sometimes we hear from patients and their families that sundowning was one of the earliest symptoms,” Graff-Radford said. Patients who have "dementia with Lewy bodies" seem to be particularly susceptible, he added.
It happens in hospitals?
It often does, the experts say. Also, it’s “very common in older adults who are living in nursing homes or assisted living,” Greminger said.
The unfamiliar surroundings seem to be a trigger.
“Any change in environment, whether it be a hospitalization or a move to a new living environment, can prompt this,” Graff-Radford said.
What causes it? And why does it happen when it does?
The short answer: No one knows. “There’s actually not much research on sundowning,” Gaugler said.
Some theorize that it’s a disorder in the circadian rhythm, Greminger said. Another theory in the early stages, Gaugler said, is that it’s related to the hypothalamic pituitary adrenal axis (HPA) and its production of the stress hormone known as cortisol.
How common is it?
Again, the answer isn’t known. According to Alzheimer’s Association data from 2006, anywhere from 2.4 to 25 percent of patients with Alzheimers also have sundowners, Greminger said.
It’s certainly a well-known, if not well-understood, phenomenon.
“I would say every hospitalist has seen it,” Greminger said. “It’s not uncommon.”
Can it happen at other times of the day?
No. “Sundowning syndrome is exactly that,” Gaugler said. “It’s this unique pattern of symptoms that happens at that time late in the afternoon, earlier in the evening.”
But it’s similar to delirium, Greminger said. Delirium, which isn’t limited by time of day, is a confused state that may be induced by medical treatment.
“Delirium tends to be brief; hours or days,” she said. “It’s not a long-term pattern. It fluctuates during the course of the day.”
Can it go away?
Patients’ symptoms often do diminish when they return home to a familiar environment, Graff-Radford said. “But maybe they don’t get quite back to where they were before.”
It’s important to not just assume the problem will go away when your loved one comes home, Gaugler said. “I don’t think it’s as simple as we’ll get them out of the hospital and we’ll get them home; it’s all great,” he said. “There does need to be some ongoing care management.”
What to do: hospitals and nursing facilities
Hospitals should try to help patients achieve somewhat normal sleep patterns, Greminger said. “Maybe not doing labs during the middle of the night; not taking vital signs during the middle of the night.”
She disagrees with telling patients to leave their glasses and their hearing aids at home.
“I’m not going to say that hospitals or nursing facilities have never lost them,” Greminger said. “That happens. But in reality, having those things, having the ability to hear like you would at home, having the ability to see like you would at home, having proper adaptation” reduces the risk.
Research suggests melatonin therapy, light therapy and moderate exercise may have benefits for those with sundowners, Gaugler said.
So can turning off TVs in the evening.
“I’ve been in many nursing homes where the TV’s always on blasting through dinnertime and such, and these kinds of distractions I don’t think are helpful for behaviors and people with memory loss,” he said.
Both Greminger and Gaugler gave two thumbs down to antipsychotic medications, at least as a first line of treatment.
“They have a number of very adverse effects and consequences,” Gaugler said. “Too often they’ll be used as … ‘chemical restraints’ by nursing homes. That’s not good for the quality of life, and it’s not good for the person.”
What to do: loved ones
If you can place familiar objects in the room such as pictures of family members, you can lower the risk of your loved one developing sundowners while in the hospital or nursing facility, Graff-Radford said.
Or bring yourself.
“Having someone familiar around them could be very helpful,” Greminger said.
Also, Graff-Radford said, if you have a loved one with dementia who is going into the hospital for even a routine procedure, you should make sure the medical team is aware of the dementia diagnosis.