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How to Manage Sundowning in Hospice Care

Understanding and Managing Sundowning in Hospice Care: Essential Strategies

Sundowning, a term often associated with the late stages of Alzheimer’s disease and other forms of dementia, refers to the increase in confusion, agitation, and anxiety that typically occurs in the late afternoon and evening. This phenomenon can be distressing not only for patients but also for caregivers and family members. In hospice care, where the focus is on comfort and quality of life, addressing sundowning effectively is crucial. This blog post will explore strategies to manage sundowning symptoms, helping caregivers provide the best possible care during these challenging times.

What is Sundowning?

Sundowning, or late-day confusion, occurs when a patient experiences changes in their behavior at sunset. Symptoms might include increased confusion, anxiety, pacing, disorientation, and aggressive behavior. These changes are particularly challenging in hospice settings, where the goal is to maintain calm and comfort.

Causes of Sundowning

The exact causes of sundowning are not well understood, but several factors may contribute to its onset:

  • Internal body clock: Disruption in the circadian rhythms that regulate sleep-wake cycles.
  • Low lighting: Increased shadows and decreased light can cause confusion and fear.
  • Fatigue: As the day progresses, tiredness can exacerbate confusion and agitation.
  • Hunger or thirst: Basic needs, when unmet, can lead to discomfort and distress.

Understanding these triggers is a step toward managing the symptoms more effectively.

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Strategies to Address Sundowning

Managing sundowning involves both environmental adjustments and personal care tactics. Here are some practical tips and strategies:

  1. Maintain a Routine
    • Keep a consistent daily schedule to reduce confusion and provide a sense of normalcy.
    • Schedule more demanding activities earlier in the day when the patient is less likely to feel overwhelmed.
  2. Optimize the Environment
    • Use adequate lighting to reduce shadows and ease transitions from daylight to evening.
    • Create a peaceful, calming environment, free from loud noises and clutter.
  3. Encourage Physical Activity and Social Interaction
    • Engage the patient in light physical activity during the day to promote better sleep at night.
    • Facilitate social interactions, which can provide comfort and reduce feelings of isolation.
  4. Monitor Diet and Hydration
    • Ensure the patient eats regular, nutritious meals and stays hydrated to prevent discomfort.
    • Limit caffeine and sugar intake, especially later in the day.
  5. Implement Relaxation Techniques
    • Use techniques such as music therapy, aromatherapy, or gentle massage to promote relaxation.
    • Encourage activities that the patient finds soothing, such as listening to soft music or reading.
  6. Foster a Safe Environment
    • Safety-proof the living area to prevent falls or injuries, especially during times of confusion or poor visibility.
    • Consider using sensors or alarms for patients who might wander.
  7. Communicate Effectively
    • Speak calmly, clearly, and reassuringly.
    • Avoid arguing or trying to reason with the patient if they are confused.
  8. Use Medications Judiciously
    • Consult with healthcare providers about medications that might help reduce symptoms without excessive sedation.
    • Regularly review medications to ensure they are still appropriate as conditions change.
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The Role of Caregivers and Family Members

Family members and caregivers play a critical role in managing sundowning. It’s important for caregivers to:

  • Stay educated about the patient’s condition and understand that sundowning is a symptom, not intentional behavior.
  • Take care of their own health and seek support when needed to prevent burnout.
  • Use community resources, such as support groups and counseling, to build a network of support.

When to Seek Professional Help

While the above strategies can be effective, sometimes professional help may be needed. If sundowning symptoms worsen or become unmanageable, it may be necessary to consult with healthcare professionals who can offer additional strategies or adjust the patient’s care plan.


Sundowning in hospice care presents unique challenges, but with the right strategies, caregivers can alleviate much of the distress associated with this condition. By understanding the causes, implementing effective coping strategies, and using a compassionate approach, caregivers can provide comfort and dignity to patients experiencing sundowning, ensuring their twilight hours are as peaceful as possible.

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