What should an overnight hospitalist note cover for an elderly patient with a history of cognitive impairment, such as dementia or Alzheimer's disease, exhibiting sundowning behaviors?

Overnight Hospitalist Documentation for Sundowning Behaviors

Critical Initial Assessment and Documentation

Document a systematic evaluation for delirium superimposed on dementia, as this represents a medical emergency requiring immediate investigation of reversible causes. 1

Establish Baseline Cognitive-Behavioral Status

• Interview nursing staff or review prior documentation to determine the patient's baseline cognitive function, behavior, and typical sleep-wake patterns before the current hospitalization 1
• Document whether the current behavioral disturbance represents an acute change (hours to days) suggesting delirium versus chronic sundowning pattern 1
• Note the time course and fluctuating nature of symptoms, as delirium fluctuates within minutes to hours while sundowning follows a predictable late afternoon/evening pattern 2, 3

Document Specific Behavioral Characteristics

• Use the "DESCRIBE" approach to characterize the exact nature of behaviors: document specific antecedents (what triggers the behavior), the precise behavior observed (agitation, confusion, wandering, verbal outbursts, aggression), and consequences 4
• Record the timing of symptom onset and peak severity (late afternoon vs. evening vs. night) to distinguish sundowning from other causes 2, 3
• Quantify severity using a validated instrument such as the Neuropsychiatric Inventory-Questionnaire (NPI-Q), which takes 5-10 minutes and documents 12 neuropsychiatric domains including agitation, delusions, hallucinations, and sleep disturbances 4

Mandatory Medical Workup Documentation

Document systematic investigation and treatment of reversible medical causes, as these are the primary drivers of behavioral disturbances in hospitalized dementia patients. 4

Tier 1 Laboratory and Clinical Assessment

• Document evaluation for infection: urinalysis with culture, chest X-ray if respiratory symptoms, complete blood count with differential 4
• Record assessment for metabolic derangements: complete metabolic panel (electrolytes, renal function, glucose), thyroid-stimulating hormone 4
• Document pain assessment using behavioral pain scales (as patients with dementia cannot reliably self-report), as untreated pain is a major contributor to behavioral disturbances 4, 5
• Record evaluation for constipation and urinary retention, both significant contributors to restlessness and agitation 4, 5
• Document oxygen saturation and assessment for hypoxia 5

Medication Review

• List all current medications and document review for anticholinergic agents (diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 4, 5
• Note any recent medication changes or additions that may contribute to behavioral symptoms 4
• Document polypharmacy burden, as multiple psychotropics increase adverse effects without demonstrated benefit 5

Environmental and Non-Pharmacological Interventions Implemented

Document all non-pharmacological interventions attempted before considering medications, as these have substantial evidence for efficacy without mortality risks. 4, 5

Environmental Modifications

• Record lighting adjustments: adequate lighting during late afternoon/evening hours, as dim lighting worsens sundowning 4, 2
• Document noise reduction strategies implemented (quiet room, minimizing overhead pages, reducing unnecessary alarms) 4
• Note removal of physical restraints if present, as restraints worsen agitation 5
• Record provision of orientation aids: visible clock, calendar, familiar objects from home if available 4

Communication and Behavioral Strategies

• Document use of calm tones, simple one-step commands, and gentle touch for reassurance rather than complex instructions 4, 5
• Record caregiver education provided: explaining that behaviors are symptoms of dementia, not intentional actions 4
• Note whether family members were encouraged to stay at bedside if available 4
• Document attempts at redirection and distraction techniques 4

Sleep-Wake Cycle Interventions

• Record daytime activity level and whether patient had excessive daytime sleep 2, 3
• Document sunlight exposure during the day (target at least 30 minutes) 4, 2
• Note establishment of predictable bedtime routine 4

Pharmacological Management Documentation (If Required)

Medications should only be documented as necessary when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have been thoroughly attempted and documented as insufficient. 4, 5

For Acute Severe Agitation with Imminent Risk of Harm

• Document discussion with family/surrogate decision maker regarding increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular risks, and treatment goals before initiating antipsychotics 4, 5
• Record low-dose haloperidol 0.5-1 mg orally or subcutaneously if used, with strict maximum of 5 mg daily in elderly patients 5
• Document baseline ECG and plan for QTc monitoring due to risk of QT prolongation and dysrhythmias 5
• Note that this is for shortest duration possible with plan for daily reassessment 5

For Chronic Agitation Pattern

• Document whether patient is already on an SSRI (citalopram or sertraline) and current dose 4, 5
• If SSRI indicated and not yet prescribed, note that daytime initiation is preferred with plan for 4-week trial before assessing response 4, 5
• Record that SSRIs are first-line for chronic agitation, not acute management 4, 5

Medications to Avoid and Document Why NOT Used

• Document that benzodiazepines were NOT used (except for alcohol/benzodiazepine withdrawal) due to increased delirium incidence and duration, paradoxical agitation in 10% of elderly patients, and respiratory depression risk 4, 5
• Note that anticholinergic medications (diphenhydramine) were avoided as they worsen agitation and cognitive function 4, 5

Safety Assessment and Plan

Falls Risk Documentation

• Record falls risk assessment, as all psychotropics and behavioral disturbances increase fall risk 4, 5
• Document safety measures implemented: bed alarm, frequent rounding, removal of trip hazards 4
• Note whether patient requires 1:1 observation for safety 5

Monitoring Plan

• Document plan for serial cognitive assessments using brief validated instrument (Confusion Assessment Method) to track fluctuations 1
• Record frequency of reassessment (every 4-8 hours minimum for behavioral symptoms) 1
• Note plan for daily evaluation if antipsychotic initiated 5

Communication and Handoff

Day Team Notification

• Document specific recommendations for daytime team: complete pending laboratory results, consider neurology or geriatric psychiatry consultation if behaviors persist despite treatment of reversible causes 4
• Note need for family meeting to discuss goals of care and behavioral management strategies 4, 5
• Record recommendation for bright light therapy trial (2 hours of morning bright light at 3,000-5,000 lux) if sundowning pattern confirmed 4

Common Pitfalls Documented and Avoided

• Do not attribute behavioral symptoms to "normal aging" or dementia alone without systematic evaluation for reversible causes 4
• Do not rely solely on patient self-report, as patients with dementia lack insight into behavioral changes 4
• Do not add multiple psychotropics simultaneously without first treating medical causes 4, 5
• Do not continue antipsychotics indefinitely—document plan for taper within 3-6 months if initiated 5