The Sundowner: A Monster of the Aged

SunsetThere comes a time in the day when the sun begins to set, and the dark shadow of dusk creeps along the walls of all hospital rooms.  This is a capricious time that has some nurses counting on one hand the number of hours left in their twelve hour day, and other nurses crunching egg shells under their well worn clogs knowing those last few hours might be the longest of their shift.

Growing up I faced a cast of classic characters that ruled the night.  My demons included such greats as Dracula and The Wolf Man, Dr. Jekyll and Mr. Hyde, Frankenstein, and The Creature from the Black Lagoon.  In my teens I was haunted by the likes of Jason and Freddie, Micheal Meyers, and The Exorcist.  When I made the choice to go into nursing I didn’t realize that I would be facing other people’s demons as well.

Last Thursday started off like any other day.  With coffee in hand I headed to the nurses’ station, signed in, got my assignment, and took report on my patients.  As I’m getting report from the night nurse it’s clear she is exhausted, frustrated, and by all accounts finished.  I’d call it at least a two drink morning.  Her patient (soon to be my patient) wreaked havoc all night long, and it was obvious her patience was worn and tattered.   An 87 year old woman had broken her over the course of her 12 hour shift.  My patience however was fresh and new, and so I began my day upbeat, and optimistic.

Why so optimistic?  I had the sun on my side; nature’s way of soothing dark forces.  It wasn’t long before the cries of the night Banshee settled, and I could go about my day unencumbered…for awhile.

The Calm before the storm

The Calm before the storm

That “while” lasted until the sun began to set.  With the quickness of Dr. Jekyll’s potion, my quiet, frail, elderly patient began to morph into what I can only describe as a possessed soul.  Her paranoid eyes stared at me with the “I know what you’re up to” look, as I’ve seen this look many, many times before.  It is the stare of The Sundowner.   This phenomenon associated with the approach of night robs the elderly of their wit, and replaces it with paranoia, aggression, obscene behavior, and super human strength.

I couldn’t help but feel like a character in a movie, removed, and yet present at the same time.  I know this lady believed I was out to get to her, any convincing to the contrary only made me all the more guilty.  Her screams could be heard up and down the hallway as she shouted, “HELP…POLICE…HELP!!”

Damn you daylight savings time!

I was trying to help. I kept reminding her of the time, and place she was in.  I had her speak with her husband over the phone but nothing I tried was working.   Then out of nowhere SLAM and it was me screaming “Ow!!”  She launched her hospital telephone at me while my back was turned and it slammed into my shoulder with such force.  Several minutes ago this woman didn’t have the strength to roll on her side, and now she’s got the arm of Mariano Rivera, and it’s strike one for her!

I look at the clock.   It’s only 5:30p.m.  I need reinforcements, so I send out my own cry for help.  But it’s busy; it’s the ICU.  Reinforcements are slow to arrive.  I speak with the doctor, who orders a pill to try and calm her down…a pill?  This woman is spinning her head like the exorcist and he thinks I’m going to accomplish anything with a pill!

So like Nurse Ratched I approach with a calm, kind demeanor, offering her her dinner tray to eat, and hoping I might sneak in that pill, but she knows, she clearly knows I’m up to no good.  She looks at me with disgust, chuckles like the devil himself, then turns her head away.  “You’re a pig, you’re nothing but a filthy pig…get out of here.”  The words come out deep and low sounding.  Each syllable articulated so I wouldn’t miss a thing.  She is completely mad.

Heeeere's Johnny!!

Heeeere’s Johnny!!

She has beaten me at my own game, but I leave the tray of food as a peace offering and I move on to the other side of her bed. Out of the corner of my eye I see her reach over for her tray and with the spryness of a child propel it to the floor.  I’m running in slow motion to stop what I cannot get to fast enough and SLAM, food and broken glass explode over the floor leaving splatter debris clinging to my uniform…strike two!

When the Dr. finally arrives, his hubris preceding him, he asks me for the pill.  I point to the unopened package on the bedside table and he asks for assistance:  spoon…yes doctor…applesauce…yes doctor…crushed pill…yes doctor; he guides the spoon in for the final approach…BAM, the spoon goes flying and now she’s got Dr. Smarty-pants by his lapels, tears the glasses off his face and mangles the frames, strike three!

It’s at this point that Dr. Smarty-pants ups the ante and orders an antidote to Dr. Jekyll’s potion.  I dutifully administer the cocktail into her I.V.  It only takes a minute; she’s not quite the lobotomized McMurphy, but she winds down like the slow moving toy whose batteries are near the end.

Time for Nighty Night...

Time for Nighty Night…

It’s at this moment, when the chaos has quelled and everyone is pulling themselves back together that I can look upon this elderly woman and reflect on how such a sinister invader had taken over her body.


Why does this have to happen to people, and how can it take someone so frail and turn them into The Hulk?

Unfortunately it is still unknown what causes Sundowning to occur.  It is connected with people who may have dementia or Alzheimer’s.  It is also believed to be caused by a change in the brains circadian rhythm, a bundle of nerves that keeps the body on a 24 hour clock.  Whatever the reason, it is one of the more challenging and heartbreaking aspects of my job.

My heart breaks for these people.

My heart breaks for these people.

When 7p.m. rolled around I couldn’t wait to get out of there.  I too was now tattered and torn.  My night shift coworker greeted me with a warm smile and the same look of optimism that I had so foolishly worn 12 hours ago…

I think it’s going to be a three drink night!

I think that's me.

I think that’s me.

16 thoughts on “The Sundowner: A Monster of the Aged

  1. What an experience. I didn’t witness that in pediatrics, thankfully, though I remember many nights where I sat at the counter with the nurses (as a resident) trying to figure out how we could best manage something until the morning. I’ve always thought that physicians should have to spend some time–maybe a couple weeks–rotating through with the nurses. Many times, doctors cover so many patients, they only see a snapshot in time. They’re not there in the trenches (except perhaps in an ICU setting) to see what nurses must endure dealing with–not just the medical side, but the human side, too, which, as you beautifully point out, can sometimes be the more difficult task of the two.

    Definitely a three-drink night!

    • You know Carrie, most of the doctor’s I work with are great, especially the ICU doctors, but this patient was not on ICU service as she was getting ready for transfer, and was on the hospitalist service. As I’m sure you know hopitalists are very busy, as was this doctor, that I have tolerance for, but being condescending to me (especially after I just got my ass kicked by an 87 y/o lady) that I have no tolerance for, especially when the patient is the one in need of more help. I would love it if doctors could rotate with us as well as vice versa. What a great idea!

      • Maybe they could add it as an elective in Medical School…The class could be called “Can’t We All Just Get Along?” or something like that…lol

      • Hopefully it’s gotten better over the years. If doctors don’t realize the team effort it is–nurses, physicians, respiratory therapists, pharmacists, ward clerks, etc.–then they should find another line of work. Luckily, I think most docs get this nowadays which is why it drives me CRAZY to see the residents on Grey’s Anatomy barking orders at the nurses. Maybe it’s different in peds, but I’ve never witnessed that. Thankfully.

      • No it is soooo much better. When I was a student many moons ago I had such old fashioned teachers who made me jump out of my chair whenever a doctor came into the nurses station. Now it’s such a collaborative effort, (at least in my ICU) no barking, and we even manage to have a few laughs!!
        On a side note I’m doing a genetics class and the current topic is newborn screening can I email you a few questions?

  2. I’ve been working with the elderly for longer than I’d care to mention but even still, “Sundowning” and all it brings never ceases to fascinate me. Almost every person I’ve cared for with Alzheimer’s has the same thing whereby around the 4pm mark, they will slowly but sure start to wind up. It’s easier to manage in a long-term residential or nursing care setting because we have some degree of trust and relationship with that person. Plus, we’ve grown familiar with the individual traits and techniques but even still, it doesn’t make it any less exhausting.

    • It is indeed a fascinating phenomenon. I give you tons of kudos for working with the elderly! I think it is one of the most challenging jobs ever. Thanks for taking the time to read/comment on my post.

    • This means a lot to me coming from a fellow nurse. (Yes I was over at your site), and I’ll be back… I read about your interest in geriatrics, I agree, the elderly are a fascinating lot, with wonderful stories to tell of a time period that seems to be fading away. I used to work out of one of the VA hospitals, and the stories ranged by the wars fought, from WWII up to Vietnam, first hand accounts; never a dull moment.
      Thanks so much for your comment and visit to my site!

  3. I’ve seen this so much. One second they need help getting their nightgown on and the next they are flipping tables over and throwing chairs across the room. The only scars I have from working on the psych ward came from an elderly woman.
    At least you are still feeling compassion for them, that definitely separates you from the Nurse Ratcheds.

    • I think the elderly’s super human strength is the most amazing thing that happens. We just had another patient at sundown (after a hip operation) climb over her bed to the floor, after getting her back to bed she fought for an hour to try to get back out of bed. She was so strong, it took two of us to prevent her from climbing out again. When I saw her a two days later, (and she was right in the head again), she needed two nurses to help her get out of her bed! Go figure.
      Psych was never my thing, so I’m in awe of anyone who chooses to work there, it definitely takes a special person!! Thanks for your comment. I love your reading your stuff btw.

  4. Wow. What an interesting, challenging, rewarding, and exhausting profession you have (and I thought my years of working with hormonal teenagers were tough!). My dad suffered from years of alcoholism-induced dementia before he passed away, and I saw some of these same characteristics in him–but never from the perspective of a caretaker.

    • So sorry to hear about your dad. Alcoholism is a cruel disease. My perspective is just one view of the complexities of caring for any individual. I’ve been on both sides as a nurse and a daughter to a dying father. None of it is easy, but we do the best we can. If I had your skills as a photographer I would try to capture those moments that touch me as a nurse (pictures of old peoples hands make me tear up…weird right?), I think they’d be so moving and tell a story all on their own.

      • Not weird at all. I’m disheartened every time I see age creeping into photos of my own hands and face, and yet some of the most beautiful, expressive photos I’ve ever seen have been faces and hands of the elderly.

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