Understanding and Minimizing Sundowner's Syndrome

82 Comments

The long list of symptoms associated with Alzheimer’s disease and other forms of dementia often includes baffling mood and behavior changes. One particularly disruptive side effect of these conditions affects some patients at a certain time each day. Known as Sundowner’s syndrome or sundowning, it involves sadness, agitation, fear, delusions and hallucinations that occur in dementia patients just before nightfall. This increased confusion around twilight can be distressing for both patients and caregivers alike.

Symptoms of Sundowning

When a senior is sundowning, they may “shadow” their caregivers or follow them around and closely observe or try to mimic everything they do. They might ask questions over and over or interrupt conversations. They may temporarily lose their ability to communicate coherently, and abstract thoughts may become especially difficult for them to comprehend. In severe cases, a patient with sundown syndrome may wander restlessly around their home or try to get outside to “escape” or get to an appointment that does not exists or an important location that they have not been to in years.

Other possible behaviors and emotions that may arise during an episode of sundowning include:

  • Anger
  • Agitation
  • Anxiety
  • Emotional outbursts
  • Delusions
  • Fear
  • Depression
  • Stubbornness
  • Restlessness
  • Rocking
  • Hallucinations
  • Hiding things
  • Paranoia
  • Violence
  • Wandering or pacing
  • Crying
  • Insomnia

Sundown syndrome typically begins later in the afternoon and can last well into the night. The exact timing and behaviors that sundowning entails vary greatly from patient to patient. Unfortunately, this side effect of dementia prevents many patients and their caregivers from getting adequate rest at night. Even worse is that sleep deprivation can cause these symptoms to worsen. Therefore it is important to understand your loved one’s routines and moods as best you can in order to minimize these symptoms.

Causes of Sundowning

Doctors and researchers aren’t sure what causes sundowning, but the theory is that the simultaneous onset of symptoms and nightfall is not entirely a coincidence. Some medical professionals believe that the syndrome occurs due to an accumulation of all the sensory stimulation one receives over the course of the day. It builds up and becomes overwhelming and stressful, causing patients to act out. Others speculate that it is caused by hormonal imbalances that occur at night and affect a patient’s natural circadian rhythm. Another theory suggests that the onset of symptoms at night is simply due to fatigue, and others believe it has to do with anxiety caused by the inability to well in the dark. Changes in lighting associated with this time of day can be very disorienting for a patient.

How to Handle Sundowner’s Syndrome

Because dementia patients are difficult, if not impossible to reason with, it is crucial for caregivers to try to stay patient throughout episodes of sundowning. Even if you do not directly express your concern or irritation, it is likely that your loved one will still be able to pick up on your mood and frustration. Reacting to their behaviors is sure to make matters worse. Instead, use the following tips to help minimize sundowning symptoms.

  • Approach your loved one in a calm manner. Don’t yell, raise your voice or touch them in an unexpected way.
  • Avoid rationalizing, arguing or asking for explanations to statements that don’t make sense.
  • Draw the curtains so they cannot see the sky change from light to dark. Turn on inside lights to keep the environment well-lit and to minimize shadows and improve visibility.
  • Provide a peaceful setting. Guide the person to an area away from noise, family activity and other distractions. Try to prevent excessive commotion during the times they normally become more agitated.
  • Plan more activities during the day. A person who rests most of the day is likely to be more awake at night. Discourage excessive napping, especially later in the day, and plan activities, such as walks, crafts and visits, to keep your loved one awake and engaged.
  • If your loved one needs something to keep them occupied in the evenings, plan simple and soothing activities. An upbeat movie or TV show or some pet therapy can have a calming effect. If they do not wish to participate, do not argue with them.
  • Have a routine. Maintaining a schedule helps orient patients and alleviates anxiety that may arise during twilight. Even simple tasks like washing up for dinner and putting on pajamas can be helpful indicators that the day is winding down.
  • Use music. Sometimes soothing music will help to calm and relax a person with Alzheimer’s or dementia.
  • Ensure their safety by installing locks and safety devices as necessary. Take precautions to provide a safe space for your loved one at night so that you can get some sleep, even if they need to stay awake and wander. This includes removing or securing potentially dangerous items in areas that they have access to.
  • Change your loved one’s sleeping arrangements. Allow them to sleep in a different bedroom, in a favorite chair or wherever they are most comfortable.
  • Use a nightlight. Keep the room they are in partially lit once they are in bed to reduce agitation that occurs when surroundings are dark or unfamiliar. Changes in vision and perception that come with dementia can make poorly lit areas particularly frightening or disorienting.
  • If they are feeling paranoid or experiencing delusions or hallucinations, meet them in their version of reality and reassure them that everything is alright, and everyone is safe.
  • Monitor their diet. Restrict sweets and caffeine consumption to the morning hours and serve dinner early.
  • Seek medical advice. Physical ailments, such as incontinence, could be making it difficult for them to sleep. A urinary tract infection (UTI) can also contribute to confusion and agitation. Your doctor may also be able to prescribe a medication to help them relax at night and sleep better.
  • Be flexible. Alzheimer’s disease and other types of dementia do not present the same way in each person. For some patients, sundowning may actually occur first thing in the morning. Others may never present these symptoms. It’s up to caregivers to roll with the punches to the best of their abilities.
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82 Comments

I think it is our opportunity to go into another world. Like play-acting with kids. I remember doing dress-ups with my kids, and doing it as a child. (I have the photos on Facebook!)

It is a shocking reversal of role: from child => adult child => caregiver, but we are the only ones that can do this. No one understood my Dad: physicians, caregivers in LTC, nurses, but I saw him almost every day. I have told me daughter at the first sign of dementia to put me on the raft in the middle of the lake with a couple of bottles of wine!

Make sure you write in a journal: write about your feelings and experiences. It really, really helps. I did a paper on autobiographical writing.
My mother has dementia and can concoct the most outlandish stories. In her mind, they're true and she cannot be convinced otherwise. It's useless to try. The sundowning for her does not necessarily correspond with the sun going down. It can occur from about 4pm on. Also, during the school year my teenaged son comes in at 3:30. This represents an environmental change - from peace and quiet all day - to whatever "noise" teenagers bring. I can't expect my son to stop living, but I do encourage him and his friends to be sensitive of my Mom's condition. Bathing, too, often represents a severe environmental change for Mom. It's hard, I suppose, to go from dry to wet if such changes are uncomfortable.
Cleverdish,
You mom is taking two medications for high blood pressure. These meds can make you use the bathroom all through night. I would get an at home blood pressure monitor so I could check your mom's blood pressure throughout the day, while keeping a log of the numbers for at least a week. I would then take it to the doctor to see what can be done to adjust her meds. Her having to get up that often is disturbing her sleep too and doesn't sound healthy at all. The doctor needs to adjust the meds. There are meds for hypertension that do NOT contain fluid pill features. Ask about them. Is she drinking a lot of fluids near bedtime?

If it's not the meds causing the frequent nightime urination, I would also check her blood sugar levels. Diabetes can cause this AND sleep apnea too. Sleep apnea causes the body to secrete a chemical that causes frequent urination. When the sleep apnea is treated, the urination normally returns to normal.

I would think that you could get to the cause with the help of the doctor.