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 group of symptoms that may arise in the middle and later stages of Alzheimer’s affects patients at a certain time each day. Known as sundowners syndrome, or sundowning, it involves a pattern of sadness, agitation, fear, delusions and hallucinations that occurs in dementia patients in the late afternoon, evening and at night. This increased confusion around twilight can be distressing for both patients and caregivers alike.
What Is Sundowning?
When a senior is sundowning, they may “shadow” their caregiver or follow them around and closely observe or try to mimic everything they do. They might ask questions over and over or interrupt conversations. The dementia patient 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 environment or try to get outside to “escape.” Common reasons for wandering include needing to get to an appointment that does not exist or wanting to go to an important location that they have not been to in years, such as a childhood home.
Behaviors and emotions that may arise during an episode of sundowning include:
- Emotional outbursts
- Visual and auditory hallucinations
- Hiding things
- Wandering or pacing
- Yelling or screaming
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 dementia behavior prevents many patients and their caregivers from getting adequate rest at night. Unfortunately, sleep deprivation can cause these symptoms to worsen. Therefore, it is important to understand your loved one’s routines and moods as best as you can to minimize these symptoms.
What Causes Sundowning?
Doctors and researchers are not 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 or sleep-wake cycles. 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 see well in the dark. Changes in lighting associated with this time of day often cause shadows that can be very disorienting for a patient.
The National Institute on Aging cites being overly tired, unmet needs like hunger or thirst, depression, pain, and boredom as factors that can contribute to sundowning behaviors as well.
How to Manage Sundowners 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.
It is recommended to try nonpharmaceutical solutions for sundowning before turning to medications. Many seniors are already taking multiple prescriptions, and adding to their medication regimen may cause severe adverse effects. Therefore, options like anti-anxiety drugs and antipsychotic drugs should be considered as a last resort for treating sundown syndrome.
Tips for Minimizing 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 or behaviors 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, 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.
- Consider using bright light therapy to help “reset” a dementia patient’s circadian rhythm. Studies have shown that the use of a full-spectrum light box has positive effects on sleep-wake cycle disorders, minimizes agitation and confusion, and improves sleep quality.
- 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.
- Develop a daily 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.
- Experiment with music therapy. Sometimes soothing music will help to calm and relax a person with Alzheimer’s or dementia.
- Be aware of certain times, people, places or activities that seem to trigger difficult dementia behaviors. Noticing patterns in their sundowning can help you avoid these triggers and adapt your loved one’s routine.
- Ensure the dementia patient’s 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 a dementia patient is feeling paranoid or experiencing delusions or hallucinations, meet them in their version of reality. Reassure them that everything is alright and everyone is safe. This approach is called validation and is far more effective than using logic to reorient a loved one with dementia.
- 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 a dementia patient to sleep. A urinary tract infection (UTI) can also contribute to confusion and agitation. Your loved one’s doctor may be able to prescribe a medication to help them relax at night and improve sleep quality. Antipsychotic drugs like haloperidol (Haldol), quetiapine (Seroquel) and risperidone (Risperdal) are sometimes prescribed for the “off-label” purpose of minimizing psychological and behavioral issues in dementia patients. Anti-depressants and anti-anxiety medications may also be considered to treat depression and agitation.
- Discuss the use of melatonin with a loved one’s doctor. This natural hormone helps regulate sleep-wake cycles and is available as a supplement without a prescription. Be sure to check with your loved one’s physician or pharmacist about possible drug interactions before adding any medications or supplements to their regimen.
- 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 exhibit these symptoms. It is up to family caregivers to roll with the punches to the best of their abilities.
Sources: Tips for Coping with Sundowning (https://www.nia.nih.gov/health/tips-coping-sundowning); Treatments for Behavior (https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior); Treatment Options for Sundowning in Patients With Dementia (https://mhc.cpnp.org/doi/full/10.9740/mhc.n204525); Sundown Syndrome in Persons with Dementia: An Update (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/)