Understanding and Minimizing Sundowners Syndrome


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?

Sundown syndrome in itself is not a disease, it is a term used to describe a group of symptoms exhibited by dementia patients. The timing of the onset of these troubling behaviors is what gives this group of characteristic symptoms its name. The National Institute on Aging uses the term sundowning, however literature on Alzheimer's and dementia commonly interchange the phrase sundowning with sundowners, late-day confusion, and sundown syndrome.

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. It is important to note that 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.

Unfortunately, this dementia behavior prevents many patients and their caregivers from getting adequate rest at night, and 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 the symptoms of sundowning.

Sundowning Symptoms

Behaviors and emotions that may arise during an episode of sundowning include:

  • Anger
  • Agitation
  • Anxiety
  • Confusion
  • Emotional outbursts
  • Delusions
  • Fear
  • Depression
  • Stubbornness
  • Restlessness
  • Rocking
  • Visual and auditory hallucinations
  • Hiding things
  • Paranoia
  • Violence
  • Wandering or pacing
  • Crying
  • Insomnia
  • Yelling or screaming
  • Shadowing

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. Ultimately, though, there is no known cause for sundowner's syndrome.

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.

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.

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How to Manage Sundowners Syndrome

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.”

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.

The first step in managing this difficult time may be recognizing and reducing triggers by making environmental changes and altering patterns of behavior. Attempts at prevention may be the best strategy in dealing with sundowning.

Preventing Sundowning Behaviors

Develop a daily routine

Maintaining a schedule helps orient patients and alleviates anxiety that may arise during twilight. Even simple tasks like drawing the curtains so they cannot see the sky change from light to dark, washing up for dinner and putting on pajamas can be helpful indicators that the day is winding down.

Try to prevent excessive commotion during the times they normally become more agitated. 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.

Make diet adjustments

Monitor their diet. Restrict sweets and caffeine consumption to the morning hours so that they don't interrupt sleep. Consider moving the heavier meal to lunch time or serving dinner early so that the hustle and bustle of clean up doesn't interfere with winding down at night. Keep evening snacks light.

Increase light

Turn on inside lights to keep the environment well-lit, minimize shadows and improve visibility.

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.

Adjust sleep schedules

Plan more activities during the day such as walks, crafts and visits to keep your loved one awake and engaged. A person who rests most of the day is likely to be more awake at night.

Discourage excessive napping, especially later in the day.

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.

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.

Improve safety and security

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.

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.

Be flexible and patient

Unfortunately even with the best efforts at prevention, at some point most caregivers dealing with mid- to advanced stages of dementia will likely need to cope with sundowning symptoms. Use the following tips to mimize the challenges when sundowning behaviors occur.

5 Tips for Minimizing Sundowning Symptoms

  1. Approach your loved one in a calm manner.
    Don’t yell, raise your voice or touch them in an unexpected way. Reacting to their behaviors may unintentionally make matters worse.
  2. Avoid rationalizing or arguing.
    Asking for explanations to statements or behaviors that don’t make sense may escalate the situation. There is no reasoning with someone who has dementia.
  3. Redirect to a non-stimulating location.
    Guide the person to an area away from noise, family activity and other distractions.
  4. Validate their experience.
    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.
  5. Provide comfort.
    Sometimes soothing or familiar music will help to calm and relax a person exhibiting anxious or restless behaviors. Provide a comfort object such as a familiar blanket, doll or turn on a favorite television show or movie as a distraction.

Sundowning syndrome can be exhausting for both the dementia patient and their caregiver. Don't hesitate to ask for help. Whether provided by a family member, private duty nurse or home care provider, regular respite is necessary for a caregiver to be able to provide the best quality of care.

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/)

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