As day progresses into night, some people with Alzheimer’s disease experience confusion and other symptoms of sundown syndrome, also known as sundowning, sundowner’s syndrome or late-day confusion.
About 20% of people with Alzheimer’s disease experience symptoms of sundowning, according to the Alzheimer’s Association. Symptoms of sundowner’s syndrome can include confusion, restlessness, agitation or irritability that begins or worsens as daylight begins to fade. Many people with sundown syndrome have trouble performing the same tasks in the evening as they perform easily during the day. For some people, sundowning can also involve wandering, delusional thinking, impulsive behavior, having trouble understanding others, moaning and even screaming.
Symptoms of sundown syndrome can persist well into the night, disrupting sleep for the person with Alzheimer’s disease and for tired caregivers. Sundowning symptoms can make it difficult to stay in bed, fall asleep and stay asleep. In the morning, they and their caregivers awaken feeling exhausted.
Causes of Sundown Syndrome
Researchers have not yet determined the underlying physiological cause or causes of sundowning. It is possible that Alzheimer’s disease and other types of dementia affect the body’s biological clock and confuse the brain’s sleep-wake cycles. Interfering with the brain and body this way, and confusion the interference causes, may also cause agitation.
While researchers are still working to understand the root cause or causes of sundowning, medical and nursing professionals have noted common triggers, which can include:
- Fatigue at the end of the day, which can interfere with one’s ability to cope with stress
- Low lighting, which can cause confusing shadows and even hallucinations, as familiar objects take on new shapes in the dim light
- Disruption of the sleep-wake cycle, as dementia prevents the person from distinguishing night from day
- Engaging in less activity during the afternoon than during the morning, which can cause someone to be restless during the evening
- Reactions to verbal and non-verbal cues from caregivers
- Disorientation – people with Alzheimer’s disease often have trouble separating dreams from reality, especially at night
- Decreased need for sleep, which is common in older adults
Finding a way to manage sundowning is often a process of trial and error – what works for one person may not work for another, and what works one night might not work the next. Many caregivers keep a daily journal, which can help pinpoint possible causes of sundown syndrome and effective strategies to control sundowning behaviors.
Rule out other causes
Make sure the behavior is not the result of discomfort or physical need, such as hunger, needing to go to the toilet, etc. People with Alzheimer’s disease often have trouble communicating their experiences and needs. Boredom can sometimes cause sleeplessness and agitation.
Avoid stressful activities, such as doctor appointments or bathing, late in the afternoon or evening. Schedule anxiety-causing situations for the morning and save the relaxing and pleasurable activities for the afternoon and evening. Scrutinize other aspects of the daily routine – something as simple as adjusting dinnertime or altering caregiver shifts can influence symptoms of sundowner’s syndrome.
Maintain a regular schedule
Once you have found a schedule that works, try to adhere to that schedule as closely as possible. Create a pre-bedtime routine, such as closing curtains, turning on lights, drinking warm milk or listening to calming music. Maintaining a regular schedule and familiar routines helps people with sundowner’s syndrome know when it is time to stay awake and when it is time to go to bed.
Manage energy levels
Burn off excess energy with brisk walks or other forms of physical activity during the day to reduce restlessness and decrease the urge to wander. Don’t overdo it, though, as fatigue can lead to agitation. Allow for rest and naps in between activities but avoid naps too close to bedtime.
Keep the home well-lit in the evening
Poor lighting can make a familiar room seem foreign. Furniture and curtains can cast shadows in dim light, which can turn a friendly and welcoming environment into a strange and scary one. Poor lighting can also increase the risk of trips and falls.
Make early evening a quiet time
Play soothing music, read or go for a slow walk. Ask a friend or family member to telephone, but only if this person has a soothing effect.
Reduce intake of coffee, tea, chocolate and other foods that contain caffeine, especially later in the day. Consuming caffeine in the afternoon or evening can lead to restlessness, sleeplessness and anxiety at night.
Adjust the sleeping arrangements
Make the bedroom more comfortable and inviting. Add a recliner as an alternate to sleeping in the bed, for example. Install a night light or leave a door open.
Administer medications as prescribed
While Alzheimer’s medications cannot cure the disease, they can reduce symptoms. To get the most out of Alzheimer’s disease therapies, administer medications as prescribed. If you think medications may be causing sundowner’s syndrome, speak to the doctor who wrote the prescription. Never change the way you administer a medication without first speaking with a doctor.
Talk to the doctor about anti-anxiety and sleep medications
Depending on the circumstances, doctors sometimes prescribe antipsychotics, sedatives or sleep-regulating hormones to reduce the symptoms of sundowning.
Ask about melatonin
Melatonin is a natural supplement that regulates the sleep-wake cycle. Research shows melatonin use by people with Alzheimer’s disease and other types of dementia can improve sleep and suppress sundowning. More research is needed, though, and people with Alzheimer’s disease should always consult with their doctor before starting melatonin or other supplements.
Create a comfortable sleep environment
Set the temperature in the bedroom at a comfortable level in the evening. The National Sleep Foundation suggests setting the thermostat to between 60 and 67 degrees Fahrenheit for optimal sleep because body temperatures decreases to initiate sleep, so cool temperatures inside a room help facilitate sleep. Cool temperatures also create the need for a heavy blanket, the weight of which can provide a feeling of comfort and security at bedtime.
10 Ways to Respond to Sundowning
It isn’t always possible to prevent sundowning, so it is always handy to know different ways to respond to it. Since symptoms and triggers of sundowning can be different between people and even from one day to the next, figuring out what works and what doesn’t may require some trial and error.
1. Close the curtains or shades
Closing the shades at night during a sundowning episode can minimize shadows and decrease anxious responses to those shadows.
2. Turn on the lights
Turning on lights provides a clearer view of the room to reduce apprehensions. Brighter light can also minimize shadows.
3. Reduce noise and clutter in the room
Noise and clutter can stimulate the senses. Turn down the volume of the television or radio, reduce the number of people in the room and remove excess objects – especially if the items move, emit light or make noise.
4. Create a distraction
Divert attention away from anxiety and troubling thoughts by redirecting focus to favorite activities, conversational topics, foods, animals and people.
5. Play soothing music or calming sounds
Nature sounds, such as rain or ocean noise, have a relaxing effect.
The smell of lavender, chamomile, rose, ylang-ylang, blue tansy, frankincense and other essential oils can soothe anxiety. Essential oil diffusers are an easy and affordable way to send the aroma of essential oils through the air.
7. Avoid arguing or reacting in anger
Your response to sundowner’s symptoms or other events in the household can trigger a positive or negative result. Try to keep arguments between all residents of the household to a minimum when possible, especially in the late afternoons and early evenings. When engaged in a passionate conversation, try to keep your voice and body language calm.
8. Allow a little bit of pacing
Pacing is a natural reaction to stress and walking is a good way to burn off excess energy. Do not prevent your family member from pacing but do keep an eye on him or her to prevent escape behaviors.
9. Give a healing touch
A gentle touch, relaxing massage or comforting hug can be physically calming and emotionally reassuring.
10. Be creative
Managing sundowner’s syndrome requires creativity, empathy, flexibility and strong observational skills to identify the triggers of sundowner’s syndrome and to address behaviors associated with it.
For more information on sundowner’s syndrome, and the management and prevention of sundowning, contact Forest Hill. Our caring and compassionate professionals at Forest Hill have many years of experience caring for people with sundown syndrome. Forest Hill was the first continuing care retirement community in Monterey, so we have a long history and reputation for offering unparalleled care. Contact us today!