Sundown Syndrome: Triggers & Management

For most of us, sunset is an occasion we celebrate. It’s a time of transition from the often frenetic energy of the day to the more subdued and relaxing nature of evening. But for many elderly people who suffer from Alzheimer’s disease or other forms of dementia, it can be a time of increased memory loss, confusion, agitation and even anger.

For family members who care for those with dementia, witnessing an increase in their loved one’s symptoms of disorientation at sunset can be nothing short of troubling, if not also painful, frightening and exhausting.

Common Sundowning Triggers

• Too Much End-of-day Activity: Some researchers believe the flurry of activity toward the end of the day as the facility’s staff changes shifts may lead to anxiety and confusion.
• Fatigue: End-of-day exhaustion or suddenly the lack of activity after the dinner hour may also be a contributor.
• Low Light: As the sun goes down, the quality of available light may diminish and shadows may increase, making already challenged vision even more challenging.
• Internal Imbalances: Some researchers even think that hormone imbalances or possible disruptions in the internal biological clock that regulates cognition between waking and sleeping hours may also be a principle cause.
• Winter: In some cases, the onset of winter’s shorter days exacerbates sundowning, which indicates the syndrome may have something to do with Seasonal Affective Disorder, a common depression caused by less exposure to natural sunlight.

Example of Sundown Syndrome Behavior

Margaret, a 72-year-old with early-stage Alzheimer’s, loves her breakfasts and is usually in temperate spirits each morning in her care facility’s dining room. While she exhibits most of the common symptoms of Alzheimer’s in the morning and after lunch, such as short-term memory loss, language impediments and disorientation, her personality is manageable and she gets along relatively well with others. But as the sun goes down and the staff changes shifts, Margaret becomes alarmingly moody and often will shout at those around her. She’s been known to strike out at staff trying to help her. Often when she goes to bed, she is ranting about people in her past, preventing her and others from getting a decent night’s sleep.

This might sound familiar to you. The phenomenon, which affects up to 20% of the more than 5 million Americans with Alzheimer’s, is referred to as “sundowning” or “Sundown Syndrome.”

Managing Sundowning Symptoms

The treatment of Sundown Syndrome, just like its cause, is not well established. But there is hope in a number of approaches that have helped calm down sufferers of the condition in the past.

“It’s not like treating blood pressure where you just give a blood pressure medicine,” says Rabins. “It’s hard to generalize about it because there’s not one treatment approach, but I think often when you focus on the individual you can find things that are more likely to work with one person than another.”

Some of the more successful approaches to managing sundowning behavior include:

• Establishing a Routine: Routines help sundowners feel safe. Routines minimize surprises and set up daily rhythms that can be relied on. Without a routine that fits your loved one’s need for regular activity and food, he or she may remain in a constant state of anxiety and confusion, their limited cognitive abilities unable to deal with the unpredictability of the day. Schedule more vigorous activities in the morning hours. Don’t schedule more than two major activities a day. As much as possible, discourage napping, especially if your loved one has problems sleeping.
• Monitoring Diet: Watch for patterns in behavior linked to certain foods. Avoid giving foods or drinks containing caffeine or large amounts of sugar, especially late in the day.
• Controlling Noise: It may be helpful to reduce the noise from televisions, radios and other household entertainment devices beginning in the late afternoon and early evening. Avoid having visitors come in the evening hours. Activities that generate noise should be done as far away from your loved one’s bedroom as possible.
• Letting Light In: Light boxes that contain full-spectrum lights (light therapy) have been found to minimize the effects of sundowning and depression. As the evening approaches, keep rooms well-lit so that your loved one can see while moving around and so that the surroundings do not seem to shift because of shadows and loss of color. Night lights often help reduce stress if he or she needs to get up in the night for any reason.
• Medicating: In some cases of sundowning, especially when associated with depression or sleep disorders, medication may be helpful. Consult a physician carefully, for some medications may actually disrupt sleep patterns and energy levels in a way that makes sundowning worse, not better.
• Taking Supplements: A few over-the-counter supplements may be of some benefit. (Remember to consult with your loved one’s doctor before giving him or her any dietary supplement.) The herbs ginkgo biloba and St. John’s Wort have assisted people with Alzheimer’s and dementia in the past. Vitamin E has also been found to minimize sundowning in some cases. Melatonin is a hormone in supplement form that helps regulate sleep.

Looking for Behavior Patterns

Sundown Syndrome is a condition most often associated with early-stage Alzheimer’s, but has been known to affect the elderly recovering from surgery in hospitals or in unfamiliar environments. Occasionally, the syndrome will affect people in the early morning hours. While the symptoms and causes of Sundown Syndrome are unique to the individual, researchers agree that it occurs during the transition between daylight and darkness, either early in the morning or late in the afternoon. But the precise cause of sundowners, like the cause of Alzheimer’s disease, remains elusive.

“There is not a clear definition of what Sundown Syndrome means,” says Dr. Peter V. Rabins, professor of psychiatry in the geriatric psychiatry and neuropsychiatry division of Johns Hopkins University School of Medicine. “It’s a phrase. Some people would only include agitation in the definition. It is a range of behaviors-something that is not usual for the person. That can range from just being restless to striking out.”

While some with Alzheimer’s express their dementia throughout the day, the behaviors encountered in sundowners are often more severe and pronounced, and almost always worsen as the sun goes down and natural daylight fades. While one person may express several of the behaviors at the same time, another may exhibit only one of them. Symptoms include rapid mood changes, anger, crying, agitation, pacing, fear, depression, stubbornness, restlessness and rocking, according to Rabin.

Occasionally you will find your loved one “shadowing” you closely from room to room. They may ask you questions and interrupt you before you can answer them. They may ask these questions more than once, but it is important to realize they have no recollection of ever asking them before. They are not purposely trying to aggravate you. They simply do not remember.

The more severe symptoms of Sundown Syndrome are also the most difficult to manage for those who care for Alzheimer’s patients and may also put others at risk: hallucinations, hiding things, paranoia, violence and wandering. Wandering, especially, is dangerous, besides also being frustrating. Not only can the person not control these behaviors or conditions, if they wander, they often do not know they are wandering and they often do not know how to return home. While it may sound rather indiscreet, it is often a good idea to give your loved one an identification bracelet and even go so far as to lock doors and fence yards with locked gates to keep him or her safe during unsupervised hours. It is never a good idea to leave a loved one with sundowners alone in a car or in a public place while you are shopping or running errands.

According to Rabins, it is not inevitable that a person with Alzheimer’s disease will also develop Sundown Syndrome. And it is also important to note that Alzheimer’s specifically and dementia in general are not the only precursors to the condition. As mentioned above, it is not uncommon for perfectly healthy elderly people to behave strangely when recovering from surgeries in which anesthesia has been administered, or during protracted hospital stays. These event-oriented psychoses are usually temporary. It is only when a pattern in behaviors at sundown is noticed that a syndrome may be developing.

“When there’s a pattern to it,” says Rabins, “it’s important to look for triggers or something in the environment. Is there something in the patient’s medication? Are their fewer activities? Is there less staffing? There might be things in the environment that may change or things in the patient: biological changes, sleep-wake cycle, hormone secretion problems. There may be things that can be done, for example, to increase the stimulation for some people, but for others it might be decreasing it. Does it happen every day, how long does it last, how severe is it?”

Because it is common, many professional caregivers who care for Alzheimer’s patients are experienced with its range of symptoms and trained to deal with them appropriately.

It is important to remember that Sundown Syndrome in your loved one is not something he or she can help. They are not purposely becoming agitated or angry or afraid as the afternoon leads to evening. Remaining calm will help you and your loved one get through these sometimes stressful moments.