Sundown Syndrome

Sun Sets, Confusion Rises

Sundowning is the term that refers to increased confusion and disorientation in the late afternoon and early evening.  As many as 20% of people with dementia experience sundown syndrome. 

This behavior usually is at its most severe during the middle stages of Alzheimer’s, becoming less as the disease progresses.  Some studies show that sundowning is associated with faster decline in the ability to think and with faster disease progression.

People who have sundown syndrome may have mood swings and may be suspicious, agitated, yelling, lashing out at caregivers, pacing more, and have tremors.  They may have difficulty sleeping, and wander more and “want to go home” as light fades and shadows appear.  They may also be aware of their own confusion which can frustrate them more.

Causes

Although the causes of sundown syndrome are not proven, many experts believe that in Alzheimer’s the changes to the brain affect the part that regulates our bodies’ rhythms of sleep and wakefulness—the cluster of nerve cells that keeps the body on a 24-hour clock. Other possible causes include:

• Mental and physical fatigue, making the resident less able to cope with stress
• Low lighting, increased shadows
• Discomfort due to pain, urinary tract infection, fecal impaction, etc.
• Medications
• Hunger
• Noisy sleeping environment
• Lack of organized evening activities
• Too much sleep during the day
• Change of shift activity with many people coming and going

Management

This is especially the time to apply basic techniques for dealing with people who have dementia:

• Reassure the resident in a calm way; tell them they will be all right and that they are in a safe place.
• Don’t argue with the resident or ask why they are confused.
• Try to find out if they have a need; are they cold, hungry, wet, in pain?
• Remove the resident to a calmer place, such as outside or his room—somewhere with fewer people and noises.
• Change caregivers if there is a chance that this is upsetting the resident.
• Reminisce with the resident about bedtime activities they followed with their children when they were young parents.

Consider alternative techniques such as: aromatherapy, a pet, calming sounds (bubbling brook, birds, wind in the trees), soothing food or warm milk, singing a favorite song or hymn, reading a familiar poem or children’s book, gently brushing hair, putting on a favorite movie, or massaging shoulders (only with the resident’s permission and in a common area). 

Prevention

Preventing problems is the best form of managing them.  These suggestions won’t work for every person, but persistence pays off if you keep trying:

• Maintain a consistent sleep schedule and daily routines; limit daytime sleep to short naps.
• Increase activity during the day including some physical activity such as walking or dancing.
• Monitor diet; avoid caffeine, or serve only in the morning.  Offer a light, bedtime snack.
• Let residents choose where they are most comfortable sleeping. 
• Consider the use of melatonin to promote sleep.
• Keep a dim light on at night and the room uncluttered.
• Have the resident occupied during shift change if this seems related to the sundowning.
• If sundowning occurs at a certain time every evening, plan for it.  Have the resident involved in an activity during this time.

Seek medical advice if other measures don’t work.  There may be medical conditions contributing to the sundowning.  The physician can also review the resident’s medications to check for drugs that can be eliminated.

Always keep in mind that this behavior is not done on purpose—the resident may be as baffled by it as you are.  But good planning can help prevent and manage sundown syndrome.

References: Mayo Clinic online; Web MD; Alzheimer’s Association, Care & Compliance Group.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.