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.

Managing Agitation in People with Dementia

Agitation in dementia has many possible causes.  It can be a result of degeneration of the nervous system which may lessen a person’s ability to cope.  Another huge factor is that the resident is unable to communicate a need.

Six Triggers
Researchers have identified six main causes of agitation in dementia.  As caregivers, it is our job to do the detective work to find out what the cause might be.  We need to imagine ourselves in his or her shoes to help figure out the trigger.  If at first you don’t succeed…be persistent, keep digging!  And always consider a combination of factors.

Fatigue: Most of us tend to be more irritable when tired and people with dementia are no exception.  Did the resident get enough sleep last night?  Has he had more activity than usual today?  You can ask, “Would you like to rest now?” 

Change: People with dementia usually like routine—everything done the same way, at the same time, every day.  What’s different today?  Think of anything new: maybe a new caregiver, clothes, holiday decorations or a change in lunch time or bath time.

Perception of loss: If the resident is reliving a loss such as the death of a loved one, empathy followed by distraction may work to divert the person’s attention.  If the loss is the perception that something has been taken, help the resident to look for it.  If the loss centers around money, it may help the resident if the family will bring in some loose change to keep in the resident’s pocket so he can be reassured that he has his money or his wallet.

Stimulus levels: Consider the environment.  What is going on around the resident?  Some people react negatively when there is too much noise, too many people or too much activity.  Others may tolerate this normally, but react badly when they are more tired.  This might be a time to walk the resident to a quiet area or his or her room where they have a chance to feel calmer.

Is it possible the resident is under-stimulated?  Could he be bored or restless?   Perhaps he or she needs physical activity such as a walk outside.  Could she be lonely?  You can ask family members to make a video of themselves doing routine activities for the resident to watch when she misses them.

Excessive demands: With dementia comes the loss of the ability to process multiple thoughts at one time.  People with dementia can’t multi-task or multi-think.  So we need to be careful in our communications that we only make one brief request of them at a time.  Saying “Brush your teeth, then you can get into your pajamas and ready for bed” may simply be too many concepts.  You may be more successful breaking it into bite-sized chunks: “Now it’s time to brush your teeth.”  When that is accomplished: “Now it’s time to put on your pajamas.”

Physical stressors: Rule out pain: it could be a headache, a pebble in the shoe, a stomach ache, a urinary tract infection or clothes that are too tight.  Look for signs of injury: red spots or bruises, limping, a bump on the head or holding a body part.  Look for signs of infections such as a rash, redness, runny nose or strong smelling urine.  Could the resident feel cold or hot and unable to tell you?  Is he or she uncomfortable due to wet briefs?

Communication

One of the greatest frustrations of having dementia is not being able to clearly communicate your wants and needs.  But we can do a lot to facilitate better communication.  First we need to make sure the resident is ready to communicate: are his glasses clean?  Is her hearing aide in, turned on and does it have a good battery?

Now the resident may be ready to communicate, but are YOU?  You should identify yourself every day, sometimes more than once a day.  Don’t assume the resident will remember you just because he knew you last week. 

Key Principles

It is essential that you know what the person’s limitations are.  If he or she has had a stroke it is important to know what parts of speech and thinking were affected.  Sometimes a stroke leaves the person unable to understand speech, other times he understands but cannot get the right words out.

Remember that agitation is a symptom that means something else is wrong.  It is the job of caregivers to figure out what the real cause is.  So when the resident is agitated, put on your detective hat and see if you can’t solve the mystery at the bottom of the behavior.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.