Last updated: October 23, 2013
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 Sundowner's Triggers
End-of-day activity (at a care facility). 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
Fatigue. End-of-day exhaustion or suddenly the
lack of activity after the dinner hour may also be a
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 Sundowner's 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
called, appropriately, "sundowners syndrome."
How to Cope: Managing the Behaviors
The treatment of sundowners 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
"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 sundowners
- 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
- 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
- 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
- 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
Looking for Behavior Patterns
Sundowners syndrome is a condition most often associated with
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 sundowners 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 sundowners 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 syndrome 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 sundowners 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 with sundowners 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-mostly sleeping-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 sundowners 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
patients are experienced with its range of symptoms and trained
to deal with them appropriately.
It is important to remember that sundowners 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.