Understanding and Minimizing Symptoms of Sundown Syndrome

For many elderly people who suffer from Alzheimer’s disease or other forms of dementia, the time of day marked by the sunset can be a time of increased memory loss, confusion, agitation, and even anger. This behavioral shift is called sundown syndrome, otherwise known as sundowners syndrome or sundowning. Doctors aren’t sure what causes sundown syndrome, but there are certain triggers to avoid and ways to manage symptoms.

What is sundown syndrome?

There is no clear definition of sundown syndrome. Generally, it’s a range of unusual behaviors — often including agitation, confusion and restlessness — that occur during the transition from daylight to darkness. It’s typically seen in the early evening but can also sometimes happen in early morning. It primarily affects people with Alzheimer’s disease or another form of dementia. In fact, as many as one in five people with Alzheimer’s will experience sundowning, according to the Alzheimer’s Association. But the elderly recovering from surgery in hospitals or unfamiliar environments will sometimes also experience sundown syndrome.

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Sundowning symptoms and behaviors

The symptoms and behaviors of sundown syndrome are unique to the individual. While one person may show several signs at the same time, another may only exhibit one of them.

What are the early signs of sundowning?

At first, symptoms of sundowning can be subtle and easy to overlook. They may also be inconsistent — one night your loved one is a little more confused or weepy at twilight while the next evening they seem slightly irritable. Because the signs are minor and varying, you may not notice a pattern right away.

Here are some of the most typical signs of sundown syndrome:

• Rapid mood changes
• Anxiety
• Anger
• Crying
• Pacing
• Agitation
• Fear
• Depression
• Restlessness
• Stubbornness
• Shadowing caregivers or others
• Repeating questions and interrupting the answerer

For some, symptoms of sundowning become more severe.

• Hallucinating
• Hiding things
• Feeling paranoid
• Acts of violence
• Wandering

Is sundown syndrome temporary? What triggers it?

Sundowning is temporary in that it generally occurs during a certain period of time — usually in the late afternoon or evening — and then passes. As mentioned above, it’s 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 you notice a consistent pattern in behaviors at sundown that signals a syndrome may be developing.

While the cause is unknown, researchers suggest several possible triggers:

• End-of-day activity
  A flurry of activity toward the end of the day may lead to anxiety and confusion.
  
• Fatigue
  End-of-day exhaustion, or lack of things to do 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 imbalance
  Some researchers even think that hormone imbalances or possible disruptions in the internal biological clock that regulates cognition between waking and sleeping hours may be a principal cause.
  
• Winter
  In some cases, the onset of winter’s shorter days amplifies sundowning. This indicates the syndrome may have something to do with Seasonal Affective Disorder, a common depression associated with shorter hours of daylight.

How to manage sundowning

While there’s not one treatment approach that works for everyone, there are a handful of remedies that can minimize the symptoms of sundown syndrome:

• Establishing a routine
  Routines can help loved ones feel safe by minimizing surprises. Without a routine that fits your loved one’s need for regular activity and food, they remain in a constant state of fear or confusion. Try not to schedule more than two major activities per day, as multiple events can start to feel overwhelming. 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 food or drinks containing caffeine or large amounts of sugar, especially late in the day, as it can disrupt sleep. Do not serve alcoholic drinks, which may add to confusion.
  
• Controlling noise
  It can be helpful to reduce noise from televisions, radios and other entertainment devices in the late afternoon or early evening. Avoid having visitors come in the evening hours. Noisy activities should be avoided or kept away from your loved one’s bedroom as much as possible. Instead, try playing soft, calming sounds or songs.
  
• Letting light in
  Light boxes with full-spectrum lights (light therapy) have been found to minimize the effects of sundowning, dementia and depression. As the evening approaches, keep rooms well-lit so your loved one can see better and surroundings don’t seem to shift because of shadows and loss of color. Night-lights can also reduce stress if your loved one needs to get up in the middle of the night.

What medications are used for sundown syndrome?

There is limited information about the effectiveness of medication in easing sundowning symptoms. In some cases, especially when symptoms are associated with depression or sleeping disorders, medication may be helpful. However, be sure to discuss possible side effects with your loved one’s doctor. Some medicines can increase the chance of dizziness, falls, and confusion, according to the National Institute on Aging.

It’s important to remember that sundown syndrome is not something your loved one can help. They’re not purposely becoming agitated, angry or afraid. Remaining calm as much as possible will help you and your loved one get through these stressful moments.

Don’t be afraid to ask for help. Call your loved one’s doctor if the signs become too frequent or difficult to handle. They may be able to pinpoint additional triggers or management techniques.

If you’d like to explore additional care options for your family member or loved one, our Senior Living Advisors are available to help.

Sources:

Canevelli M, et al. (2016). Sundowning in dementia: Clinical relevance, pathophysiological determinants, and therapeutic approaches. Frontiers in Medicine (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5187352/)

Understanding and Minimizing Symptoms of Sundown Syndrome posted by Dana Larsen