Sundowning in Alzheimer's Patients: A Definition
Sundowning is a term used with Alzheimer's in order to describe behaviour difficulties that can occur in the late afternoon, evening or night hours.
Just how common sundowing is can be difficult to assess as many people with dementia are cared for in a variety of care settings such as their home, private clinics and hospitals.
Sundowning still lacks a precise definition and so the debate about what sundowning really is tends to include the causes, strategies for coping and how best to provide care for people with dementia.
People with Alzheimer's disease, and many other forms of dementia, are often at their best earlier in the day. As the day progresses the person's memory and ability to carry out tasks can deteriorate. For this blog I have defined sundowning as the following: increased confusion and agitation leading to behavioral changes that occur later in the day and evening.
Sundowning can be more common in the moderate to severe stages of Alzheimer's. There is evidence that Alzheimer's disease damages or disrupts the parts of the brain that control the circadian rhythms, the body clock and the sleep-wake cycle.
Sundowning is Exhausting for Caregivers and People with Dementia
The difficult thing about sundowning is that towards the end of the day the person with Alzheimer's and his or her caregiver are tired and not always at their best. But if you know that sundowning is a feature of dementia then it can be less frustrating and something that can be prepared for.
Signs and Symptoms of Sundowning:
Sundowning occurs in the later part of the day and in the evening. Behavior can include the following:
- Increased agitation
- Increased anxiety
- Increased confusion
- Being less cooperative
- Being more argumentative
It is important not to misinterpret the behaviors I've just listed. It may be that people with Alzheimer's disease are behaving differently because of other things. For example, are you being more demanding? Are you making unrealistic demands? Are they suffering from physical discomforts (noise, continence problems, medications, illness, pain), is a belief and resulting confusion contributing to increased difficult behavior ?
Ways to Minimize or Prevent Sundowning
- Make sure sundowning is not the result of physical illness or medication.
- Caregivers need to be flexible in their approach and in their expectations.
- Avoid caffeine drinks in the afternoon and evening.
- Have non-glare lighting. Make sure lighting is appropriate to the time of day. Make sure lighting in the room allows clear vision-shadows, inability to see objects and people can increase agitation.
- Be soothing and try to be undemanding. Try to make the person with Alzheimer's feel safe and secure.
- Make sure the person's physical needs are met, i.e. that they are not hungry, thirsty, constipated, or need the bathroom.
- Avoid too many naps during the day.
- Soothing music may help relax them.
- Provide stimulating activities in the day without exhausting the person.
- Remember that a person with Alzheimer's does not have control over their behavior.
Sundowning strategies do not always work the first time, or even the second or third time. You have to find out what suits each individual to minimize the problematic behaviors of sundowning. Keeping a diary of different strategies and their results over time can help you isolate some important key features. Medical intervention or medication may be required if things do become too difficult.
Ladislav Volicer, M.D., Ph.D., David G. Harper, Ph.D., Barbara C. Manning, M.Ed., Rachel Goldstein, B.S., and Andrew Satlin, M.D. 2001 Sundowning and Circadian Rythums in Alzheimer's Disease Am J Psychiatry 158:704-711