Sundowning and troubling behavior in people with dementia

By Micha Shalev

Some people with Alzheimer’s disease experience confusion and agitation that escalate in the late afternoon or evening. They have trouble going to bed and staying asleep. Experts believe this behavior, commonly called sundowning, is caused by a combination of exhaustion and changes in the person’s biological clock that confuse day and night.

Known as sundown syndrome, it is not a disease but a set of symptoms often associated with cognitive and affective disorders common in older adults like delirium, dementia and depression.

Symptoms include benign visual hallucinations (as opposed to frightening hallucinations that occur in psychotic patients one may see a visitor no one else can see, for example), disorientation/confusion; agitation, disinhibition and paranoia.

The direct cause of sundowning is unknown, but circadian rhythm is thought to be related as it influences physiological processes that regulate body functions and behavior. Disruptions in circadian rhythm may cause irregular changes in these physiological processes such as core body temperature and hormonal secretions.

Other factors, like fatigue, low lighting and shadows may contribute to sundowning.

Social and environmental interventions may help to mitigate sundowning symptoms. Attention should be given to lighting appropriate to the time of day and sleep needs; providing window shades that may be open or closed; structured meal times; suitable visitors and visiting hours; and morning and bedtime routines.

A mid-afternoon nap or quiet time should be encouraged. Noise and other sensory stimulation should be limited before bedtime. And in an unfamiliar setting such as a hospital, familiar items like photographs may help reduce agitation and confusion.

Try to increase his or her activity during the daytime. Watch out for foods that can increase insomnia — such as sugar, caffeine and some types of junk food. Eliminate or restrict these types of foods and beverages to early in the day.

Plan smaller meals throughout the day, including a light meal, such as half a sandwich, before bedtime.

Plan the day so afternoon and evening hours are quiet and calm but not boring or empty. Quiet, structured activity helps.

Turning on lights well before sunset and closing the curtains at dusk will minimize shadows and may help diminish confusion, dementia experts advise. Provide nightlights in the person’s room, hallway and bathroom.

Also be sure the house is safe. Block off stairs with gates, lock all doors to the outside and put away dangerous items. If nothing helps, you may want to talk to the doctor about medication to help an agitated person relax and sleep. Be aware that sleeping pills and tranquilizers may solve one problem and create another, such as being able to sleep at night but being more confused the next day.

It’s essential that you, the caregiver, get enough sleep.