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Sundowners Syndrome (Sundowning) in the Elderly

What is Sundowners Syndrome?

Sundowners syndrome, or sundowning, is a state of confusion that occurs later in the afternoon and into the night. This state of confusion is most often found in patients who have dementia or Alzheimer's disease and is comprised of a range of behaviors including increased confusion, anxiety and aggression. Sometimes people with this condition tend to pace or wander, and they may ignore or not hear instructions.

While not a disease in itself, sundown syndrome is a common pattern of behavior to watch for in seniors at a specific period of time each day especially if they have been diagnosed with a form of dementia. The cause of these behaviors is unknown.

What are the Signs & Symptoms of Sundowners Syndrome?

Symptoms range in severity and tend to begin in early to late evening and may continue throughout the night. These symptoms include:

  • Sudden mood swings
  • Anxiety
  • Sadness
  • Restlessness
  • Energy surges
  • Increased confusion
  • Hallucinations
  • Delusions
  • Pacing
  • Rocking
  • Crying
  • Screaming
  • Disorientation
  • Resistance
  • Anger
  • Aggression
  • Violence

Often you will see these symptoms paired together rather than one at a time. In some people, days and nights get reversed while others only have symptoms for an hour or two in the evenings.

Factors that Can Aggravate Sundowners Syndrome

There are several factors that can aggravate sundown syndrome in the elderly, although sundowning behaviors can happen without these triggers. Typical aggravating factors are:

  • Fatigue or illness
  • Low or dim lighting
  • Increasing shadows
  • Disruption of a person's body clock
  • Presence of an infection such as a urinary tract infection (UTI)
  • Difficulty separating reality from dreams
  • Disruption of regular daily schedule

Tips for Managing Sundowners Syndrome in the Elderly

While it is difficult to completely eliminate sundown syndrome behaviors, you can work to minimize or manage them. Managing behavior requires a caregiver's strict attention to details and monitoring a patient's activities throughout the day. Try these tips to help you manage these behaviors:

  1. Maintain a predictable daily schedule for waking up, meals, activities and bedtime. Routine helps reduce uncertainty.
  2. Plan daytime activities and adequate exposure to light to create strict day and nighttime separation and to encourage sleepiness at night.
  3. Limit daytime napping to increase sleepiness at night.
  4. Limit caffeine and sugar in the diet to early in the day or not at all.
  5. Use a night light to illuminate dark spaces to reduce anxiety at night when surroundings seem unfamiliar.
  6. In the evening, turn off the TV to reduce background noise, upsetting sounds and extra stimulation.
  7. If you need to go to an unfamiliar setting, bring familiar things along to make it more soothing. These things can be pictures or favorite items such as a throw blanket or pillow.
  8. Play calming music or sounds of nature in the evenings to create a soothing atmosphere.
  9. Visit your geriatrician regularly to diagnose any underlying infections such as a UTI. These types of infections are fairly common in seniors.

General Dementia Help for Sundowners Syndrome

  • There are some tips that help with overall dementia issues that can also assist in reducing sundowning. Reducing overall stress throughout the day by keeping things familiar and routine is a good practice for all patients with dementia. You can reduce emotional stress by simplifying the physical environment. Removing clutter, using soothing colors, and blocking extraneous light from windows or light fixtures in the bedroom will reduce stimulation and lower stress.
  • Distraction is a good technique for any type of agitated behaviors. Keep favorite things on hand to distract with such as a videotape of a favorite movie, scrapbook, or even a pet or service animal to cuddle with. During the day, getting mild exercise by taking a walk or dancing will help distract from negative behaviors.
  • Adjusting lighting during the day to ensure that there is enough exposure to natural light will help keep the body clock in sync. If you don't have access to natural light, full-spectrum light is a good substitute.
  • Massage, even a short hand or foot massage, is a well-proven method of calming someone down and can help slow down anxiety or agitated behaviors. Some people will also respond to alternative treatments such as essential oils or acupuncture.
  • Other potential alternative health treatments include herbal supplements such as lemon balm, valerian, chamomile, kava and holy basil. Another supplement that some people recommend is melatonin.
  • It is crucial that any alternative treatments are discussed with your geriatrician to ensure that there aren't any conflicts with current medications. Vitamin and herbal supplements can contradict some medications and cause severe reactions. Your doctor may refer you to a geriatric psychiatrist who specializes in dementia and Alzheimer's disease patients. The psychiatrist may recommend medications used to treat anxiety and/or depression to help with sundown syndrome or other symptoms.

Seeking Treatment is Important

It is important to seek help from experts and assistance from friends and family. Managing sundown syndrome requires flexibility and creativity as well as a lot of patience and empathy. Often it takes trial and error to discover triggers in your senior before you can find solutions. Every person with dementia reacts differently to triggers and treatment, so you will have to try one thing at a time.

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