Sundowning Syndrome (Sundowning) in Seniors

What Is Sundowning Syndrome?

Sundowning syndrome, or sundowning, is a state of confusion that occurs later in the afternoon and early evening. This condition is most often found in patients who have dementia, including Alzheimer's disease, and comprises a range of behaviors including increased confusion, anxiety, and aggression. Sometimes people with this condition pace, wander, or yell. Each person is unique and might react differently.

While not a disease in itself, sundown syndrome is a common pattern of behavior to watch for in seniors at a specific 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 and Symptoms of Sundowning Syndrome?

Symptoms range in severity and tend to begin in the 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 Whether these factors cause, contribute to, or aggravate the condition isn’t known for sure. But there are several factors that can make sundowning syndrome worse in seniors. The condition can occur without these triggers, but the typical aggravating factors are:
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 Sundowning Syndrome in Seniors

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 detail and monitoring of 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.4
2. Plan daytime activities and adequate exposure to light to create strict day and nighttime separation and to encourage sleepiness at night.5
3. Limit daytime napping to increase sleepiness at night.
4. Use a night light to illuminate dark spaces to reduce anxiety at night when surroundings seem unfamiliar.
5. In the evening, turn off the TV to reduce background noise, upsetting sounds and extra stimulation.
6. 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.6
7. Play calming music or sounds of nature in the evenings to create a soothing atmosphere.
8. Visit your geriatrician regularly to diagnose any underlying infections such as a UTI. These types of infections are fairly common in seniors.

Regarding managing sundowning syndrome, Dr. Abby Altman, a geropsychologist and SeniorLiving.org expert, notes, “I recall working with Margaret (not her real name changed), a woman in her late 70s diagnosed with Alzheimer's disease. Her family noticed she became increasingly agitated and confused by late afternoon, often pacing and shouting. We established a consistent daily routine for Margaret, ensuring she had ample exposure to natural light and engaging her in some light activities she used to enjoy, like gardening and listening to familiar music. As the evening approached, we dimmed the lights and played soothing music to create a calm environment.

One evening, as Margaret knitted a scarf while humming along to a familiar tune, her daughter was amazed at the transformation. Margaret's sundowning symptoms didn't disappear completely, but they became more manageable, significantly reducing her agitation. This experience reinforced the profound impact that a structured routine and personalized activities can have on individuals with dementia experiencing sundowning.”

Helping Those With Dementia and Sundowning Syndrome

Here are some suggestions to help with dementia issues and assist in reducing sundowning. Reduce stress throughout the day by keeping things consistent. Routine is important for all dementia patients. You can lessen anxiety by simplifying the physical environment. Removing clutter and unnecessary background noise as well as painting the walls in soothing colors can reduce stimulation and lower restlessness and angry outbursts.

Here are other tips:

• Speak calmly, slowly, and reassuringly.
• Be sure to check on their physical comfort. Do they need to go to the bathroom? Are they hot or cold? Have they missed a meal?
• Encourage mild exercise like gardening, for example, which can also mitigate negative behaviors.
• Ensure your loved one has enough exposure to natural light to keep the body clock in sync. Full-spectrum light is a good substitute if you can’t access natural light.
• Take your loved one outside in the fresh air. Being in nature has myriad benefits and has been proven in many studies to reduce depression, improve focus, and add a host of other mental and physical health benefits.8
• Reduce caffeine and alcohol intake to ensure restful sleep.
• Distraction is a good technique for most agitated behaviors. You can distract the individual with a favorite movie, scrapbook, or pet or service animal.
• Limited studies have shown positive effects from using massage in Alzheimer’s patients. It’s a calming activity that can help reduce agitated behavior.
• Many also respond to alternative treatments such as essential oils, acupuncture, and supplements. Melatonin, a natural hormone, is sometimes recommended for sundowning.

Expert Insights

From Dr. Abby Altman, Ph.D, Geropsychologist

Alternative treatments should be used only under the guidance of the patient’s doctors or trusted health care professionals to ensure they’re safe and there are no negative drug interactions. Vitamins and herbal supplements can sometimes cause negative interactions and severe reactions with certain medications. In addition, the efficacy of alternative treatments like essential oils and acupuncture varies, and the evidence supporting these interventions is limited.

Dr. Altman says, “I remember working with Henry (not his real name), an 82-year-old man with dementia and sundowning symptoms like agitation and anxiety. To ease his stress, we revamped his environment, clearing out clutter and painting his room in soothing colors. We also made it a point to check on his comfort regularly, ensuring he wasn’t too hot or cold and offering snacks when needed. Removing some extra layers of clothing he’d put on unintentionally and providing high-protein snacks throughout the day made a big difference.

We played Henry’s favorite old movies during moments of overstimulation and pacing and flipped through family scrapbooks. These simple distractions helped him stay calm and engaged. By tweaking his daily routine and environment, we were able to significantly improve his well-being and make his sundowning episodes much easier to manage.”

How To Cope With and Treat Sundowning Syndrome

Try to note the triggers for your loved one’s sundowning behavior. Is it due to discomfort caused by the physical environment (lack of light, too much noise)? Is it caused by their physical health (lack of sleep and rest, lack of sustenance, lack of physical activity)? Is it due to a disruptive routine or new medication? Once you have an idea about one or two possible triggers, see if the tips above can help you mitigate the problem.

Sundowning can happen anytime in Alzheimer’s patients. Most commonly it’s seen during the middle and later stages of the disease. So, caregivers should pay special attention at those times.

Because sundowning can be caused by multiple factors, doctors should evaluate this condition using a multi-dimensional approach.9 Your doctor may provide a referral for a geriatric psychiatrist who specializes in dementia, including Alzheimer's disease. The psychiatrist may also recommend medications for the treatment of anxiety or depression to help with sundowning or other symptoms.