How to Understand & Minimize Sundowners Syndrome

A confused elderly woman.

Sundowning syndrome, or nocturnal delirium, refers to a change in mood, personality, and behavior that occurs in the late afternoon, evening, and at night. Sundowners syndrome is not a disease but a group of symptoms. It occurs in people with cognitive impairments like dementia, and most notably, Alzheimer’s disease. Sundowners syndrome affects 20 to 45% of Alzheimer’s patients. 

Alzheimer’s disease is a disorder that progresses as brain cells waste away and expire. The main symptom of Alzheimer’s is memory loss. Alzheimer’s disease is the most common cause of dementia. It makes up 60 to 80% of dementia cases. The greatest known risk factor for Alzheimer’s disease is age. Most people with Alzheimer’s disease are 65 years of age or older. However, as many as 200,000 Americans under 65 have early-onset Alzheimer’s disease. Alzheimer’s is a progressive disease. It starts with memory loss and progresses to the inability to hold a conversation or respond to their environment. There is currently no cure for Alzheimer’s disease, though there are treatment options for symptoms. Learn more about Alzheimer’s disease at alz.org and the national institute of aging.

Dementia is a general term for a decline in cognition, behavioral, and social skills. While Alzheimer’s is a specific disease, dementia is not. A person with dementia gradually becomes unable to function independently. There are many different types of dementia, and there are many conditions that cause it. Mixed dementia happens when different forms of dementia happen to the brain simultaneously. Sundowning can occur at any stage of these diseases. However, sundowners syndrome usually peaks during the middle stages of Alzheimer’s and mixed dementia. It usually fades as dementia progresses into the later stages.

Symptoms of Sundowners Syndrome

Sundowners syndrome, sometimes known as “late-day confusion,” may be difficult to detect in its early stages. This is because the symptoms may be subtle and inconsistent. Early signs include agitation, restlessness, suspiciousness, confusion, irritability, disorientation, and becoming demanding during the night. As Sundowners progresses, these symptoms become more pronounced. Some of the most common symptoms include:

  • Difficulty sleeping/insomnia
  • Hiding objects
  • Pacing
  • Wandering
  • Rocking
  • Restlessness
  • Visual and auditory hallucinations
  • Emotional outbursts
  • Crying
  • Paranoia
  • Delusions
  • Extreme agitation/mood swings
  • Fear
  • Anxiety
  • Depression
  • Anger
  • Confusion
  • Vertigo
  • Bladder incontinence
  • Stubbornness
  • Violence
  • Yelling or screaming
  • Shadowing/mimicking
  • Increased tremors

It is important to note that these behaviors alone do not necessarily mean the person has sundowners syndrome. The behaviors could be manifestations of delirium, varying types of dementia, sleep disturbances, or Parkinson’s disease. What most notably distinguishes these symptoms as sundowners syndrome is the fact that they occur consistently in the late afternoon, evening, and nighttime hours. Symptoms tend to develop between 4:30 in the afternoon to about 11 at night. They appear when daylight begins to fade and may get progressively worse as night falls. Sundowning syndrome usually starts at about the same time of day for each individual. It usually lasts a few hours, and then most return to their regular selves.

Delirium can be easily mistaken for sundowner’s syndrome. It is important to first rule this out as a possibility when examining your loved one’s symptoms. Delirium is a medical condition in and of itself. However, people with dementia are highly susceptible to it. People with delirium experience confusion as well as changes in attention span, moods, perceptions, and activity level. To determine whether your loved one is experiencing delirium, it is important to look at the timing. Delirium sets in much quicker than sundowners syndrome. It occurs quickly over the span of days or weeks, while sundowners syndrome occurs over months or years. Also, delirium occurs throughout the day while sundowners syndrome occurs only in the late afternoon through the nighttime period. 

The onset of symptoms varies from person to person. In some cases, sundowning syndrome symptoms begin to interfere with the body’s sleep-wake cycle. The sleep deprivation then triggers more episodes of sundowners syndrome and also triggers more dementia symptoms.

How quickly sundowners syndrome progresses is a direct reflection of how their dementia is progressing. Dementia tends to progress slowly in the early stages and can get faster in the later stages. It is also important to remember that everyone progresses differently. Some factors that may affect the rate of progression are genetics, cardiovascular health, physical health, age, and other pre-existing medical conditions. Unfortunately, there is no cure for dementia, and thus no cure for sundowners syndrome. You can, however, lessen its effects by knowing the triggers and learning to minimize them.

It’s always important to monitor your loved ones or your patients if they are sundowning.

Triggers of Sundowners Syndrome

Monitor your loved one’s behaviors. It is important to notice any triggers that cause these behaviors to occur. We have compiled a list of some of the triggers that may bring on the symptoms of sundowners syndrome: 

  • Sensory deprivation or overload
  • Low light or excessive light
  • Increased shadows
  • Unmet physical needs like hunger, pain, fatigue
  • Boredom
  • Limited mobility
  • Social isolation
  • Increased stress
  • Hearing/vision loss
  • Not feeling safe/secure
  • Anxiety, fear, depression
  • Sleep problems/deprivation
  • Hormonal imbalance
  • Unfamiliar environment/hospitalization
  • Medications wearing off
  • Reminding when they were younger
  • Expecting a spouse or children to come home
  • Having a frustrated/exhausted caregiver
  • Unexpected change
  • Difficulty separating dreams from reality
  • Presence of an infection, like a urinary tract infection (UTI)
  • Disruption of the circadian rhythm
Stress can be one of the leading causes of sundowners.

Cause of Sundowners Syndrome

There is still very little known about why sundowners syndrome occurs. The exact cause remains unclear. Some believe that the neurological changes that happen during the progression of Alzheimer’s disease affect the internal body clock. This could mean that the part of the brain that signals when you are awake or asleep is starting to break down. 

The setting of the sun triggers a reduction of dopamine levels in humans. Melatonin is then produced to prepare the body for sleep. In dementia patients, the production of melatonin has decreased. It is theorized that this may affect other neurotransmitter systems. And when the body’s internal clock is disrupted in this way, this can leave your loved one confused and exhausted. In turn, their behavior and mental state can be negatively affected. 

How to Minimize and Deal With Sundowners Syndrome

  • Keep predictable bedtime, waking, meal, and activity times: Try to keep your loved one’s daily schedule in a routine. This helps keep your loved one stay calm. Unexpected stresses can keep them agitated. Try to especially have evening routines that signify the day is coming to an end. For example, have them put their pajamas on at the same time every evening.
  • Notice patterns: Pay attention to certain times, people, activities, or places that seem to trigger the symptoms. Use this knowledge to adapt your loved one’s daily routine.
  • Monitor what they eat and drink: If your loved one is not eating enough, hunger pangs can trigger symptoms. Try to have dinner early so they will be more likely to go to bed earlier. If your loved one is a diabetic or borderline diabetic, he or she may react to the change in glucose level. Avoid large meals. Blood pressure drops after a large meal which means a smaller amount of oxygen reaching the brain. This reduction in oxygen levels can trigger an episode.
  • Only allow limited amounts of sugar and caffeine in the morning hours: You do not want any extra stimulants to keep them awake. Also, avoid alcohol and nicotine. 
  • Avoid napping during the day: They mustn’t nap in the afternoon. This will keep them awake at night, which is when sundowners occurs. Try to keep your loved one awake as much as possible during the day.
  • Get a vision check: The better your loved one can see, the less they will experience visual hallucinations.
  • Do not raise your voice or make any unexpected movements: Remain calm and do not touch them unexpectedly.
  • Ask questions to identify unmet needs: Sometimes your loved one is unable to communicate to you when they require something.
  • Do not rationalize or argue: It is fruitless to ask your loved one to explain things that don’t make sense. 
  • Keep him/her busy with activities to promote sleepiness at night: Plan things to keep them busy. Take your loved one on a long walk. Organize crafts. Visit family members. Keep them engaged to improve their sleep quality
  • Keep the curtains drawn: You want to avoid your loved one seeing the sky change from light to dark.
  • Keep the environment well-lit: Turn on all the lights. You want to decrease shadows and increase visibility. Low lighting exacerbates symptoms.
  • Avoid any sudden changes in light: This could trigger an episode.
  • Make sure doors and windows have child-proof locks and are secure: Take this precaution in case your loved one tries to escape in a fit of agitation. Make sure the environment is safe enough to allow your loved one to wander the house during the night. Remove any potentially dangerous items in areas they have access to. 
  • Maintain a peaceful environment: Keep your loved one away from commotion, noise, and distractions during the time of their usual episodes. Turn off violent news and loud action movies. Avoid boisterous children running around the home.
  • Declutter: Keeping the house free of clutter can prevent confusion for your loved one, as well as minimize possible accidents.
  • Plan calming activities for the early evening: You want to keep your loved one distracted during this time. Play cards. Help them with a crossword puzzle. Watch a relaxing movie or tv show. Help your loved one do the dishes or fold towels together. Bring your household pet around to help comfort your loved one. 
  • In the evening, do not encourage stimulating activities that will keep him/her awake: This could include anything movement-related.
  • When he or she is in an unfamiliar place: Bring familiar possessions, such as photographs.
  • Play gentle music or nature sounds that your loved one finds relaxing: Pick out some music from your loved one’s era. They will be soothed by the familiar music. 
  • Allow your loved one to sleep where he/she is most comfortable: This could even be in his or her favorite rocking chair. Give your loved one the choice of where they sleep.
  • Keep a night light on: Dementia patients experience changes in vision and perception. Keeping a light on helps reduce agitation when the room feels dark, frightening, or unfamiliar to them. 
  • Seek medical advice if you suspect an underlying issue: If Sundowners symptoms develop quickly and you suspect an underlying issue, such as sleep apnea, incontinence, or a urinary tract infection (UTI). Incontinence could be keeping your loved one from getting enough sleep, and a UTI can leave them confused and agitated. Talk to a doctor to resolve these underlying issues.
  • A low dose of melatonin can help ease symptoms: An average recommended dose is 6 mg for at least 4 months. It is said to help decrease behavioral symptoms such as agitation, especially combined with exposure to bright light during the day. Though you do not need a prescription, please consult your doctor before you try. Since melatonin is subject to prescription regulations, your doctor must recommend a melatonin product that has been licensed and meets pharmaceutical standards. It is also important to be aware of any possible drug interactions when adding any new medications or supplements to your loved one’s regimen. Even though sundowners syndrome is not curable, you can consult a doctor about possible medications that could help deal with symptoms: These might include hypnotic, anti-anxiety, and neuroleptic medications.
  • Bright light therapy: Treatment with a bright light is said to help sundowners improve the sleep-wake cycle and decrease nighttime activity. As a result, sundowning behaviors are said to improve. Examine the sleep cycle of your loved one to determine when to expose them to bright light. You could try 2 hours of morning light, or 2 hours of evening light, or 1 hour of both. Another option is to consider purchasing a full spectrum light box for your loved one. A light box is like a lamp, but much brighter than your normal indoor lighting. Your loved one mustn’t look directly into the light. It is best incorporated into their average daily activities. 
  • Aromatherapy: Particularly lavender oil has been said to cause a significant decrease in nighttime behaviors. It is important to note that studies have had some conflicting evidence, so it is wise to consult a certified aromatherapist if you are interested in this option.
  • Music therapy: A trained and certified music therapist can use musical experiences to help diminish symptoms of sundowning. These decreased symptoms can include agitation, anxiety, irritation, and disturbances in nighttime behavior.
  • Dronabinol & Cannabinoids: Cannabinoids have been shown to mediate important brain functions, such as cognition, motor activity, and mood. Please consult your doctor. 
  • Antipsychotics:  Commonly prescribed for agitation and psychosis by doctors. Although short-term trials show modest effectiveness in terms of aggression, taking antipsychotics to require a careful risk versus benefit assessment. Exposure to antipsychotics can cause negative side effects, including confusion and impaired cognition. Studies show an increased risk of death, cerebrovascular accidents, and myocardial infarction. Antipsychotics should be considered only after trying non-pharmacologic therapies.
  • Prolong enrollment into a senior care facility: The longer your loved one stays in a familiar environment that feels comfortable for them, the less likely they will have symptoms. 

Sometimes symptoms can be triggered in a care facility due to the bustle of activity during the afternoon or evening. These noises may trigger a reaction in the Alzheimer’s patient to perform behaviors that they would do in the past at that time of day. For instance, the noise would remind them of their children coming home, so they would start preparing a meal. It is best to keep them busy at this time of day with an activity that will distract them from the sounds. If your loved one is awake and triggered, here are a few things you can do to help:

  • Approach him or her calmly.
  • Try to determine if he/she needs something.
  • Remind him or her of the time.
  • Meet them in their version of reality if they are experiencing hallucinations or delusions. Reassure him or her that everything is okay. Validating them will help calm them more than trying to use logic to explain the situation.
  • Do not restrain him or her physically. Allow your loved one to pace around under your supervision.

One of the constants in your loved one’s ever-progressing disease is you. Make sure to stay flexible in this difficult process. Sundown syndrome is not the same in every person, and the symptoms are not always predictable. Keep your daily regimen of self-care to keep yourself useful in your loved one’s trying time. Enlist the help of other family caregivers or employ a home care worker. Consider enrolling your loved one into memory care or think about live-in care if you find your loved one’s symptoms rapidly increasing. Do not be afraid to get help if your loved one’s disease overwhelms you. We are here for you. 

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