How to Identify and Manage Sundown Syndrome

June 13, 2019 | Blog | Reading Time 10:00 Minutes

The terms “sundowning” or “late-day confusion” refer to a state of agitation and confusion that some individuals with dementia experience later in the day — from late afternoon into the nighttime hours — typically between the hours of 4:30 in the late afternoon until 11:00 at night. Anyone who has ever been around someone experiencing sundown syndrome symptoms will find themselves searching for answers. If that’s you, you’ve come to the right place.

What is Sundown Syndrome?

Sundown syndrome, also referred to as sundowning, is most often seen in individuals who have Alzheimer’s disease or some other form of dementia. Sundown syndrome is not a disease; rather, it’s a common pattern of neuropsychiatric symptoms or behaviors that occur during a specific period of time each day, from late afternoon and into the night. It’s from this specific time period that the term “sundowning” is derived — the time of the day when the sun begins to go down.

The exact cause of sundowning and its associated late-day confusion is unclear; however, one study indicates that sundowning includes “a constellation of emotional, cognitive, behavioral and motor dysfunction.” Some believe that sundowning may be associated with decreased cognition and impaired circadian rhythm, which is the natural, internal process that regulates the sleep-wake cycle.

Sundown syndrome is characterized by a worsening of symptoms in the late afternoon, evening and sometimes into the nighttime hours. When most people are beginning to relax and wind down at the end of the day, individuals with sundown syndrome become increasingly active.

Sundown syndrome symptoms may include:

• Fear
• Confusion
• Anxiety
• Agitation
• Restlessness
• Wandering
• Aggressive behavior
• Disorientation
• Screaming and yelling
• Sleep disturbances, including repeated waking during the night with episodes of wandering. This can lead to excessive sleep during the daytime hours, as well.
• Difficulty speaking or thinking clearly

Just like SAD (Seasonal Affective Disorder), symptoms may be worse during the fall and winter months when the daylight hours are shorter.

Some of the behaviors may not be specific to sundowning, but instead, may be the manifestation of dementia and the increased confusion and agitation that is experienced due to sundowning.

By comparison, sundowning symptoms are more pronounced than the same symptoms that were experienced earlier in the day. Some individuals who experience sundown syndrome may also be more prone to pace and wander. Plus, they tend to ignore instructions and directions that are given to them when they are sundowning.

The clinical symptoms of sundowning include:

• Abnormally demanding attitude
• Mood swings
• Suspiciousness
• Visual and auditory hallucinations
• Delusional thinking
• Paranoia

These behaviors can be very difficult for the family caregiver, especially those behaviors that make it difficult to get a good night’s sleep. Studies indicate that agitation caused by sundown syndrome is one of the common reasons families choose to turn to a memory care community for the care of their family member.

Although sundown syndrome typically occurs along with Alzheimer’s disease or some other form of dementia, not all individuals with Alzheimer’s or dementia will develop sundown syndrome or every symptom associated with it.

Factors that Worsen Symptoms of Late-Day Confusion

Individuals whose dementia is mid- to advanced-stage dementia are more likely to experience late-day confusion. In fact, studies indicate that up to 66% of older adults with mid-to-late stage Alzheimer’s or dementia will experience late-day confusion and sundowning. Additionally, the appearance of symptoms often marks a progression from the early stages to the more serious later stages of dementia, accompanied by a more serious deterioration of cognitive function. Certain factors appear to worsen the symptoms of sundowning. These include:

• Low lighting
• Fatigue
• Increased shadows
• The presence of an infection, such as a urinary tract infection
• Problems identifying reality from dreams
• Disruption of the body’s “internal clock”

Diagnosis and Medical Treatment of Sundown Syndrome

Sundown syndrome is diagnosed entirely on the repeated occurrence of symptoms at the specified times. Currently, there are no laboratory tests or imaging studies that will determine if an individual has sundown syndrome. It will help your medical professional if family members, friends and care providers document the exact symptoms and behaviors, along with the time in which they occurred. You should also document:

• What time of day do the symptoms begin to worsen?
• What time do they begin to improve?
• Are there any precipitating activities or events that tend to cause symptoms to appear or worsen?
• Do symptoms worsen as a particular medication is wearing off?
• Do large meals cause symptoms to worsen?

Keeping a log of symptoms, along with answers to the above questions will assist your healthcare professional to diagnose sundown syndrome. It will also assist you in knowing more about what causes the individual to sundown so it can be avoided in the future.

Prescription medications may be used to reduce some symptoms of sundown syndrome and to improve sleep quality. The aim of treatment is to make sure that the individual doesn’t experience extreme fear and that they don’t accidentally injure themselves or others.

How to Manage the Symptoms of Sundown Syndrome

There are non-medical ways to reduce and manage the occurrence of sundown syndrome and its associated symptoms. Just as each person’s experience with dementia is unique, the same can be said of sundown syndrome. It’s also the same in regard to the fact that symptoms change. All this means is that it may require a bit of trial and error to discover what strategy works best for each person at any given time; and what works now may not work in the future.

Let’s look at some strategies you can try to ease some of the common sundowning symptoms.

Increase Light in their Environment

Although healthy older adults have a normal, “consolidated,” sleep/wake cycle, individuals with dementia have random patterns of rest and activity. One theory about the cause for sundowning is that the brain doesn’t take in environmental stimuli as it once did, in this case — light. Sundown syndrome is largely triggered by changes in light. Since dwindling light and the onset of night can trigger symptoms, having appropriate and adequate lighting can help.

Light therapy can reduce agitation and confusion and improve sleep efficiency as well as rest/activity rhythms for individuals with Alzheimer’s disease and other forms of dementia.

Increasing the overall light, both artificial and natural, in their environment, especially later in the day, may help counteract sundown syndrome symptoms. This can be accomplished by opening windows to let more light in, moving the individual to a brighter location (not in sunlight that is too direct or bright, however) or providing artificial light sources. Consider placing a full-spectrum fluorescent light about three feet from them a couple of hours each morning and during the day when they feel confused or agitated. It’s important to use nightlights or low-light lamps, also, to help them know where they are when they wake up during the night which keeps them safe and helps to eliminate fear.

Avoid or Lessen Fatigue

Sleep disturbances are common for individuals with dementia; therefore, naps at certain times may be beneficial to overcome the negative impact of those sleep disturbances.

Some individuals with sundown syndrome can come to the end of a long day (in the late afternoon or early evening) and find that they don’t have the ability to self-monitor or control their feelings of frustration and anxiety. For these individuals, a nap could be helpful.

Dementia can cause a change in a person’s circadian rhythm, making it difficult for them to sleep at night. So, if an individual who is tired when mid-afternoon rolls around, and if after a nap, their sundowning symptoms are reduced or eliminated, encourage them to take a daily nap (routines are important) especially on days when they demonstrate fatigue.

If they feel better after the nap and the nap doesn’t impact their ability to sleep well later that night, you will know that you’ve hit on a strategy that works for them.

Naps that interrupt sleep habits at night, on the other hand, are a problem. If they cause sleep issues at night, naps should be reduced or eliminated. To further avoid sleep disruption, sugar and caffeine consumption should be restricted to the morning hours or up to 2:00 pm at the absolute latest. Avoid stimulating activities in the late afternoon and evening, as well.

Factors that contribute to sleep disturbances and sundowning:

• Mental or physical end-of-the-day exhaustion
• A disruption in circadian rhythm
• Disorientation that occurs when unable to separate dreams from reality
• Increased shadows and reduced lighting
• Less need for sleep (common among older adults)
• Reactions to nonverbal cues of frustration from exhausted care providers

Avoid Too Much Inactivity

Although we don’t want them to be fatigued, they shouldn’t be too inactive either.

As already discussed, many individuals who sundown also have trouble sleeping at night. Additionally, too much inactivity and daytime dozing can make sleeping at night difficult. It can become a vicious cycle.

To help them get a good night’s sleep, incorporate exercise into their day. You can go for a walk and enjoy the great outdoors together. Turn on a Jazzercise video. Enjoy a Wii sport. Activity may help improve their sleep quality and reduce symptoms.

Take a Deep Breath… Yes, You!

The care provider should try to remain calm and in control without being controlling. It rarely works to try to make the person who is sundowning do something because you know it will make them feel better. In fact, it often backfires, making them feel worse, leading to agitation because they feel like they’re being controlled or bossed around like a child. Arguing and reasoning with them is also likely to increase their agitation. Rather than trying to control a specific behavior, such as pacing or a repetitive motion with their hands, give them a safe place to do the activity or something safe to do it with. Although you may not understand their need to do a certain activity, it may be exactly what they need to cope with a given situation or a means of relieving their stress and anxiety.

Minimize Their Stress

When you, the caregiver, can relax, you have gone a long way toward minimizing their stress as well. There are other things, however, you can do as well to make things better for both of you by minimizing their stress. During the late afternoon and evening, encourage them to do activities that will help them to remain calm — activities that aren’t too challenging, frustrating or frightening. Stress and frustration often lead to irritability and confusion.

Watching television can even be too difficult for someone with mid- to advanced-stage dementia. Many times, especially for these individuals, a calm environment can be created through the use of soft music. Cuddling with a beloved pet is always beneficial.

Develop Routines and Stick to Them

Create and maintain a predictable routine for waking, activities, meals and bedtime. Familiar places, items and routines help to ground the person with dementia. Developing and then having to remember new routines can be very difficult for them and can cause feelings of confusion, stress and anger. These feelings can produce havoc when it comes to sundown syndrome. If a routine works, don’t change it. Stick to the same routines and schedules to help the individual with sundown syndrome feel more collected and calmer. If changes must be made, make them in slow, small incremental steps.

Modify Eating Habits

Eating large meals, especially later in the day, can cause symptoms. Consumption of alcohol, large amounts of sugar and caffeine, especially after the noon meal, can do it as well. Limit the evening meal to the equivalent of a hearty snack or light meal. Encourage them to avoid alcohol and large amounts of sugar and caffeine, limiting the consumption of these items to earlier in the day at a minimum. These adjustments will help them sleep better at night and avoid the symptoms of sundowning.

Dementia Care at The Brielle

Remember, as you try some of these tips, that it’s through trial and error that you’ll discover what works best for you and your family member. If you find that the symptoms of sundown syndrome are just too much for you, you’re not alone. These symptoms are one of the major factors that lead to someone choosing to utilize the services of a memory care community. If you need us, we’re here for you.

At The Brielle, our memory care neighborhood offers programming that has been specifically adapted to assist residents who have memory impairments and those who experience sundowning. Our programming fosters each resident’s social, intellectual, spiritual and physical well-being. Customized to the individual, our programming helps each resident to thrive and have meaningful interactions, build relationships with others and grow connections through positive approaches to socialization. Contact us to learn more.