What is Sundown Syndrome?

Sudden behavior changes are common in Alzheimer’s patients. The reasons for this are not fully known, but they are often seen in late afternoon or early evening. Patients can become agitated, suspicious, or even aggressive. Unless properly managed, this behavior can drag on into the night, leaving patients and caregivers exhausted. Because these episodes occur frequently around the end of the day, doctors refer to them as sundown syndrome, or “sundowning.” Understanding what sundown syndrome is and how to respond helps families and assisted living homes caring for victims of the disease.

What Causes Sundown Syndrome?

The roots of sundown syndrome are not well understood. Because it is usually triggered by fading light, many suspect Alzheimer’s affects the body’s circadian rhythm, the internal clock that governs the sleep-wake cycle. Problem behavior is influenced by several other factors as well, such as:

• Fatigue
• Hunger
• Thirst
• Pain
• Infection

Urinary tract infections are notorious for exacerbating sundown symptoms. Cognitive decline makes it harder for patients to control their bladder, while simultaneously lessening bowel urges. As Alzheimer’s progresses, patients gradually lose the ability to clean themselves, opening the way to disease. Unable to understand why they are in pain, patients grow increasingly agitated, confused, and belligerent. For this reason, when dealing with problem behaviors, caregivers should start by looking for an infection.

What are the Symptoms of Sundown Syndrome?

Sundown symptoms normally begin in late afternoon but can occur earlier. At Verona Court, nurses have noticed patients with their days and nights mixed up who have started sundowning at midday. This type of troubling behavior may include:

• Fidgeting
• Confusion
• Pacing
• Mood Swings
• Crying
• Arguing
• Suspicion (Accusations of Lying, Stealing, or Cheating)
• Refusing Care
• Resisting Being Toileted
• Anxiety (Picking at Clothes, Wringing Hands)
• Following Caregivers from Room to Room
• Repetitive Behavior (Asking the Same Question, Repeating a Word or Task)
• Asking to Go Home When They Already Are Home

Sundown patients normally have a pattern. Although they might not happen at sunset, episodes do tend to occur around the same time each day and are preceded by the same warning signs.

What is the Best Way to Manage Sundown Syndrome?

As soon as caregivers notice a patient is sundowning, they need to intervene straightaway before the patient becomes aggressive and starts hitting, pushing, shouting, or name-calling. This is not only distressing to the patient, but puts other people in the house at risk, especially if it occurs in an assisted living home.

During an Episode

For caregivers, the most important thing is to remain calm. They should not raise their voice or demand an explanation. Scolding (frowning, pointing fingers, putting their hands on their hips) will only escalate the situation. Do not try to reason with patients either. It is counterproductive. Stick to these tested strategies instead.

Aggression

Respect personal space and stay an arm’s length away. Make sure no one has been hurt. Wait for the patient to calm down before trying to redirect them. In many cases, aggression is caused by sensory overload. Take them to a quiet room away from everyone else and see if they settle down.

Suspicion

Start by assuring them they are safe. Listen to what they are saying. Pay attention to their feelings. Give simple answers. Suspicion is often triggered by a lost or misplaced possession, so offer to help them find it. If the patient keeps losing the same item over and over (e.g., toothbrush, eyeglasses, keys) keep several spares on hand.

Agitation

Say comforting words and use a quiet tone. For example:

• “May I help you?”
• “You’re safe.”
• “Everything is fine.”

Listen to what the patient is telling you. Are they hungry, thirsty, constipated, or in pain? Are their clothes too tight or too loose? Redirect with a simple art project. Put on soothing music. Use gentle touch (e.g., hugs, holding hands). Show them old photographs and encourage them to talk about their memories. If they are still agitated, try taking them for a walk or playing a game.

Pacing

Walk with them. Hold their hand. Offer them a snack. Keep their path clear of obstacles, so they do not trip. If you can, redirect by giving them a simple task, like sorting spoons or wiping down the table.

Refusing Care

Always make sure the supplies you need are ready ahead of time (e.g., toothbrush, nail clippers, soap, shampoo). Explain what they will be doing in simple terms. Do not ask if they want to do the activity; tell them it is time to do the activity. If they become combative, step back for a few minutes before trying again.

Remember

What is an effective tactic for sundown syndrome differs from patient to patient. One of our nurses was caring for a man who would not shower but loved banana muffins. Giving him one to hold in each hand kept him distracted so she could get him undressed and cleaned.

Before an Episode

Caregivers can take steps to prevent or minimize sundowning. For instance:

1. Establish a routine. Creating a familiar flow to the day reduces agitation and confusion. Because some major activities, like doctor’s appointments, cannot be avoided, never schedule more than two on the same date.
2. Avoid hustle and bustle late in the day. Turn down the volume on the television, radio, and sound speakers. Never have visitors over in the evening. At the end of the day, relieve stress by playing soft music or nature sounds.
3. Close the blinds and turn up the lights. Installing full-spectrum light boxes has also been shown to reduce incidents.
4. Make sure they get enough rest. Do not let patients smoke or drink alcohol. Limit caffeine and sugar to the morning. Make a big lunch, but a small dinner, 500 calories or less. (Prolonged digestion interferes with sleep.) Prevent patients from napping as much as possible. If they must sleep, keep it short and never later than four hours before bedtime.
5. Buy a nightlight. For sundown patients, waking up in a dark place can be frightening and confusing.

If symptoms grow worse, it may be time to consider medication. Like any other disease, Alzheimer’s progresses in stages, and medication is sometimes necessary to manage symptoms. However, because our administrators are fully qualified nurses, Verona Court residents remain fully functional in their environment. Our staff works closely with physicians, recommending they raise or lower the dosage in order to keep patients calm but alert.

What is the Advantage of a Small Environment?

Alzheimer’s Disease requires complex care, beyond what a family can typically provide on their own. Assisted living homes ease the burden, with support services, medical care, and 24-hour supervision. However, smaller homes such as Verona Court are normally ideal because they provide a better care ratio. We have two full-time caregivers and only six residents, which means our staff gets to know each individual and the nuances of their personalities. We learn to anticipate problem behavior and take measures to prevent or minimize it. Caregivers in larger environments cannot provide such close monitoring and sometimes fail to redirect in time.

Read more about the importance of intimate nursing care and how it impacts the health and happiness of your loved ones.

Lewis Jackson writes about technology and healthcare. His work provides practical insight into modern medicine and healthy living.