Ideas on How to Handle

Sundowning

Sundowning Comes with the Setting Sun

Coping and Prevention Strategies for Sundowning and Sleep Disturbance

Sundowning Comes with Sun Set     

     Sundowning comes by its name because it’s a behavior seen in many dementia patients around the time the sun goes down each day in late afternoon or evening hours. In most cases, symptoms are less pronounced earlier in the day. As the day progresses toward nighttime, the individual becomes increasingly agitated, confused, and restless. Whereas during the day, they may act perfectly calm and well-behaved, their personality completely changes by the time the sun goes down.  The dramatic difference can be frightening to both the individual and the caregiver, not to mention extremely disruptive and exhaustive for the rest of the night.

Sundowning and Delirium

     Sundowning and delirium, which occurs as a temporary symptom with other conditions, may be difficult to distinguish from one another. Underlying infections, changes in medications, dehydration, and exhaustion from lack of sleep may trigger delirium or sundowning episodes. Therefore, if symptoms are new, describe behaviors to your doctor and let him determine the best course of action for treatment.

 

Finally, Take Care of Yourself

     I think the most difficult caregiver job is managing someone who is a nighttime wanderer. You’re up all-day providing care and only partially sleeping at night because you only sleep half-way if you sleep at all.  Permit yourself to nap when you can.  You’re sleep-deprived, and that takes a toll. If you have neighborhood Senior drop-off or something similar, use them for a break. You’re not the Eveready Bunny.

 

Senior man with dementia disease putting shoe in microwave oven.
Senior man with dementia disease putting shoe in microwave oven

Typically, caregivers see sundowning symptoms between the hours of 4:30 p.m. and 11:00 p.m. Suddenly their family member demonstrates some or all the following behaviors:

  • Confused about where they are and who the people are around them
  • They do not clear up when given clarifying information. The confusion remains.  There is no reasoning with them to resolve a misunderstanding related to hallucinations or delusions.
  • Experience paranoia and suspicion about everything and everybody.
  • Can’t go to sleep; if they do fall asleep, it’s a restless sleep with several awakenings during the night leading to excessive sleepiness the next day.
  • Sudden changes in behavior unexplained by any other trigger
  • Trouble talking and thinking clearly.
  • Visual hallucinations
  • Wandering
  • Yelling or aggressive behavior potentially resulting in injury to self or others.
  • Rapid walking may lead to falls and potential injury.
  • Agitation may result in throwing objects, removing medical alert bracelets, emptying drawers, and chaotic, random destruction during extreme agitation.

     Sundowning is a symptom of a condition, not a condition or disease itself, but symptoms are what we as caregivers treat in caring for our family. We can independently take all the actions noted above to treat this symptom. However, medical treatments that your family member’s doctor can also provide to help this situation.

  • Antipsychotic drugs may reduce some of the behavioral symptoms. They may not take them away, but they can at least reduce them.  
  • Light therapy where the person is exposed to bright fluorescent lamp light for 1-2 hours each morning. There’s a study that says doing that helps to reduce symptoms in the afternoon. I don’t know if it works, however.
  • Using Melatonin to help with sleep. You can get Melatonin over the counter in any grocery store or pharmacy without a prescription. Disrupted sleep causes a drop or malfunction in Melatonin’s hormone production in our body, so taking it helps. You might want to use it yourself.
Confusion about what to do next even with post it notes giving directions
Confusion about what to do next even with post it notes giving directions

Ideas for Coping with Sundowning Behaviors

     How you cope with sundowning behavior and the way you prevent them from happening is much the same.  Therefore, I will present both coping and prevention strategies as one topic and give you a master list of ideas that could be used in either area as you feel works best in your situation.  As with all medical or mental health conditions, what works for one may differ for another based on your lifestyle. 

 

Look for Patterns

     I recommend that you look for patterns of behavior to determine what triggers episodes of sundowning.  Write down when they occur and how your family member responds.  In doing so, you may be able to figure out the triggers to avoid or the coping strategies that work best for you.

 

Establish a Daily Routine

     Keep a daily routine that your family member learns to follow. Once he establishes a pattern of eating, dressing, resting, and other activities at a certain time, it will bring him comfort and help reduce overall anxiety. Schedule appointments, outings, visits, and bath time in the earlier part of the day when he is likely to be at his best.

Adjusting Lifestyle

  • Keep the home well-lit in the evening to reduce shadows and confusion regarding what they see before them.
  • Eating larger meals or ones full of spice, loaded with sugar and calories, or consuming a lot of caffeine or alcohol can cause problems with getting restful sleep. Indigestion or problems with either falling to sleep or staying asleep are common with these types of meals.  Therefore, keep meals small.  If they need to eat more often, give six small meals a day, or use healthy snacks to supplement between meals. 
  • Encourage activity during the day that will provide exercise. Maybe they are not the type to participate in an exercise program, but maybe they like to dance?  Try dancing with an activity or making up a game with movement.
  • Walk around outside to get some fresh air and sunshine and exposure to bright light.
  • Surround your loved one with things that bring them comfort and feel like home to them—a favorite blanket, family photos, some even have a special stuffed animal a grandchild may have given them.

Caregiving Training:  Sundowning

The above link takes you to UCLA’s Alzheimer’s and Dementia Care Program.  This video about Sundowning is one of many on their site that you might find useful.

Set the Stage for Sleeping

Help make the sleeping environment conducive to sleep by

  • Avoid coffee, tea, nicotine, caffeine, alcohol, large helpings of sweets, competitive games, or watching adrenalin-producing television.
  • Eat a lite dinner but a big lunch with a small snack just before bedtime.
  • Don’t let them take a nap within the last four hours before bedtime. If they are exhausted and MUST nap, keep it brief.
  • Avoid excitement, keep early afternoons quiet by playing soothing music, reading, going for walks, quiet visits, family time.
  • Keeping the area quiet or play soothing music softly as they fall to sleep.
  • Maintaining a comfortable room temperature based on your family member’s preference.
  • Keeping a night light near the floor to prevent tripping if they get up.
  • Placing a snack on the table to prevent the use of the stove during the night.

 

Plan for safety in case of wandering by
  • Purchasing window and door alarms that alert you if your family member wanders during the night.
  • Using a gate to block stairs and putting away anything dangerous like kitchen tools. You may need to put locks on cabinet doors as well.
  • Installing baby monitors, motion detectors, and door and window locks in prime locations to capture wandering behavior should it occur during the night.
Alzheimer's aggression with angry outbursts
Alzheimer's aggression with angry outbursts

Approaches to Reduce Agitation

  • Talk to them and listen calmly to concerns and frustrations
  • Find out if there is a specific need or concern
  • Avoid arguing, try to go along with whatever the issue may be
  • Do not restrain them. Allow them to pace under your supervision to burn off restless energy
  • Provide reassurance
    • Confirm that all is well by pointing out facts that support safety around their concern
    • Remind them of previous times everything was okay
    • Reassure them that you are with them and they will not be alone
    • Attempt to determine if a basis for their concern exists and if so, try to remove it
  • Distract with a favorite snack, object, activities, favorite TV show (not news or anything upsetting or chaotic), simple tasks, offers something to eat or drink, etc.
  • Reduce noise, clutter, and the number of people around them
  • Close curtains to prevent shadows from forming as the sun goes down and turn on lights. Use bright bulbs (60 watts instead of 40) in lamps.
  • If they have a pet, could they calmly stroke the pet without harming it? Evaluate their ability to do so carefully to prevent injury to the animal.
  • Always keep your voice low, calm, and speak slowly. In conversations, the party with whom you’re speaking will often mimic your tone and speed of conversation unconsciously. If you remain calm and lower your speaking speed, you may be able to get them to do the same. If they are distracted, they may not notice, but it may work if they are engaged in the conversation.
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