Sundowning in Dementia: What Is It? Which Non-Drug Interventions Help?

Sundowning, also called sundown syndrome, is the increased anxiety and agitation that some people with dementia (and occasionally some without dementia) often display in the later afternoon and evening hours. Sundowning behaviors include restlessness, falls, calling out, crying, pacing, wandering, fearfulness, mood swings, paranoia, hallucinations and shadowing.

Sundowning sometimes seems to develop suddenly as evening approaches. Your loved one may be doing fine in the afternoon and then seem to be a different person as the sun goes down. For example, if someone is cared for in a nursing home, the staff who work on the day shift might describe this person completely differently than the evening shift because of sundowning behaviors. Thus, different approaches by caregivers for different times of the day may be needed.

The Alzheimer's Association estimates that approximately 20% of people with Alzheimer's exhibit sundowning behavior. However, some research has placed that number as high as 66%, specifically for people with dementia who are living at home.

Sundowning behaviors, along with other challenging behaviors, most often develop in the middle stages of dementia and increase as the disease progresses.

• What to Expect in the Middle Stages of Dementia

There are several theories as to what triggers sundowning. These include the following:

• Fatigue
• Over-stimulation
• Boredom
• Loneliness
• Medications wearing off as the day progresses
• Chronic pain from arthritis or other medical conditions
• Lighting changes in fall and winter
• Caregiver stress, fatigue or burnout
• Shadows from the windows and blinds as evening approaches
• Hunger
• Unmet needs

Approaches that are individualized to each person are the best way to respond to, prevent and minimize sundowning. Some specific non-drug approaches that may be helpful include the following:

• Bright light therapy
• Planned activities
• Consistent caregivers
• Reduced television/movie viewing
• Caregiver education
• Sleep hygiene
• Naps
• Snacks
• Distractions
• Music therapy
• Meeting physical needs such as pain control, hunger, thirst
• Keeping the blinds closed to reduce frightening shadows
• Good interior lighting
• Reduced stimulation
• Changing the routine

Some physicians have also prescribed medication to “take the edge off” these behaviors. Medications should always be a second resort after non-drug interventions have been attempted. Medications should not be given to alleviate the caregiver's burden but rather should be focused on minimizing the distress of the person.

• Can Too Many Medications Increase Dementia Symptoms?

Melatonin, acetylcholinesterase inhibitors and antipsychotic medications have all shown some benefit for some people with sundowning behaviors in research studies.