What Is Sundowning? Which Non-Drug Interventions Help?

What Is Sundowning?

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.

Prevalance

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.

In Which Stage of Dementia Does Sundowning Behavior Develop?

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

What Causes Sundowning?

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

Which Interventions Should Be Used to Help in Sundowning?

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

Possible Medications

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.

_Sources:

_{Alzheimer's Association. Sleep Issues and Sundowning. https://www.alz.org/care/alzheimers-dementia-sleep-issues-sundowning.asp}

_{Alzheimer Society Canada. October 11, 2012. Sundowning. http://www.alzheimer.ca/en/Living-with-dementia/Understanding-behaviour/Sundowning}

Khachiyants N, Trinkle D, Son SJ, Kim KY. Sundown syndrome in persons with dementia: An update. 2011;8(4). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/.

_{National Institute on Aging. June 2013. Alzheimer’s Disease Education and Referral Center. Alzheimer's Caregiving Tips: Sundowning. http://www.nia.nih.gov/sites/default/files/caregivingtips_sundowning-final_13jun24_0.pdf}