Sundowning

FACTS

• Sundowning is not a diagnosis but a syndrome, a group of behavioral symptoms.
• The cause is unknown but contributing factors are fatigue, depression, pain, boredom, and unmet needs such as hunger or thirst.
• It is more common in elderly patients with dementia, occurring in up to 66% of diagnosed people.
• The syndrome tends to occur as the day progresses, occurring mid-afternoon or into the night
• It is believed that a disruption in a structure at the base of the brain affects the sleep-wake cycle. Normal reactions to increasing darkness as the day progresses do not occur.

SYMPTOMS

• Confusion
• Nervousness
• Tension
• Restlessness
• Anxiety
• Agitation
• Aggressiveness
• Paranoia
• Delusions
• Pacing
• Wandering

TRIGGERS

• Environment
  • Bright light in the room where the person is located but dim lights in surrounding rooms
  • Lights creating shadows that can be misinterpreted and cause agitation
  • Fatigue
  • Caregiver stress mounting as the day progresses contributes to increased stress by the person with dementia
• Medication side effects
• Medical conditions
  • Heart failure
  • Lung conditions
  • Pain
  • Infection, especially of the urinary tract

STRATEGIES

• Maintain a consistent sleep-wake cycle with routine awakening, mealtime, activities, and bedtime; consider limiting daytime naps.
• Pace activities to avoid excess fatigue.
• Schedule outings including doctor’s appointments earlier in the day when sundowning is less likely.
• Consider daily walks or time outside in sunlight.
• Avoid alcohol, caffeine and nicotine which affect normal sleep-wake cycles.
• Maintain consistent lighting until bedtime.
• During sundowning, gently distract and redirect behavior to a different focus.
  • Read the website document Engagement Activities for more information.
• Reassure and avoid confrontation.
• Transition to bedtime with “cool down” activities.
  • Engage in quiet activities.
  • Limit exposure to blue light from televisions and computers.
  • Listen to music or relaxing sounds of nature.
  • Start hygiene activities and preparation for sleep an hour before bedtime.
• If in a strange or unfamiliar setting, bring common items such as photographs and personal items to create a more familiar surrounding.
• Manage caregiver stress.
  • Read the website document Strategies to Reduce Caregiver Stress for more information.
• Medications may be prescribed.
  • Melatonin
    • Augments the normal melatonin released by the body
    • Administer at sundown.
  • Donepezil
    • May help in a limited population
  • Great caution is used prescribing sedatives such as Xanax or Ativan due to the high risk of falls and a paradoxical effect causing greater agitation.
  • Trazodone may be prescribed in low doses to provide calmness.
  • Antipsychotics like Seroquel or Risperidone may be prescribed only if there is a safety risk.