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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.