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.
