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How to Manage "Sundowning"

Medically Reviewed by Christopher Melinosky, MD on December 04, 2019

When you are with someone who has Alzheimer's disease, you may notice big changes in how they act in the late afternoon or early evening. Doctors call it sundowning, or sundown syndrome.

Fading light seems to be the trigger. The symptoms can get worse as the night goes on and usually get better by morning.

Although you may not be able to stop it completely, you can take steps to help manage this challenging time of day so you both sleep better and are less tired during the day.

Let your loved one’s doctor know what changes you have seen, too.

Symptoms

When someone is sundowning, they may be:

  • Agitated (upset or anxious)
  • Restless
  • Irritable
  • Confused
  • Disoriented
  • Demanding
  • Suspicious

They also may:

  • Yell
  • Pace
  • Hear or see things that aren’t there
  • Have mood swings

Up to 1 out of 5 people with Alzheimer’s get sundown syndrome. But it can also happen to older people who don’t have dementia.

Causes

Doctors aren’t sure why sundowning happens.

Some scientists think that changes in the brain of someone with dementia might affect their inner “body clock.” The area of the brain that signals when you’re awake or asleep breaks down in people with Alzheimer’s. That could cause sundowning.

It may be more likely if your loved one is:

What happens around someone can also set off sundowning symptoms. Some triggers are:

  • Less light and more shadows in the house. This can cause confusion and fear.
  • Trouble separating dreams from reality. This can be disorienting.

If you feel tired or frustrated at the end of a day of caregiving, your loved one may notice, even without you saying anything. This can upset them, too. It’s normal for you, as a caregiver, to have feelings like that. Try to be aware of how you manage those emotions if you think that might make a difference.

How to Help Someone Who Is Sundowning

Look for patterns. Note the things that seem to trigger it, and then do your best to avoid or limit those triggers.

Keep a daily routine. Set regular times for waking up, meals, and going to sleep. Help them get regular exercise, such as walking, in the early part of the day. Try to schedule their appointments, outings, visits, and bath time in the earlier part of the day, when they are likely to feel their best.

Limit or avoid things that affect sleep.

  • Don’t let your loved one smoke or drink alcohol.
  • Give them sweets and caffeine only in the morning. Offer healthy food and drink later in the day.
  • Make a big lunch, and keep their evening meal smaller and simple.
  • Avoid letting your loved one nap or exercise later than 4 hours before bedtime. If they absolutely need to nap, try to keep it brief and early in the day.

Keep things calm in the evening.

  • Close curtains and blinds and turn on lights. Darkness and shadows can make them more upset.
  • Fix the room temperature so they're comfortable.
  • Tell other family members or visitors not to make too much noise.
  • Put on relaxing music, read, play cards, or go for a walk to wind down.
  • Make sure their sleeping area is comfortable and safe.
  • Turn loud, distracting noises, such as phones, stereos, or TVs, down or off.

If your loved one is increasingly confused, anxious, or agitated during the evening, try to figure out the causes and then make a plan to stay away from or stop these things. For example, if you think loud TV shows or too much activity could be the cause, try to cut down on these activities at night.

How to React

  • Stay calm.
  • Ask your loved one if they need something.
  • Remind them what time it is.
  • Don’t argue with them.
  • Reassure them. Tell them everything is OK.
  • If they need to get up and move around or pace, don’t try to hold them back. Just stay close by to keep an eye on them.
  • Keep them safe with night-lights and locks on doors or windows. Use a gate to block the stairs, and put away anything dangerous, like kitchen tools.

Also, consider getting a baby monitor, motion detectors, or door sensors. They can let you know if your loved one is walking around.

Sundowning vs. Delirium

The main difference between this and delirium is that delirium happens suddenly and comes and goes throughout the day.

It’s normal for people with Alzheimer’s disease to feel more confused as time passes. But sometimes, this confusion gets worse very quickly, over a matter of hours or days. If this happens with your loved one, take them to a doctor as soon as possible to be sure that it’s not delirium.

If your loved one is sundowning for the first time, call their doctor to make sure it’s not delirium.

Doctors don’t fully understand why sundowning happens, but it could be related to exhaustion, less light, or an issue with the “internal body clock.”

Treatment usually involves things you can try at home, such as turning on more lights, planning more daily activities, and helping your loved one get plenty of rest.

When You Need a Doctor’s Help

If the above tips don't work, tell their doctor, who can check to make sure that your loved one’s medicines that help them relax and sleep don’t cause more confusion the next day.

Take Care of Yourself

Caring for a loved one who is sundowning can make it hard for you to get restful sleep. And you need to take care of yourself in order to be there for your loved one.

It’s normal to feel scared or overwhelmed when you care for someone with delirium and/or sundowning. Even things you do to help can upset them. It can also cause them to do things that are unsafe for you and them.

It can be hard to know if or when delirium and sundowning may cause someone to get aggressive. To keep your loved one from hurting themselves or others, take away or lock up anything in the home that could be used as a weapon. If they get physically violent, stop what you’re doing and back away. Call for help if you need to.

Remember that delirium may cause a person to say or do things that are rude or hurtful, but it’s not something they can control.

If you feel overwhelmed, you can:

  • Ask a friend or relative to fill in for you at night.
  • Try to nap during the day.
  • Take breaks whenever you can during the day.
  • Hire a home health care service for backup.

Other ways to take care of yourself are to:

  • Exercise
  • Eat healthy
  • Spend time with friends
  • Try to find time -- even if it’s not a lot -- for your own hobbies and interests. 

Consider joining a caregivers’ support group, too. Your doctor can help you find one.

WebMD Medical Reference

Sources

SOURCES:

National Institute on Aging: “Sundowning.”

Alzheimer’s Association: “Sundowning,” “Sleep issues and Sundowning.”

Khachiyants, N. Psychiatry Investigation, December 2011.

Alzheimer’s Foundation of America: “Behavioral Challenges: Coping With … Sundowning.”

Schwartz, J. Current Neuropharmacology, December 2008.

Alzheimer’s Association: “Sleep Issues and Sundowning.”

Family Caregiver Alliance: “Caregiver’s Guide to Understanding Dementia Behaviors.”

National Institute on Aging: “Caring for a Person with Alzheimer’s Disease.”

Alzheimer Disease and Associated Disorders: “Delirium in Alzheimer Disease.”

American Family Physician: “Delirium.”

American Journal of Alzheimer's Disease and Other Dementias: “Review: Delirium in the Elderly: A Comprehensive Review.”

Annals of Internal Medicine: “Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium.”

BMJ (Clinical Research Ed.): “Delirium: Optimising Management.”

Geriatric Nursing: “A Pilot Study of the Relationship Between Discomfort and Agitation in Patients with Dementia.”

The Gerontologist: “Modeling Causes of Aggressive Behavior in Patients with Dementia.”

Journal of the American Geriatrics Society: “Delirium Superimposed on Dementia: A Systematic Review.”

New England Journal of Medicine: “Delirium in the Elderly Patient.”

Official Journal of the Society for Academic Emergency Medicine: “Delirium in Older Emergency Department Patients: Recognition, Risk Factors, and Psychomotor Subtypes.”

Pain Management Nursing: “The Assessment of Discomfort in Dementia Protocol.”

The Western Journal of Emergency Medicine: “Emergency Department Management of Delirium in the Elderly.”

American Medical Directors Association: “American Medical Directors Association: Protocols for Physician Notification: Assessing Patients and Collecting Data on Nursing Facility Patients.”

Assisted Living, Senior Living, Home Care, and Caregiver Support: “Alzheimer’s Symptoms: Hallucinates (Sees, Hears, Smells Things That Aren't Real).”

UpToDate: “Delirium and Acute Confusional States: Prevention, Treatment, and Prognosis,” “Diagnosis of Delirium and Confusional States,” “Patient information: Delirium (Beyond the Basics).”

 

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