A Caregivers' Challenge: Dealing with "Sundowning" in Alzheimer's Disease

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Medical Author: Melissa Conrad Stöppler, MD
Medical Editor: William C. Shiel Jr., MD, FACP, FACR

"Sundowning" or "Sundown Syndrome" is a phenomenon well known to many of the estimated 2.4 to 3.1 million caregivers to persons with Alzheimer's disease in the U.S. Sundowning refers to the changes in behavior and mood that often occur in the late afternoon or evening in people with Alzheimer's disease and similar conditions that alter brain function. These changes in mood and behavior can be particularly challenging for caregivers and loved ones.

Symptoms associated with sundowning include:

• aggression,
  
  
• agitation,
  
  
• delusions,
  
  
• hallucinations,
  
  
• paranoia,
  
  
• increased disorientation, and
  
  
• wandering.

Sometimes sundowning occurs together with "shadowing," in which the person mimics or follows the caregiver, sometimes asking repetitive questions.

It's not clear why these troubling behaviors occur most commonly at night and in late afternoon. The circadian rhythm and hormonal factors may predispose to the late-day agitation and restlessness in some people. Other possible reasons for might be reduced vision due to lower light levels, tiredness after a full day, boredom and the absence of planned activities at night, insomnia, or stress and anxiety of the caregiver that is communicated to or perceived by the patient.

According to the Alzheimer's Association, caregivers can take steps to help ease the difficulties associated with sundowning. While not all activities will be appropriate or helpful for every individual, some suggestions for dealing with sundowning/shadowing include:

• Provide calming and repetitive tasks such as winding a ball of yarn, folding laundry, sweeping, or stacking mail or papers during the difficult times of day.
  
  
• Encourage adequate and appropriate levels of exercise earlier in the day, and discourage napping during the day if nighttime sleeplessness is a problem.
  
  
• Keep rooms well-lit; a nightlight may be reassuring and help orient the person with Alzheimer's disease.
  
  
• Reassure the person about the time of day and presence of the caregiver.
  
  
• Reduce outside stimuli in the form of noises, TV, radios, or visitors; however, some people may find it comforting to listen to relaxing music with headphones
  
  
• Restrict consumption of caffeine-containing foods and beverages to the morning hours.
  
  
• Plan challenging activities such as outings or doctor visits for early in the day.
  
  
• Avoid arguments, lengthy discussions, and conflicts during the sundowning hours.
  
  
• Control specific "triggers" of problem behaviors; keeping a behavior log (noting time of day, events, behaviors, and what worked best to soothe the person) may be helpful.
  
  
• Take advantage of support groups; other caregivers can be invaluable sources of tips for dealing with sundowning behaviors.