What is Sundowners Syndrome?

Explore effective strategies to manage sundowning in dementia, enhancing care and quality of life for loved ones.
Published on
March 13, 2024
Written by
Katie Wilkinson
Katie Wilkinson
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As a family caregiver, it can be heart-wrenching to watch a loved one live with dementia. The experience is emotionally draining, but your constant support makes all the difference in their journey. Sundowner syndrome causes behavioral changes in the late afternoon, evening, or nighttime in people with dementia or cognitive impairment. Understanding sundowning helps you provide the best supportive care as a family caregiver. What are common symptoms of sundowner syndrome, and how can you help your care recipient?

What is sundowner syndrome?

Sundowner syndrome, also known as "sundowning," is a symptom complex associated primarily with Alzheimer's disease and other forms of dementia. However, it can sometimes be observed in patients without these diagnoses. It is characterized by a noticeable increase in confusion, agitation, anxiety, and sometimes aggression that occurs late in the afternoon and extends into the night. 

Sundowning can occur at various stages of dementia, but it is more commonly observed in the middle to later stages. This variation is partly because sundowning is associated with an increase in confusion, agitation, and other behavioral symptoms, which tend to worsen as dementia progresses.

Common symptoms of sundowning

Sundowner syndrome has many common symptoms that range from mood swings to hallucinations. Here are some potential symptoms:

  •  Agitation, increased restlessness, irritability, or excitability
  •  Anxiety, nervousness, tension, fearfulness
  •  Confusion, disorientation, inability to recognize people or places
  •  Impulsiveness, acting hastily without thinking
  •  Suspicion is a belief others have bad intentions
  •  Pacing and wandering, repetitive walking patterns
  •  Hallucinations, seeing or hearing things that are not present
  •  Fatigue increased tiredness earlier than usual
  •  Mood swings, rapid changes between emotions

Call a healthcare professional for guidance and support if you or someone you know is experiencing these symptoms. With the proper treatment and care, caregivers can manage sundowner syndrome and improve quality of life.

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Causes and risk factors

The exact cause of sundowning is not well understood, but several factors are thought to contribute to its occurrence, including:

Disruption of the internal body clock

The human body operates on a roughly 24-hour cycle known as the circadian rhythm, which regulates sleep, wakefulness, hormone production, and other physiological processes. In dementia patients, the brain regions that synchronize this internal clock can be impaired due to neurodegenerative changes. This disruption can lead to confusion and agitation as the external environment cues (like daylight) that help regulate this cycle become less effective. As evening approaches and these cues diminish, individuals may experience increased confusion and restlessness, characteristic of sundowning.

Increased shadows and reduced lighting

As natural light fades towards the evening, shadows in the environment can become more pronounced, and overall lighting may be reduced. For individuals with dementia, visual processing difficulties are common, and these changes in light and shadow can lead to misinterpretations or hallucinations. For example, a coat on a chair might be mistaken for a person, leading to fear and agitation. These misinterpretations can significantly contribute to the anxiety and agitation experienced during sundowning.

Fatigue

Fatigue is a common issue for older adults, especially for those with dementia, who may find daily activities more physically and mentally exhausting. As the day progresses, the accumulation of tiredness can exacerbate confusion and irritability. The brain's diminished capacity to regulate stress and emotion in the face of tiredness can increase sundowning symptoms.

Hunger or thirst

Sensory and cognitive impairments associated with dementia can make it challenging for individuals to recognize or communicate basic needs such as hunger and thirst. If these needs are not adequately anticipated and met, discomfort can increase, leading to agitation and distress. Evening times can be particularly challenging as the structure of the day wanes, potentially leading to missed or delayed meals and hydration.

Depression

Depression is relatively common in individuals with dementia and can significantly impact their well-being. The symptoms of depression, such as sadness, hopelessness, and irritability, can worsen as the day progresses, particularly if the individual feels more isolated or less engaged in meaningful activities. This worsening mood towards the evening can intersect with the other factors mentioned, amplifying the effects of sundowning.

Understanding these factors highlights the complexity of sundowning and underscores the importance of a comprehensive approach to care. Strategies that address these contributing elements—such as maintaining a consistent daily routine, optimizing lighting, ensuring regular meal and hydration schedules, and providing emotional support—can help mitigate the impact of sundowning.

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Management and treatment

Managing sundowning, a term often associated with Alzheimer's disease and other forms of dementia involves a combination of non-medication strategies and, in some cases, medication to help reduce symptoms. Sundowning refers to increased confusion, agitation, and anxiety that typically occur late afternoon and evening.

Non-medication strategies

Before considering medication, healthcare providers usually recommend non-medication strategies, such as:

  • Establishing a routine to reduce confusion and agitation.
  • Keeping the environment well-lit in the evening to minimize shadows and potential confusion.
  • Reducing caffeine and sugar intake late in the day.
  • Encouraging regular daytime activity and limited naps to improve nighttime sleep.
  • Using calming techniques, such as music therapy or aromatherapy.

Medication

When non-medication strategies are not sufficient, doctors may consider medications. However, there is no "best" medication for sundowning due to individual variations in response and potential side effects. Some of the medication options include:

  • Melatonin or melatonin agonists may help regulate sleep-wake cycles.
  • Cholinesterase inhibitors, such as donepezil, rivastigmine, and galantamine, can sometimes help with confusion and agitation.
  • Antipsychotics: In severe cases, antipsychotics may be used to manage agitation and aggression, but they come with significant risks, especially in older adults, and are generally considered a last resort.
  • Antidepressants can help if the patient experiences depression or anxiety.

The decision to use medication should be carefully considered and monitored by a healthcare professional, as older adults, particularly those with dementia, are at increased risk for adverse effects. What works best can vary significantly from person to person, and ongoing assessment is essential to balance benefits and risks.

How caregivers can help minimize the frequency and severity of sundowning 

Stopping sundowning entirely can be challenging, as it is a complex symptom of dementia with various contributing factors. However, several strategies can be used by caregivers and healthcare providers to minimize the frequency and severity of sundowning episodes. These strategies primarily focus on environmental adjustments, lifestyle changes, and non-pharmacological interventions.

Environmental adjustments

  • Increase lighting: As the day transitions to evening, increase indoor lighting to reduce shadows and help minimize confusion.
  • Create a calm environment: Reduce noise, clutter, and the number of people coming and going to minimize overstimulation.
  • Maintain a comfortable sleep environment: Ensure the bedroom is comfortable, secure, and conducive to sleep, with appropriate bedding and temperature control.

Lifestyle changes

  • Establish routine: To help regulate the internal clock, maintain a consistent daily routine for waking, meals, activities, and bedtime.
  • Encourage daytime activities: Engage the person in physical and social activities during the day to promote better sleep at night.
  • Limit naps: Try to reduce long or frequent naps during the day to avoid disrupting nighttime sleep patterns.
  • Adjust dietary habits: Limit caffeine and sugar intake in the afternoon and evening. Ensure a balanced diet and consider offering a light snack before bedtime to prevent hunger at night.

Non-pharmacological Interventions

  • Use of comforting items: Familiar and comforting items, like a favorite blanket or photo, can provide a sense of security.
  • Music and aromatherapy: Soft music and calming scents may help reduce agitation and promote relaxation.
  • Reassurance: Providing calm, reassuring verbal responses can help reduce anxiety and agitation.

Caregivers also need to take care of their own well-being, as managing sundowning can be emotionally and physically demanding. Support from healthcare professionals, support groups, or respite care services can provide necessary breaks and coping strategies.

While it may not be possible to stop sundowning entirely, implementing these strategies can significantly reduce its impact on both the individual experiencing dementia and their caregivers.

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