Sundowner’s syndrome, or sundowning, is a type of confusion that can happen in the late afternoon and evening. It can affect people living with early on-set Alzheimer’s or Dementia, but can affect the elderly recovering from surgery in hospitals or in unfamiliar environments. Sunset is typically a time where people go through the transition after their busy day of slowing down to relax. It’s during this period that those living with Alzheimer’s and other forms of Dementia can experience increased anxiety, memory loss, confusion, or anger.

Sundowner’s syndrome is a phenomenon that affects around 20% of older people living with Alzheimer’s. Read on to learn what causes sundowner’s syndrome, how you can manage the behaviours, and understand the science behind sundowning in Dementia and Alzheimer’s.

What causes sundowner’s syndrome?

• Tiredness: Having nothing to do after dinner or exhaustion at the end of the day could contribute a lot to sundowning. Research tells us that there is a link between being tired experiencing an increased level of confusion and agitation in the hours after sunset.
• Sudden burst of activities: Research has proven that when there is a rush of activities towards the end of the day, it can cause sundowning because there’s a tendency for increased confusion or anxiety.
• Winter: For some, winter periods worsens sundowning, meaning that the sundowning syndrome may be linked to Seasonal Affective Disorder or SAD (a type of known depression caused by reduced contact with natural sunlight).
• Imbalances internally: Research has also suggested that hormonal imbalances or disturbances in the internal biological clock, which orders understanding between sleeping hours and waking up hours could likewise be a principle factor.
• Decrease in light: As the brightness of the sun goes down, shadows will increase, making it more difficult for those with vision problems to see clearly.

Looking for sundowning behaviour patterns

While the symptoms and causes of sundowner’s syndrome are unique to the individual, researchers agree that it occurs during the transition between daylight and darkness, either early in the morning or late in the afternoon.

Dr. Peter V. Rabins, a Professor in Geriatric Psychiatry, explains that…

“There is not a clear definition of what sundowner’s syndrome means. It’s a phrase. Some people would only include agitation in the definition. It is a range of behaviours – something that is not usual for the person. That can range from just being restless to striking out.”

When do people experience sundowning?

While some people living with Alzheimer’s express their Dementia throughout the day, the behaviours encountered with sundowner’s syndrome are often more severe and pronounced. They almost always worsen as the sun goes down and natural daylight fades.

What are the symptoms of sundowner’s syndrome?

While one person may express several of the behaviours at the same time, another may exhibit only one of them. You might notice some of the more common symptoms, including:

• Rapid mood change
• Anger or agitation
• Crying
• Pacing
• Fear
• Depression
• Stubbornness
• Restlessness or rocking

Occasionally you will find your loved one “shadowing” you closely from room to room. They may ask you questions and interrupt you before you can answer them. They may ask these questions more than once, but it is important to realise they have no recollection of ever asking them before. They are not purposely trying to aggravate you. They simply do not remember.

What are the most severe symptoms of sundowner’s syndrome?

The more severe symptoms of sundowner’s syndrome can be difficult to manage for those who care for someone living with Alzheimer’s. These symptoms can include:

• Hallucinations
• Hiding things
• Paranoia
• Violence
• Wandering

If you’re looking after someone experiencing sundowning, try to keep in mind that they can’t help or control these behaviours. For example, if they wander, it may well be that they aren’t aware they are doing so, and that they don’t know how to return home. They are not purposely becoming agitated or angry or afraid as the afternoon leads to evening. Remaining calm will help you and your loved one get through these sometimes stressful moments.

What can sundowning look like?

Margaret is a 72-year-old woman diagnosed with an early-stage Alzheimer’s. Margaret loves to eat her breakfast every morning, and she’s often in a mild spirit every morning while at her Live in Care facility dining room.

Although she displays many of the known symptoms of Alzheimer’s during the morning hours and after having her lunch, like impediments in her speech, short-term memory loss, disorientation, and more, Margaret’s situation is quite manageable because she gets along quite well with other people.

However, as the sun goes out, Margaret would change and become moody, sometimes shouting at those around her. And when she goes to sleep, she often rages about those in her past, making it impossible for her and those around her to enjoy a good night’s sleep.

If you think you’ve recognised any of these symptoms of sundowner’s syndrome in a loved one, don’t worry. There are ways you can try to deal with the behaviours.

7 ways you can try managing sundowning behaviours in Dementia

Rabins tells us that…

“It’s not like treating blood pressure where you just give a blood pressure medicine. It’s hard to generalise about it because there’s not one treatment approach, but I think often when you focus on the individual you can find things that are more likely to work with one person than another.”

The treatment of sundowner’s syndrome, just like its cause, is not well established. But there are techniques you can try that can help reduce the symptoms in daily life.

1.Establish a routine

Routines help those with sundowner’s syndrome feel safe, minimising surprises and setting up daily rhythms that can be relied on. Without a routine that fits your loved one’s need for regular activity and food, they may remain in a constant state of anxiety and confusion. A lack of routine means that they can find it difficult to deal with the unpredictability of the day.

Schedule more vigourous activities in the morning hours. Don’t schedule more than two major activities a day. As much as possible, discourage napping, especially if your loved one has problems sleeping.

2. Monitor their diet

Watch for patterns in behaviour linked to certain foods. Avoid giving your loved one food or drinks containing caffeine or large amounts of sugar, especially late in the day. This can cause more agitation later in the day.

3. Control noise

It may be helpful to reduce noise from televisions, radios and other household entertainment devices beginning in the late afternoon and early evening. Avoid having visitors come in the evening hours. Activities that generate noise should be done as far away from your loved one’s bedroom as possible.

4. Let light in

Light boxes that contain full-spectrum lights, like light therapy, have been found to minimise the effects of sundowning and depression. As the evening approaches, keep rooms well-lit so that your loved one can see clearly while moving around.

That way, their surroundings don’t seem to shift because of shadows and loss of colour. Night lights often help reduce stress if they need to get up in the night for any reason.

5. See your GP to discuss medication to help

In some cases of sundowning, especially when associated with depression or sleep disorders, medication may be helpful. Consult your GP carefully. They should be able to advise as some medications may disrupt sleep patterns and energy levels in a way that makes sundowning worse, not better.

6. Take supplements

Some over-the-counter supplements may benefit, but remember to discuss this with your loved one’s GP before proceeding. Herbs ginkgo biloba and St. John’s Wort have assisted people with Alzheimer’s and Dementia in the past. Vitamin E has also been found to minimise sundowning in some cases. Melatonin is a hormone in supplement form that helps regulate sleep.

7. Keep your loved one safe

It depends on the extremity of their sundowning behaviours as it may sound rather indiscreet, but consider trying to give your loved one an identification bracelet. You could even consider going as far as locking doors and fence yards with locked gates to keep your loved one safe from any accidents, trips or falls during unsupervised hours, should you need to. It’s best to avoid leaving a loved one with sundowner’s syndrome alone in a car or in a public place while you are shopping or running errands, should they wander off and experience any distress.

Professor Rabins talks about managing sundowning behaviours

“When there’s a pattern to it, it’s important to look for triggers or something in the environment. Is there something in the patient’s medication? Are they participating in fewer activities?  There might be things in the environment that may change or things in the patient: biological changes, sleep-wake cycle, hormone secretion problems. There may be things that can be done, for example, to increase the stimulation for some people, but for others it might be decreasing it. Does it happen every day, how long does it last, how severe is it?”

If you’ve spotted some of the symptoms of sundowner’s syndrome in your loved one, and are looking for extra care and support – then our specialist team of carers can help. Find out more about what our live-in care service for Dementia entails and how you could benefit from tailored, professional help.