Sundowning:
How You Can Help

Sundowning is a common condition among clients with Alzheimer’s disease. It consists of an increase in agitation, confusion and restless behavior, which normally occurs in the late afternoon or evening.

Sundowning clients may become extremely anxious, fearful and disorientated later in the day. They may pace incessantly, yell,
threaten or repeatedly ask to go home. In some cases, they may show aggressive behaviors or symptoms of delirium. In some cases, the behaviors may be relatively harmless. But, in other situations they may be potentially harmful.

Coping with these behaviors is different, depending upon what they are. And the other problem is, if not properly addressed, these
behaviors can continue throughout the night, resulting in loss of sleep and exhaustion.

OCCURS AT NIGHT
Many researchers believe these behaviors occur at night because the clients are tired. Plus things look different at night – there’s not as much light and lots of shadows, which may be confusing to a client with Alzheimer’s.
 

Also, the arrival of visitors, staff shift changes, and so on can trigger worry and confusion in the Alzheimer’s client. Clients with Alzheimer’s disease are often at their best early in the day. As the day progresses, however, a person suffering with sundowner's memory and ability to carry out tasks can deteriorate. Adding to the problem is that the caregivers are often tired and not at their best toward the end of the day, which adds to the frustration of coping with sundowning.
 

Caregivers need to note, too, that some sundowning may simply be due to old echoes of the client’s life. They may have liked to go
on long walks or participated in hobbies or other evening activities, and sundowning may be a reflection of that, as they attempt
to relive old habits and desires. They may be simply believing that they are going on one of their previously and much-loved
evening walks.
 

There’s also evidence that Alzheimer’s disease damages or disrupts the parts of the brain that control the circadian rhythms, which is what regulates the body clock and the sleep-wake cycle. In this case, the client is confused about which is nighttime, and
which is daytime.

WATCH FOR PHYSICAL PROBLEMS
In other instances, researchers report that sundowning can be caused by a client who is in pain, hungry, who needs to use the
bathroom, or may have problems with incontinence. In these situations, the client with Alzheimer’s may not know what their problem is, or even be able to tell you. Therefore, it’s up to skilled caregivers and their knowledge of the client to discover what the real problem might be.
 

Sundowning can be a serious condition, often resulting in delusions or hallucinations which means they are no longer perceiving reality, but are in their own world. And they may react to it as if it is reality, putting themselves and others in danger. These clients may become more frantic in trying to restore their sense of familiarity or security as their delusions overtake their senses.
 

Also, caregivers often say that their client becomes more anxious about "going home" or "finding mother" late in the day, which may
indicate a need for security and protection. Researchers say that they may be trying to find an environment that is familiar to them, particularly a place that was familiar to them at an earlier time in their lives.

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Sundowning is more common in the moderate to severe stages of Alzheimer’s.
 

WHAT CAN YOU DO?
Resolving persistent sundowning can be a difficult challenge. You need to do the best you can, though, because even if it seems to
be relatively harmless, it can cause sleep deprivation with the client and others if they are living with family or in a facility. If there are safety issues involved, those definitely need to be resolved. Here are some relatively simple measures that research has shown to be effective in helping with sundowning:

• Ensure appropriate lighting. Some research has shown that brighter lighting in the nighttime hours, that reduces shadows, can help reduce sundowning. Shadows can be especially troubling to some suffering from Alzheimer’s disease.

• Limit activities, outings and visits from relatives and friends to the earlier part of the day. The morning hours are usually the best, as this is when Alzheimer’s clients are generally more relaxed and willing to do things.

• Leave the afternoon to quiet activities, such as reading or listening to gentle, soft music together.

• Watch to learn how taking naps impacts your client. In some cases, if they don’t take enough naps, they can become over-tired and agitated, which can cause sundowning. In other cases, if they take too many naps, they’re not tired enough to go to sleep at night. This is something you will have to figure out with each case.

• If they’re new to a facility, keep familiar items in their rooms, such as photographs.

• Make sure that they are not suffering from some physical disorder, such as incontinence problems, illness or pain.

• Check on their medications. While some medications can help with sundowning, others can make it worse and be the direct cause of delusions and hallucinations. If you think it might be medication or if their medications have been recently changed, notify the office or family members so it can be addressed with their physician.

• Try soothing music or music that you know your client liked in the past. This works well in most cases.

• An exercise program that helps drain off excess energy may work.

•  Make it easy for the elder to use the bathroom at night. Consider using a bedside urinal or commode. If the client has prostate problems, this can cause frequent trips to the bathroom at night and sometimes difficulties in urination. If this may be the case, notify the office and/or family as there are possible solutions to this problem.

• Consider whether an afternoon bath or shower is appropriate for each client. Some may be calmed by a bath or shower, while others may be terrified of it, in which case you will not want to give them a bath or shower in the afternoon. Mornings may be best for these clients.

TRY SIMPLE TASKS
Some experts also suggest providing clients suffering from sundowning with a simple task to do in the afternoon hours; something that distracts their attention while making them feel helpful, such as folding towels or helping with other simple activities around the house. This helps distract them from all the unusual activity that often occurs in the evenings, such as shift changes and/or visitors coming and going.
 

IDENTIFY TRIGGERS
In addition, it’s very important to identify – and avoid – possible triggers of the sundowning behavior. If you can find things that are directly triggering sundowning in some clients, the fix might be easy – just eliminate the trigger. These may vary from client to client and may include things like the sight of a particular picture, mirrors, certain TV programs, loud noises, or being in a room with too many people.

WHEN SUNDOWNING OCCURS

You need to accept that your first attempts at resolving sundowning may not work. Even for those that eventually become effective, it may take more than one try to see results. Methods that work for some clients will not work for others. So, this is often a "search and discover" caregiving method.

The best way to develop valuable information is to keep up with what works and what doesn't in their client binder. Keeping track of every thing that occurs around your client that may be a potential cause for sundowning can help you, the family and other co-workers. You will want to record things that you try and whether or not they worked. After a while, you will begin to see clues
for things that work to help ease this issue with your client. Some general suggestions that can help you to effectively assist your client during their period of sundowning include:

• Making sure the surrounding environment is safe for the person. Eliminate dangerous objects and clear the client’s walking path from anything that could cause them to fall.

• Avoid arguing or directly confronting the person and do not restrain them as this may cause accidents rather than improving the sundowning.

• Often the client does not know what their problem is, where they are or even what’s going on around them, so they will not be able to correctly respond to you anyway.

• Give your client comfort and reassurance. Respect, a caring touch, and calm and loving manners may help you considerably in keeping the situation under control.

• Do all you possibly can to make them feel safe and reassured that everything is okay.

• If they happen to fall asleep in a chair or other location that’s safe, it’s usually okay to let them do this.