Alzheimer's disease is a progressive neurological condition and one of the most common forms of dementia. Symptoms include increasing forgetfulness, mental confusion, memory loss, difficulty performing daily tasks, and changes in mood or behavior. A multi-stage disease, Alzheimer's symptoms progress over the course of several years, culminating in a complete inability to communicate or care for oneself.
Though symptoms progress in a familiar pattern, each case is unique, and some patients experience a worsening of symptoms just before nightfall.
This is called sundowners syndrome.
Sundowners syndrome is poorly understood, but there are specific symptoms to watch for and simple methods for its management.
What Is Sundowning?
Sundowning occurs when a dementia patient exhibits changes in mood, personality, or behavior in the late afternoon and early evening. Doctors do not understand why this phenomenon occurs, but it affects roughly 1 in 5 Alzheimer's patients. Some scientists have suggested the neurochemical changes that occur in the brain with Alzheimer's might affect the patient's biological clock, causing the part of the brain that signals when you are awake or sleeping to break down.
It can also be triggered by low light, depression, boredom, pain, or sleep problems.
When a patient is sundowning, instead of new symptoms, existing symptoms typically worsen – particularly mental and behavioral symptoms.
Patients experiencing sundowners syndrome have also been known to shadow their caregivers, following them closely and mimicking their movements. They may ask the same questions repeatedly or temporarily lose the ability to communicate. In severe cases, patients become extremely restless and may try to go outside.
Common Symptoms of Sundowners Syndrome
In the early stages of sundowners disease, symptoms may be subtle, inconsistent, and difficult to notice. Early signs of sundowners syndrome include restlessness and agitation, irritability, confusion, disorientation, suspiciousness, and becoming demanding. As the condition progresses, these symptoms become more pronounced and more regular.
At their peak, sundowning symptoms typically develop in the late afternoon, and they can go long into the night. Some of the most common symptoms of sundowning include the following:
When it comes to sundowning, the timing of onset (and individual behaviors) varies from one patient to the next and symptoms can often interfere with sleep. Sleep deprivation can then trigger ongoing episodes of sundowning while simultaneously contributing to other symptoms of dementia.
What Causes Sundowners Syndrome?
Some studies suggest that as many as 20% of Alzheimer’s patients experience worsening confusion, agitation, and anxiety beginning in the afternoon or evening. Again, doctors do not fully understand sundowning syndrome or its causes, but some potential triggers have been identified. Research suggests that contributing factors may include the following:
Is it Sundowners Syndrome or Delirium?
When it comes to treating and managing symptoms of sundowning, the first step is to confirm that it is, in fact, sundowners syndrome and not delirium. Delirium is a medical condition that results in mental confusion and changes in attention span, perception, mood, and activity level. Though delirium is a stand-alone medical condition, people with dementia are highly susceptible to it.
The best way to tell whether your loved one is suffering from delirium or sundowners syndrome is to look at the timing. Delirium sets in quickly over the course of days or weeks rather than months or years, and its associated confusion may fluctuate throughout the day instead of along a predictable late-afternoon or early-evening timeline.
Sundowning Treatment & Management Options
Once behavioral changes have been identified as sundowners syndrome, there are steps you can take to both prevent and manage it.
First and foremost, you must be patient. Dementia patients can be difficult – if not impossible – to reason with, but it is important to set aside frustration and take whatever steps necessary to minimize triggers and symptoms.
Below are some simple tips for dealing with sundowners syndrome:
In addition to taking steps to manage or prevent sundowning, certain safety precautions can help:
While it is normal for dementia patients to experience sundowning from time to time, you should never ignore serious or dangerous symptoms. Chronic sleep deprivation can worsen symptoms of dementia, so speak to your loved one's doctor if they are having trouble sleeping. You should also contact your doctor if your loved one's symptoms become more frequent or severe.
What Does Sundowners Look Like?
Sundowners syndrome presents in different ways for each patient, though there are some predictable patterns of changing behavior. To give you a better idea what this condition might look like, here is a hypothetical case of sundowners in a patient with Alzheimer’s disease:
Marjory, a 75-year-old woman, is in the early stages of Alzheimer’s disease. She resides in an assisted living facility and is generally in good spirits. She participates in group activities, eats regular meals, and gets along well with the staff and other residents during the morning and early afternoon. As the day progresses, however, her Alzheimer’s symptoms tend to worsen. After lunch, she often exhibits symptoms of disorientation and increasing mental confusion – she also has trouble speaking and often repeats questions. When the sun starts to set, these symptoms worsen, and Marjory begins to exhibit changes in mood and behavior. She becomes more volatile and has been known to yell or lash out at staff members and other residents. At bedtime, she is often too agitated to sleep, sometimes taking hours to calm down.
Every case of sundowners is different, but it often follows a similar pattern in which symptoms worsen as the day turns to night, with patients becoming increasingly agitated and more difficult to manage.