Sundowners Syndrome


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:

  • Anger
  • Depression
  • Anxiety
  • Extreme Agitation
  • Fear
  • Delusions
  • Emotional Outbursts
  • Paranoia
  • Hallucinations
  • Crying
  • Pacing or Wandering
  • Restlessness
  • Hiding Objects
  • Rocking
  • Trouble Sleeping

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.

Abstract Distress Canvas Painting

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 sundowners syndrome or its causes, but some potential triggers have been identified. Research suggests that contributing factors may include the following:

  • Sensory deprivation or overload (e.g. too little or too much light)
  • Unmet physical needs (e.g. hunger, pain, fatigue)
  • Limited mobility or social isolation
  • Increased stress levels
  • Decreased sense of security/feeling of safety
  • Anxiety, fear, or depression
  • Unfamiliar environment or unexpected change
  • Disrupted circadian rhythm, sleep deprivation

Is it Sundowners Syndrome or Delirium?

When it comes to treating and managing sundowning symptoms, 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 how to deal with sundowning:

  • Remain calm. Avoid raising your voice and do not make any unexpected movements.
  • Ask questions to identify any unmet needs, but avoid asking for an explanation of things that do not make sense.
  • Keep the curtains drawn to avoid any changes in light, which could trigger an episode.
  • Provide a peaceful setting with limited distractions in the afternoon and evening.
  • Keep your loved one active and busy during the day, increasing the likelihood they are tired enough to rest at night. Discourage excessive napping, especially in the afternoon.
  • Set and maintain a daily routine to help keep your loved one oriented and reduce anxiety.
  • Engage your loved one in calming activities in the afternoon and evening, such as watching a movie, listening to music, or playing a card game.
  • Consult a physician for potential medications that could positively impact symptoms. While there is no known cure for sundowners syndrome, sundowning medication may include anti-anxiety, hypnotic, and neuroleptic medicines.
  • Cognitive, light, music, and aroma therapies may be explored as non-pharmacologic options, but these will likely have varying results and may or may not diminish symptoms.

In addition to these care approaches for sundowning, certain safety precautions can help:

  1. Make sure all doors and windows have child-proof locks in case your loved one becomes agitated to the point they try to escape the house.
  2. Install nightlights to keep things partially lit at night and prevent further disorientation or fear.
  3. Keep a close eye on your loved one's diet, making sure to restrict caffeine and sugar intake in the afternoon.

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 hours and early afternoon. As the day progresses, however, her Alzheimer's symptoms tend to worsen. After lunch, she often seems disoriented and has increased 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.

Frequently Asked Questions About Sundowners Syndrome

  1. What Are the Early Signs of Sundowners Syndrome?
    Sundowners syndrome causes a wide variety of behavioral changes that, in the early stages, can be subtle and inconsistent. Early signs of sundowners syndrome include restlessness, agitation, irritability, and mental confusion in the elderly at night. The patient may also appear disoriented, or they could become more suspicious or demanding. As the condition progresses, these symptoms may become more pronounced and may progress into more serious behavioral disturbances including extreme agitation, emotional outbursts, anxiety, paranoia, and hallucinations.
  2. What Causes Sundowning?
    Doctors and researchers have not yet identified a clear cause for sundowning, but it may be related to the body's internal clock and worsening dementia. Dementia typically causes progressive confusion and difficulty with processing and reasoning skills – it can also change the body's internal clock that differentiates between day and night. When the body's internal clock is disrupted, it can lead to confusion and exhaustion which may exacerbate mental and behavioral symptoms commonly seen in sundowners patients.
  3. When Does Sundowning Occur?
    The symptoms of sundowners syndrome typically develop between the hours of 4:30 in the afternoon and 11 at night. Symptoms start to develop as daylight begins to fade and may become progressively worse as day turns to night.
  4. How Long Does Sundowning Last In Dementia?
    Sundowning typically occurs around the same time of day for each patient, and usually lasts for a few hours. Fortunately, the impact of sundowning fades and most seniors revert back to their normal selves after the bout has run its course.
  5. How is Sundowning Typically Discovered?
    Agitation, confusion, and disorientation are common symptoms of dementia and they typically worsen over time as the condition progresses. Sundowners is usually identified when the patient's doctor or caregiver begins to notice a predictable worsening of symptoms in the afternoon or evening – they may also notice symptoms worsening in relation to specific triggers.
  6. Is the Progression Quick or Gradual?
    The progression of sundowners syndrome is linked to the progression of the patient's dementia. The rate of progression differs for every patient and some factors which may impact the rate of progression include age, genetics, physical health, cardiovascular health, and concurrent medical conditions such as diabetes or infection. Generally speaking, dementia progresses slowly in the early stages but may speed up in the later stages – the same may be true for sundowners syndrome.
  7. What Are the Most Common Triggers for Sundowner's Syndrome?
    Every patient is different, but some of the most common triggers for sundowners syndrome include too much activity at the end of the day, end-of-day fatigue, low light, hormonal imbalance, and changing seasons. Other factors that can contribute to sundowning include depression, anxiety, thirst, hunger, fatigue, pain, boredom, and sleep deprivation.
  8. How Can You Prevent Sundowning?
    Though you may not be able to prevent the condition from developing, you can manage it and reduce its severity by avoiding the patient's triggers. Regular physical activity, adequate sleep at night, and controlled intake of alcohol and caffeine can help mitigate symptoms of sundowners.
  9. Does Sundowners Syndrome Go Away?
    There is no cure for dementia, which unfortunately means there is no cure for sundowners syndrome. Still, instances of sundowning typically only last for a few hours at a time.
  10. How is Sundowning Different from Delirium?
    Delirium is characterized by a serious mental disturbance that results in confusion and reduced awareness of the patient's environment. Certain symptoms like confusion, anxiety, irritability, and behavioral changes overlap with symptoms of sundowning, but the key differentiating factor is the timing of onset. Delirium usually sets in quickly, within a few hours or over the course of a few days, whereas sundowners develops along a predictable schedule in the late afternoon or early evening.
  11. In What Stage of Alzheimer's Does Sundowning Occur?
    Researchers suggest that sundowners affects as many as 66% of patients with Alzheimer's and other dementias. Sundowners can occur at any stage of Alzheimer's disease, but it typically peaks during the middle stages. Symptoms may be mild and inconsistent during the early stages of Alzheimer's but worsen over time before tapering toward the end of the patient's life.

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