Sundowning, or sundown syndrome are terms that have been used for over 20 years to describe the reversal of day and night which often occurs in Alzheimer’s and other dementing illnesses. (2) Those who are impacted are often called Sundowners and they act as if their biological clocks have reversed their day and night cycles. Some are able to function on little sleep throughout their 24-hour day cycle. Some individuals stay up all night and will then continually doze off during the day.
This alteration in the sleep-wake cycle is not necessarily permanent and they may revert to earlier patterns of sleep, or may sleep for increasing periods of time. (1)
Those suffering from acute or chronic confusion increasingly become highly agitated, confused, suspicious, active and restless, combative and disoriented late in the day, especially after dark. (2,3) They may see, hear and believe things that are not real. Patients become more impulsive and respond to their own ideas of reality, often in ways that can that get them in trouble. The confusion is often worse after a move or change in routine and can happen in any setting, whether they are living at home or in a facility.
The behavior may be totally out of character for the person. And, the change is drastic. You may see them in the morning and the person seems mentally competent and alert. The same individual may not recognize you or other family members, seem lethargic, become easily agitated, confused, or disoriented late in the afternoon or evening. (1)
There is currently no conclusive evidence about the reasons for these changes in the sleep-wake cycle. (2) However, in the online articles “Sundowning and Sleeping” and “The Sundown Syndrome” there are some theories identified about the cause.
1) The decreasing levels of light may be disorienting. The lower light provides fewer clues as to the person’s surroundings and shadows may be frightening.
2) The person may feel they are supposed to “go home” around this time.
3) The person may be fatigued by the end of the day and thus be more easily frustrated.
4)At this time of day the care giver may be tired as well and may be communicating their fatigue and frustration to the person.
5) The routine noises can be a source of security for the Alzheimer’s person. Comforting noise, such as talking and music may no longer be present and may cause panic.
6) Shift changes in facilities often occur at this time and the increase in activity may cause confusion.
7)The person may be afraid of the dark and may be making noises to fill the emptiness.
8) Changes in barometric pressure.
9) The brain centers that trigger waking and sleeping schedules may be damaged by Alzheimer’s.
This condition is often harder on the care giver than it is on the persons with Alzheimers. Care givers often find themselves exhausted. The online articles “Sundowning and Sleeping” and “Sundown Syndrome and the Elderly” provide some steps that can be taken to lessen the effects using a coordinated approach by family members and health care providers.
1) It may be possible to make part of the house so safe that the person can be up and pacing while his care giver sleeps in a separate room.
2) When sleeping problems are especially severe other family members may need to provide temporary supervision at night so that the primary care giver can sleep. It is important that the caregiver is well rested.
3) Leave lights on and close blinds to shut out the darkness. Leave a night light on and make sure there is a well-lit path to the bathroom.
4) Try to reduce activity around the person at sundown so they are not overstimulated. Keep plans simple.
5) Reduce the person’s caffeine intake which can interfere with sleep. Avoid coffee, soft drinks, and tea for several hours before bedtime.
6) Try to get the person to take an afternoon nap to see if this reduces fatigue and agitation. There is a flip side to that though, efforts should be made to try to keep the person from napping during the day. People who sleep all day are less likely to sleep at night.
7) Try a soothing bath before bedtime or anything that relaxes the person.
8) Encourage more activity and exercise earlier in the day to use up energy and reduce stress. Many people with Alzheimer’s have extraordinary needs to pace for hours. If possible, pacing should not be restricted. At the very least, one to two brisk walks during the day should be encouraged.
9) Persons with Alzheimer’s may not sleep in their beds but will have no problem falling asleep in a favorite chair or on a couch. And, this is better than not sleeping at all.
10)Plan activities of the day so that there is less to do in late afternoon
11) Schedule appointments and trips for the earlier part of the day
12)Play quiet music in the late afternoon instead of loud television
13) Assure the person that everything is all right and everyone is safe. It is important that they secure and protected.
14) Try to get the restless person interested in some quiet activity such as folding laundry.
There are also some methods to avoid. (3)
1) Never restrain the patient unless absolutely necessary.
2) Do not argue with the person as this only escalates the situation.
3) Do not ask the person to explain what is bothering him or her because they do not know and cannot tell you.
There has been research done in the area of special lighting and some studies conclude that it is an effective approach in dealing with the effects of sundown syndrome. (4) Those conducting the research in this area believe that light is the reason for the sundowning behavior. Donna Falvo, a professor of rehabilitation counseling at Southern Illinois University (SIU) doesn’t think that it is a coincidence that the behavior can begin to occur as early as 2 p.m., about the time that the sun’s decline begins to be noticeable. She further states “light just makes sense as a possible triggering mechanism, ” and her reasons “light certainly has an effect on animal behavior . There’s a lot of research in that regard, in terms of reproduction and other types of behavior.” She also referred to seasonal affective disorder, a depression related to low light levels, particularly in the winter. In the study conducted by SIU, researchers involved concluded that there was as much as a 41% decrease in sundowning behavior when the light was manipulated to give the appearance of the sun’s rays very late in the evening. (4)
In the online article “Sundown Syndrome and the Elderly”, George T. Grossberg, M.D., director of geriatric psychiatry at St. Louis University School of Medicine in Missouri, says “sundown syndrome is usually the result of living in low-light institutions that do not offer adequate sensory stimulation. “They’re in a strange setting, with little activity and conversation to keep their minds active.” Dr. Grossberg recommends “increased physical, mental, and social activity, and bright light therapy…” as treatment for sundown syndrome.
When other measures have been tried, a sleeping medication may be reasonable. Although this method does not always work, major tranquilizers may sometimes help the person sleep. This approach may not improve sleeping at night and cause the person to be confused all day. (2) Medications often can and do help with agitation if it is possible to determine the cause of the agitation. If it is related to depression, antidepressants can be effective and tend to make patients drowsy and are given before bed to help a person sleep. (1)
There are some things to consider before assuming the behaviors are related to sundowning.
1) Depressed people often have difficulty sleeping. The appropriate drug and other kinds of therapy may improve sleep.
2) Individuals in pain often cannot sleep. Persons with Alzheimers may have difficulty communicating their pain. A physical examination may identify some unexpected sources of pain. In some cases, an over-the-counter pain medication may be appropriate.
3)Medications may influence the sleep-wake cycle. It may be appropriate for the physician to consider the side effects of the medication the person is on and determine if it is absolutely necessary or if an alternative medication would have less effect on sleep.
In summary, sundowning or sundown syndrome are terms that have been used to describe the reversal of the day and night sleep-wake cycle which often occurs in Alzheimer’s patients. And, while there is currently no conclusive evidence regarding the reasons for these changes, some theories have been identified about the cause. This syndrome can be exhausting for the caregiver. Some measures have been identified that may lessen the effects. It is important to realize with sundown syndrome, as in any behavior related to Alzheimer’s Disease, that the person does not have control over their behavior and that it is a result of the brain tryng to sort out a confusing environment.REFERENCES
1. Alzheimers.com. Sundown Syndrome and the Elderly. Alzheimers.com feature story. [On-Line]
2. Crystal, H. (1998). Sundowning and Sleeping. Northern Virginia Chapter of Alzheimer’s Association. [On-Line]. Available: http://www.alz-nova.org/sundown.htm.
3. Davis, M. (1997). Light in the Darkess. Perspectives Magazine. [On-line].
4. Nitram, R. (1997). The Sundown Syndrome. The Arizona Daily Star Online. Availabnle: http://www.azstarnet.com/~rnitram/sundown.html