Are you taking care of an elderly person suffering from dementia or Alzheimer’s and noticing unusual and new behaviors that start in the late afternoon and sometimes last late into the night? Have you noticed this behavior in a friend, or even yourself? The behaviors in question can range from anxiety and aggression, to restlessness, or even delusions and hallucinations. You (and they) might be dealing with Sundowners; also called Sundown Syndrome, "Sundowning," or "late-day confusion."

These symptoms are frustrating for everyone involved, and the periodic random restlessness and associated wanderings means an increased chance of accidents --- tripping over furniture, falling and breaking a hip, or wandering off into the street, for instance.

The term Sundowners may be more familiar as the word for a pleasant late-afternoon cocktail, and there's a reason for this. It's basically a state of late-day confusion, with a host of possible symptoms, that afflicts people with dementia. As the sun goes down, so to speak, which is the reason for its name. Sundowners is not a disease but a set of symptoms.

What Is Sundowners?

elder woman with sundowners syndrome

According to the Mayo Clinic, Sundowners isn't a disease, but "a group of neuropsychiatric symptoms that occur in people with mid-to-late stage Alzheimer’s or other forms of dementia." These happen at a specific time of the day, such as the late afternoon, and can last into the night. Behavioral changes include confusion, anxiety, aggression and the ignoring of directions. Sundowners can also trigger restlessness that leads to the need to wander about the house or pace the room. It can also cause people to wake up throughout the night and walk around while everyone else is asleep.

Is It Location-Based?

old man having memory problem

This set of symptoms can appear in people being taken care of at home by their family or a caretaker or in persons in a facility or institution specializing in dementia. Research has not been able to pinpoint an exact trigger, but certain factors that can aggravate late-day confusion include fatigue, disruption of the body's internal biological clock, hormone imbalances, difficulty separating reality from dreams, an infection such as an UTI, or even the onset of winter’s shorter days: similar to a type of depression called Seasonal Affective Disorder.


How Many People Get It?

group of elder people sitting on a bench

The  symptoms afflict about 66% of older adults, according to the US National Library of Medicine, but the cause of this "distinct clinical phenomena" is still a mystery. Researchers at the Johns Hopkins University School of Medicine say "it's a phrase [...] and 'there is not a clear definition of what Sundown Syndrome means." Some people would only include agitation in the definition. It is a range of behaviors." One thing research is certain about, however, and that is the Syndrome occurs during the transition between daylight and darkness, therefore late in the afternoon.

 

What Are The Symptoms Of Sundowners?

old woman being comforted by the lady

Sundowner symptoms arise as day progresses, especially as natural daylight dims and shadow grow longer. The patient will begin to show signs of anxiety and even fear, confusion and disorientation, aggression--possibly with shouting and even hitting people--, paranoia and hallucinations or pacing, or wandering and escape behaviors.


The person might also start "shadowing" another person in the household, following them around and asking them same questions repeatedly, not all of them making sense. Of course, not all of these symptoms occur all at once, but your loved on or patient may experience several to a mild or severe degree. In summary, the most common symptoms include:

  • Anxiety and fear
  • Mood swings
  • Confusion and disorientation
  • Aggression
  • Restlessness
  • Pacing and wandering
  • Visual and auditory hallucinations
  • Delusional thinking

When Do The Symptoms Strike?

old man sitting by the beach

The symptoms occur in the late afternoon and can last into the night. Factors such as lower lighting and longer shadows as the day draws to a close can trigger Sundowners.

Tips For Dealing With Sundowners

Although it's unlikely that you can stop the symptoms completely, there are steps to help manage this tricky time of day. It will make both of your lives less stressful and easier to manage, you will both sleep better and feel less exhausted and overwhelmed. The things one can do to ease the symptoms of this syndrome rage from exposing the patient to bright daylight or bright light therapy to the behavioral modifications below. Yes, it requires careful structuring and morning of the day's and evening's activities, but once you get into a groove, it will become quite intuitive and actually easier to manage.

Your Sundowner Treatment Plan

time to plan

Keep a daily routine with regular times for waking up, meals, bedtime, and outside appointments. Schedule the latter in the morning, along with other high-energy outings, since these can trigger symptoms later in the afternoon. Be sure to transition from day into night carefully by turning on soft lights as the afternoon or evening daylight wanes.


Play soft music and create a soothing mood. Don't allow a Sundowner patient to nap or exercise late in the afternoon, since this can disrupt the sleep cycle. Avoid stimulants later in the day such as caffeine, alcohol, and nicotine. Keep in mind that even that afternoon snack, like a muffin or donut, can cause a sugar spike that acts like a stimulant.


Create a calm bedtime routine. The next suggestion is much harder to implement but will ultimately help you keep a healthy state of mind: stay calm when confronted with anxiety or hostility. Do not react and understand that your loved one has no control. Allow them to pace, but make sure they are safe and cannot escape to wander the streets unsupervised. Hallucinations or delusions and paranoia are even harder to tackle. This is where medication might need to enter the picture.

Medical Interventions

medicine tablets and capsules

There's also the option of prescribing melatonin, antipsychotics, acetylcholinesterase inhibitors, or N-methyl-d-aspartate receptor antagonists and antipsychotics. While the latter three types of drugs need to be prescribed by a psychiatrist or physician, melatonin is prescription-free and available over the counter at different strengths: but it's always wise to consult with a physician first.


Melatonin is a hormone produced in the pineal gland in the brain, which helps control sleep-wake cycles. The precursor to melatonin is serotonin, a neurotransmitter derived from the amino acid tryptophan. According to the US National Library of Medicine, "serotonin loss in normal aging and neuropsychiatric diseases of late life may contribute to behavioral changes commonly observed in the elderly population. In other words, serotonin loss is a byproduct of aging and melatonin may assist in easing the agitation and restlessness of Sundowners.


Antipsychotics also have a calming effect and are often effective in stopping delusions and hallucinations, while the aforementioned acetylcholinesterase inhibitors can provide some improvement such as allowing the patient with dementia to think more clearly and help with the behavioral and psychological symptoms detailed here.


Behavioral Modifications For Dealing With Sundowners

  • Turn on the lights in the afternoon and evening to eliminate triggers such as darkness and shadows
  • Avoid stimulants such as caffeine, sugar and nicotine
  • Limit or avoid other things that affect sleep, such as disturbing movies or TV shows
  • Schedule outings and appointments that can be stressful or high-energy for the morning
  • Don't react to anxiety with anxiety and anger with anger; stay calm, cool and collected, in voice and body language
  • Keep a daily routine with regular times for waking up, meals, bedtime, and outside appointments
  • Permit no napping or exercising later than four hours before bedtime
  • Opt for calm activities in the afternoon and evening and create a soothing atmosphere

Consider Medications Or Supplements To Tackle Symptoms

  • Melatonin
  • Ginkgo biloba
  • St. John’s Wort
  • Vitamin E
  • Antipsychotics
  • Acetylcholinesterase inhibitors
  • N-methyl-d-aspartate receptor antagonists

Conclusion

It’s not easy to stay calm under duress, but you are certainly not alone. This set of symptoms is very common, with about one in five people, or up to 20% of the roughly five million Americans with Alzheimer’s showing the symptoms at some point. Luckily, there are concrete things you can do at home to ease everyone’s mood swings, and if all fails, there’s also the option of medication.

Professional caregivers who take of Alzheimer’s and dementia patients usually know how to deal with these commonplace symptoms and know how to handle them. For a non-expert, they can be quite unsettling and disruptive, especially in the middle of the night when they encounter a confused, anxious and agitatedly wandering or pacing loved one.

The late afternoon and early evening ideally should be a pleasant time when the day's work and errands are done and things can calm and settle down. This is not the case for most of us modern folks. Evenings can get even more hectic and activities never stop. To a person being triggered by daylight changing to darkness, this time of the day can feel like an episode of the "Twilight Zone." Let's all remember that these episodes pass and that there are lots of things we can do to avoid triggers and treat the phenomenon as it occurs.

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