Sundowning ... Just the Facts

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People with diseases such as Alzheimer's often have behavior problems in the late afternoon and evening. They may become demanding, suspicious, upset or disoriented, see or hear things that are not there and believe things that aren't true. Or they may pace or wander around the house when others are sleeping.

While experts are unsure how or why this behavior occurs, they suspect that the problem of late afternoon confusion, which is sometimes called "sundowning," or "sundown syndrome," may be due to these factors:

• The person with Alzheimer's can't see well in dim light and becomes confused.
• The impaired person may have a hormone imbalance or a disturbance in his/her "biological clock."
• The person with Alzheimer's gets tired at the end of the day and is less able to cope with stress.
• The person is involved in activities all day long and grows restless if there's nothing to do in the late afternoon or evening.
• The caregiver communicates fatigue and stress to the person with Alzheimer's and the person becomes anxious.


Action Steps

Try these ways to lessen behaviors of "sundowning":

• Make afternoon and evening hours less hectic. Schedule appointments, trips, and activities such as baths or showers early in the day.
• Help the person to use up extra energy through exercise. For the person who tends to pace or wander in the evening, you may want to arrange at least one or two brisk walks during the day.
• Control the person's diet. Reduce foods and beverages with caffeine (chocolate, coffee, tea, and soda) or restrict them to the morning hours to reduce agitation and sleeplessness. An early dinner or late afternoon snack may also help.
• It's so important to provide regular activities and you may want to discourage napping during the day if nighttime sleeplessness is a problem.
• You may want to reduce the level of noise from radios, televisions or stereos, control the number of people who visit in the evening hours, or confine noisier family activities to another area of the house.
• Consult with your physician. Your physician may be able to prescribe medication to encourage sleep. At the same time, your physician can check for signs of depression, or physical problems, such as prostate difficulties that might lead to frequent urination. This condition can cause pain and make sleep uncomfortable.
• Make it easy for the person to use the bathroom. Consider a bedside urinal or commode. Or encourage the person to use the bathroom before going to bed.
• Keep rooms adequately lit. Good lighting may reduce the person's confusion. A nightlight may prevent the person from becoming agitated in unfamiliar surroundings.


Remain flexible and consider the person's needs.

• While people with Alzheimer's may find it difficult to sleep in their beds, they may fall asleep more easily on the living room couch or in a reclining chair.
• Reassure and comfort the person. Tell the person experiencing sundowning what time it is and what's going on in the house. Let the person know you are there and will remain there. Then try to involve the person in a meaningful activity such as setting the table, folding towels, doing dishes, or sweeping the floor.
• Avoid arguing or asking for explanations. The person may not know what's wrong or be able to tell you if he does. Keep in mind that the person with Alzheimer's has no control over annoying, repetitive behavior. Confusion and restlessness occur because the brain can no longer sort our cues in the environment.


Remember to care for yourself.

• Make sure you get adequate rest. Just because the person with Alzheimer's can't sleep at night doesn't mean you should go without sleep. Arrange for another family member to supervise the person at night. Or arrange the room so that it is safe enough (and has locked doors) to let the person stay awake and pace there while you nap or sleep in another room.


Shadowing

"Sundowning" is often accompanied by "shadowing," where the person with Alzheimer's follows or mimics the caregiver, or talks, interrupts, and asks questions repeatedly. At times, the person may become upset if the caregiver wants to be alone. While shadowing and other forms of agitation vary from person to person, you may be able to manage the behavior by following these steps:

Action Steps

Examine factors that encourage agitation. Consider these questions:

• How long does the behavior last?
• At what time of day does it occur?
• Is the behavior triggered by certain people or surroundings?
• What seems to calm the impaired person?

Once you develop answers to these questions, you may be able to avoid the situations that bring about agitation and introduce activities that help calm the person with Alzheimer's.

• Protect your privacy. You may want to install a childproof doorknob on the bathroom door or use a timer and reassure the person by saying, "I'll be back when the timer goes off."
• Try to keep the person occupied. Find simple, repetitious activities to occupy the person even if you could do them better on your own. Possibilities including folding the wash, dusting, stacking papers or magazines, stuffing envelopes, or winding a ball of yarn. Or provide the Alzheimer's person with headphones for listening to calming music.
• Rely on ideas of support groups. Caregivers are always discovering new ways to deal with behaviors such as shadowing and sundowning and are happy to share them.

A better understanding of the feelings of the person with Alzheimer's disease, such as fear, frustration, and anger, may help you accept the resulting behaviors. Providing reassurance and helping your loved one respond to his/her changing environment can help you manage the person's behavior.


Resources

One of the best places to turn for additional help is the Alzheimer's Association. The Alzheimer's Association has more than 200 Chapter and 1,600 support groups nationwide, where family members share their experiences, provide each other with emotional support, hear practical suggestions and learn to rebuild their lives.

The primary source for this fact sheet was Peter Rabins, M.D., M.P.H., Associate Professor of Psychiatry, Director of the Psychogeriatric Unit, and Director of the T. Rowe and Eleanor Price Teaching Services of the Department of Psychiatry and Behavioral Sciences of the Johns Hopkins University School of Medicine. Dr. Rabins is the co-author, with Nancy L. Mace, M.A., of The 36-Hour Day (Baltimore: Johns Hopkins University Press, 1991).

Additional information was provided by the following Chapters of the Alzheimer's Association: Eastern Massachusetts, Flint & Genesee Counties, Michigan.

Lin E. Noyes. CAREGIVING AT A GLANCE. Family Respite Center, Falls Church, Virginia. "STEPS TO SELECTING ACTIVITIES FOR THE PERSON WITH ALZHEIMER'S DISEASE," Alzheimer's Association, 1992.*

DOCUMENTATION GUIDE, Alzheimer's Association, revised 1991.*

*These materials are available through your local chapter of the Alzheimer's Association.