WHAT IS SUNDOWNING, WHAT CAUSES IT AND HOW DOES IT IMPACT THE CAREGIVER?

Sundowning is basically a group of symptoms that may come with or without a disease. By itself, it is not a disease; however, it may affect people with Parkinson’s, dementia, Alzheimer’s, Lewy Body Variant and the like. Sundowning, by its very name, occurs at a specific time of day, generally starting in the late afternoon and lasting until bedtime. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition.

Sundowning can be exhibited in any or all of the following examples: Agitation, anxiety, confusion, combativeness, ignoring directions, irritability, restlessness, and screaming or yelling and may even manifest in constant pacing and/or wandering. Some of these behaviors may not be specific to Sundowning and can be the manifestation of dementia, delirium, Parkinson’s disease, and sleep disturbances. Other clinical features of Sundowning include mood swings, abnormally demanding attitude, suspiciousness, and visual and auditory hallucinations in the late afternoon and evening.

Research indicates that 20–45% of Alzheimer’s patients will experience some sort of Sundowning symptoms.

The exact cause of Sundown syndrome is unknown. Several theories have been proposed to understand the clinical phenomenon of Sundowning. Studies that have attempted to explain etiology of Sundown syndrome can be divided into three major groups: physiological, psychological, and environmental. A change in the biologic clock caused by dementia is a likely reason.

A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon to decrease the morbidity from this specific condition, improve patient’s well-being, lessen caregiver burden, and delay institutionalization: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications.

Before considering any specific treatment for Sundown syndrome, it is reasonable to gather a careful history including a journal of the patient’s daily timeline and activities as they pertain to the Sundowning, and have performed a thorough physical examination, and laboratory investigations in order to evaluate a patient for the Sundowning syndrome’s possible connection to various medical conditions.

Determining What Triggers Your Loved One’s Sundowning – As stated earlier, it is very helpful for caregivers to try to determine what may trigger Sundowning symptoms. There may be specific things that you might alter if you determine they may be triggering the behaviors. These alterations may prevent Sundowning from occurring or at least lessening its intensity.

• Check medications for possible side effects.
• Check with the physician to rule out pain or other developments that might be causing increased behaviors.
• Have the lighting levels up which will reduce shadows and gloom.
• Maintain an afternoon, evening and bedtime routine.
• Play soothing music in the place of television or talk radio activities.
• Stay physically active during the day; however, keep the daily activities from being overtiring or over stimulating.
• Go outside into the sunshine during the day.
• Keep naps short so as to keep them from being wide awake when they should be ready to go to sleep for the night.
• Reduce caffeine.
• Ensure the environment is calm and quiet, reduce noise, move to a quiet room.
• Perhaps offer food and beverages prior to sunset.
• Try to reduce their agitation by talking to them reassuringly about their concerns.
• Redirect their behavior. Give them a task to refocus them and relieve boredom.
• Keep nightlights on in areas that can be dark.
• Ask the doctor if melatonin would help with sleep routine.

Unfortunately, most of the aggression is directed at the caregiver and the patient’s behavior changes about the time the caregiver is tired from a long day and is hoping to begin to unwind. Even worse, the behavior changes and anxieties can last until bedtime, further worsening symptoms and escalating behaviors making it harder for the person with dementia to fall to sleep. The effect Sundowning has on a caregiver is not only difficult for the caregiver to deal with, it can be super stressful causing caregiver illness and burn out.

We continually encourage caregivers to care for themselves first by scheduling an hour, an afternoon, a day or longer of time for yourself. It is imperative to focus on your own needs, care for your own health and get support and respite every chance possible, especially when dealing with a person with dementia. If possible, schedule paid caregivers, friends, family members or others to take over some responsibilities so you can take time for yourself. Paid caregivers, friends, family members or others can help with household tasks or caregiving duties. In order to continue be a good caregiver it is critical to maintain your own well-being.

A caregiver can get wonderful emotional support from others who are in the same or similar situations. Join a caregiver group. Learn from and share with others their and your experiences. Others may have tips and techniques that could help you deal with your situation, while you may have tips and techniques that can help them. Mostly you will know that you are not alone.

Learn what is coming next in your loved one’s disease process so you can be prepared. Ask for the Five Stages of Parkinson’s and/or learn The Five Stages of Dementia which describe a patient’s ability to perform in six different areas of cognition and functioning: orientation, memory, judgment, home and hobbies, personal care, and community.

The most effective way to deal with your loved one’s Sundowning is to learn from each experience they have by keeping a journal of the symptoms; what may have triggered them? How was this day different from others? What physical signs did they show? How long did the episode last? What worked to calm them this time? By using what you’ve learned from each occurrence will make it easier to deal with the next one. Perhaps you will be able to lessen each episode or reduce the frequency of the experiences, which will make your job as a caregiver easier.