Early evening, often considered one of the most peaceful times of day, can present tremendous challenges for people with Alzheimer’s disease. About 20% of Alzheimer’s patients experience a pronounced increase in their symptoms starting in the late afternoon and continuing into the night. This pattern of behavior is known as “Sundowning”.

Symptoms of Sundowning

Those who experience Sundowning can display an array of symptoms, including:

• Increased agitation
• Anxiety
• Restlessness
• Wandering
• Aggression
• Resistance to redirection
• Difficulty understanding others

While all of the above symptoms are characteristic of Alzheimer’s disease, Sundowning involves the presentation or intensification of these symptoms starting in the late afternoon, on a consistent basis.

Cause of Sundowning

What causes Sundowning is not known.  It is one of the most difficult aspects of Alzheimer’s, causing disrupted sleep, deep fatigue, heightened stress and loss of quality of life for caregiver and patient alike.  It often leads to the placement of patients in health care facilities.  There are several theories about its causes:

• Damage to the portion of the brain that controls circadian rhythms.  A small part of the brain’s hypothalamus regulates the sleep/wake cycle through the release of the hormone melatonin.  This portion of the brain also controls body temperature and heart rate.  One theory is that Alzheimer’s damages this part of the brain, resulting in disruptions to sleep patterns.  One potential treatment is to give additional melatonin to those who are Sundowning.  However, to date, clinical trials of melatonin have had mixed results.

• Continued awareness of the normal change in activities at the end of the day.  People who remain aware of the normal change in activities at the end of the day, such as leaving work, picking up children, or making dinner may get restless at this time of day.  This restlessness may be triggered or exacerbated by lower light levels or by the awareness of staff leaving at the end of a shift.

How to Manage Sundowning

Sundowning  affects people differently.  As the symptoms can vary so widely, caregivers should try different approaches to find the ones that work for them.  To start, caregivers should rule out medical causes, such as infection or fever.  If there is no underlying medical issue, experiment with the following techniques:

• Establish predictable daily routines for meals, exercise and sleep
• Limit or eliminate afternoon naps
• Limit sugar and caffeine after lunch
• Engage the people in the late afternoon in activities that distract them or address their need to shift gears, such as involving them in preparing a meal or setting the table
• Manage shift changes in health care facilities to minimize patient awareness of departures and arrivals
• Keep the light levels high until bedtime
• Use a rocking chair to ease anxiety
• Limit television viewing
• Avoid stressful activities at the end of the afternoon
• Make sure the sleeping environment is comfortable, warm, without bright lights, but with a night light

Final Thoughts

Not everyone who has Alzheimer’s disease will experience Sundowning.  And since the response to Sundowning is so wide-ranging, it is possible that there is more than one cause for this condition.  Due to the high toll it has on caregiver and patient health, understanding the causes of this phenomenon would provide great relief to families dealing with Alzheimer’s.