Sometimes people with Alzheimer's disease become more and more agitated as afternoon dissolves into evening. They pace and wander about, becoming more and more aggravated as the darkness deepens. Confusion, paranoia, and demanding behavior all become increasingly noticeable. Eventually, the person might yell or even lash out physically because of their growing frustration.
This phenomenon has long been called "sundowning" because of its prevalence during evening hours. Doctors now believe, however, that this behavior has little, if anything, to do with the sun going down. "That term has been around since the 1960s and 1970s and is now a little outdated," says Christopher Callahan, MD, a professor at the Indiana University School of Medicine and director of the Indiana University Center for Aging Research in Indianapolis. "The notion used to be that when the sun went down and it got dark outside, there were less external stimuli, and patients would get confused." But doctors now say that symptoms associated with sundowner's syndrome can occur at any point during the day or night in Alzheimer's patients.
Still, an estimated 12 to 25 percent of people with Alzheimer's experience this phenomenon, so if you're caring for a loved one with the disease, it's important to know how to handle sundowning symptoms in the event that they present themselves.
Alzheimer's Disease: Causes of Agitation
Doctors now believe that agitation can occur in Alzheimer's patients for a number of reasons, many of them overlapping. Underlying factors involved in the development of so-called sundowning symptoms can include:
- Feeling tired and overwhelmed. "Your brain is often vulnerable after eight hours of being awake. You're tired and you can't handle stimulation as well, you aren't processing it," says Malaz Boustani, MD, a researcher with the Regenstrief Institute and the Indiana University Center for Aging Research, both in Indianapolis. ·
- Having a biological clock that is out of whack. Suffering a hormone imbalance or reacting to other issues that disturb one's "biological clock" can lead to sundowning symptoms. A common cause of biological clock disturbance, for instance, is a lack of exposure to sunlight. ·
- Changing routines. For those accustomed to daylong activities, a lull in their afternoon or evening schedule can cause them to grow bored and restless. ·
- Suffering depression symptoms. People with Alzheimer's may feel depressed and as a result may have trouble in their daily functioning, increasing their potential for agitation.
Some doctors believe that the caregiver or facility looking after the Alzheimer's patient can also be a reason for the person's behavior. "You see it most of the time in an institutional situation," Dr. Boustani says. If your loved one is cared for in a nursing facility or by other hired help, Dr. Boustani recommends looking at sundowning symptoms as "a red flag that the staffing isn't adequate or skilled enough to meet the needs of Alzheimer's patients."
For example, the caregiver could be inadvertently communicating stress or fatigue to the Alzheimer's patient, making the person nervous or anxious. Or a nursing home may regularly have a sudden increase in stimulation late in the day, through noise or social interactions, which can then make the person with Alzheimer's agitated. Even bright lights kept on all night can lead to irritation in an Alzheimer's patient.
Easing Sundowning Symptoms: Begin with a Structured, Calm Day
The best way to keep people with Alzheimer’s from becoming agitated is to introduce some structure and peace into their daily routine. The following tips can help:
- Maintain a regular schedule. Wake the person at the same time every day and provide meals on a regular schedule each day. Make bedtime the same time every day, too. ·
- Limit caffeine. Be aware of the caffeine content in any food or drinks that your loved one consumes and limit intake as much as possible, especially in the afternoon and evening. ·
- Provide regular activity. It's important to keep people with Alzheimer's involved or interested in activities during the day; this will not only distract them from the agitation and confusion of Alzheimer's but it also discourages napping so that the person is able to fall asleep at bedtime. Activities that incorporate exercise are encouraged as they burn up additional energy and make it easier for the patient to sleep at night. A daily walk, which benefits both the patient and the caregiver, is often recommended, for instance. ·
- Wind down the day. As it gets closer to the person's bedtime, gradually decreasing the amount of stimulation the person experiences will help them to calm down. Turn down the sound on radios, televisions, and stereos and try to keep the home as dark as possible. Limit evening visitors and move noisy family activities to another part of the house, away from the person with Alzheimer's. ·
- Seek out medical help. If your loved one is unable to become calm enough to get to sleep at night, visit your doctor — he or she can look into other medical conditions that might be making it difficult for your loved one to sleep, and can recommend specific treatments.