Sundowning Syndrome: Recognizing the Signs and Symptoms

For many of our elderly loved ones, late afternoons and evenings are filled with panic, confusion and behavioral changes. It’s called sundowning. A broad term for behavioral disturbances that commonly peak later in the day — though they can occur at other times — sundowning can be especially unsettling on first appearance. The cause of this condition is not fully understood, but it does indicate it’s time to adjust daily routines to prevent symptoms.

Sundowning affects up to two-thirds of patients with dementia, according to UpToDate, and it may be a sign that the disease is progressing. Dementia is an umbrella term for cognitive decline interfering with daily activities, while Alzheimer’s disease is a specific type of dementia. Sundowning can also be particularly strenuous for caregivers.

Why Does Sundowning Occur?

The mechanisms that cause sundowning are still being studied. Research published in 2016 in Frontiers in Medicine, for instance, hypothesized that there are multiple elements — neurobiological, pharmacological, physiological, medical and environmental — that contribute to sundowning.

Factors that may influence sundowning include:

— Physical changes in the brain, including altered neurotransmitters (the body’s chemical messengers) and melatonin production. Melatonin, or the “darkness hormone,” helps regulate your sleep.

— Disrupted circadian rhythms, causing changes to blood glucose levels and body temperature.

— Medications.

— Sleep disorders.

— Chronic pain.

— Environmental factors, like little exposure to sunlight and overstimulation.

[Signs It’s Time for Memory Care]

Factors That Aggravate Sundowning

Just as the causes of sundowning are multifactorial, there are numerous factors that can worsen sundowning.

“A common cause (of worsening sundowning) is mental and physical exhaustion and trying to keep up with an unfamiliar or confusing environment,” explains Dr. Kuljit Kapur, chief medical officer at Transitions Care in the Chicago area. Transitions Care helps seniors with end-of-life care, finding and managing their primary care and managing chronic symptoms through palliative care services.

Because one cause of sundowning may be disturbed circadian rhythms and melatonin production, a biological mix-up between day and night can worsen sundowning.

Factors that contribute to sundowning include:

— Mental and physical exhaustion.

— Disturbance of the internal body clock.

— Unfamiliar or confusing environments.

— Increased stress.

— Reduced lighting and sunlight.

Care facilities may also play a role in the prevalence of sundowning in their residents. If you are looking to place your loved one in a senior care facility, consider observing if the environment could make residents susceptible to sundowning symptoms.

Facilities with short staffing, for example, may have difficulty adhering to a stable daily schedule and may cause stress. Some facilities also wake up their least cognitive residents as early as 4 a.m. to get a head start on the day. This contributes to sleep deprivation and may increase stress and confusion.

Some facilities also have less natural light. “This can increase shadows and may cause the person living with the disease to misinterpret what they see and subsequently become more agitated,” Kapur says.

[READ: Sleep and Aging.]

How Is Sundowning Diagnosed?

Sundowning is usually diagnosed after caregiver-reported observations. Providers will take a medical history of their patients and ask them about hallucinations, mental health and sleep. They will also inquire if the caregiver has noticed concerning behaviors in their loved one or care recipient.

Kapur says that the next step is to rule out delirium. Delirium may happen anytime throughout the day and can occur in patients of all ages. Delirium may sprout from many sources, including medication or illicit substance use, dehydration or prolonged sleep deprivation.

It is possible that other medical conditions, such as depression, urinary tract infections, sleep apnea or pain, may be contributing to sundowning symptoms. “It’s also important to make sure any medications to help with sleep or relaxation aren’t causing next-day confusion for the care recipient,” Kapur adds.

[Read: Which Doctor Should I See for Dementia and Cognitive Decline?]

Sundowning Treatment

“The best initial treatment to sundowning is nonpharmacologic,” says Dr. Lisa Gibbs, chief of the division of geriatric medicine and gerontology and the Ronald Reagan Chair in Geriatric Medicine at the University of California, Irvine. Avoiding medications is crucial in this population to avoid drug-to-drug interaction and polypharmacy, which is the use of multiple medications at the same time.

If medication is determined to be necessary, a health care provider should review both prescription and over-the-counter medications their elderly patient is taking to avoid any additional cognitive dysfunction and confusion that may occur with introducing a new drug. Medications that may be used include antidepressants, antipsychotics, anxiolytics (anti-anxiety medication) or melatonin, Kapur says.

For more natural options, Kapur suggests cannabinoids, which have been shown to improve neuropsychiatric symptoms like memory loss, disorientation and mood changes. Aromatherapy, especially lavender oil, can also help create a sense of calm and relaxation. Kapur recommends bright light therapy as well. Using a bright light box with fluorescent bulbs in the morning or afternoon has been shown to improve behavioral and psychiatric disturbances.

Tips to Reduce Sundowning

Because sundowning has many possible causes, the treatment should also have a multidimensional approach. Gibbs, who is also the medical director of the Senior Health Center at UCI Health in Orange, California, recommends first identifying any triggers.

For example, “if the pain from arthritis is a problem throughout the day, then treating the pain may alleviate the physical discomfort that can result in agitation or confusion,” she says. She also implores caregivers to pay attention to sleep deprivation, hunger and other physical needs of their elderly loved one or patient.

Kapur provides the following suggestions to reduce sundowning symptoms:

— Schedule appointments and activities in the morning or early afternoon.

— Establish a regular morning and bedtime routine.

— Ensure that bedtime allows plenty of time for rest.

— Incorporate outdoor activities and walks during the day.

— Make note of what worsens sundowning in your loved one to identify and reduce triggers.

— Reduce stimulation in the evening hours, including limiting electronics.

— Offer a larger meal at lunch and a smaller one at dinner.

— Keep adequate lighting in the evening.

— Identify helpful and soothing activities for your loved one, such as reading a book or listening to music, that improve their sundowning.

Prevention Is Paramount

“Prevention is key, if possible,” Gibbs says. She proposes that caregivers create a daily structure that encourages a sense of comfort and predictability early into the course of Alzheimer’s disease or dementia. Those with dementia have difficulty responding to change or unfamiliar events, which can cause fear and agitation, so this structure can help offset those emotional responses.

Gibbs also suggests that caregivers stay attuned to their own stress levels. “Individuals with dementia may mirror caregiver behavior and feelings, whether calmness, stress or frustration. Caregiver self-care is just as critical,” she says.

If you are dealing with sundowning in a loved one and have already tried natural remedies, speak with a medical provider about prescription medications or supplements. If you’re considering moving your loved one into a senior care facility, tour the facility to see how it could impact their sundowning condition and overall mental and physical health.

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