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Understanding Sundowning in Dementia Patients

elderly woman wearing robe in bed with arms crossed and unhappy expression

Dementia patients may experience restlessness, agitation, irritability, or confusion late in the day, referred to as sundowning. A neuropsychiatric symptom of Alzheimer’s and other dementias, it can be “among the most challenging elements of dementia care,” according to Practical Neurology.

In the long-term care setting, sundowning may affect as many as 80% of dementia patients, they report. As the name suggests, the condition is closely correlated to loss of daylight. As such, sundowning may become more pronounced in fall and winter, say the authors. Sundowning is “associated with faster rates of cognitive decline and increased risk for wandering,” they add.

The National Institutes of Health (NIH) note that sundowning can extend through the night, meaning it is difficult for affected patients to sleep. (Learn more about managing poor sleep in dementia.)

Causes of sundowning

While the problem is not fully understood, there are clearly disturbances in circadian rhythms at play, disrupting sleep-wake cycles, says NIH. Practical Neurology points to a loss of neurons in the suprachiasmatic nucleus, leading to a reduction in production of melatonin. They also comment that “medications with anticholinergic properties and sedatives may also exacerbate sundowning.”

One model for understanding sundowning, according to Practical Neurology, is the Progressively Lowered Stress Threshold (PLST) model: “Diurnal alterations in circadian rhythms temporally correlate with increases in pain, hunger, or fatigue that occur later in the day. Disruptions in emotional regulation emerge when a person’s ability to tolerate such stressors is exceeded.”

Steven Posar, MD, CEO of GuideStar Eldercare, explains, “Sundowning actually begins after lunch.” A patient with sundowning is “unable to manage adrenergic input to the brain.” While experiencing normal spikes in neurotransmitter levels, such as norepinephrine, the spikes that ordinarily occur upon waking up and eating meals never drop throughout the day. Instead, “they plateau high,” which leads to hypervigilance, anxiety, and irritability building throughout the day. (Learn more in his presentation to AMDA, Neurologic Versus Psychiatric Diagnoses in Dementia.)

Managing sundowning

The NIH cautions that becoming overly tired during the day can exacerbate sundowning symptoms later on. They recommend these caregiving tips:

  • Stick to a schedule.
  • Arrange a time for patients to go outside or sit by a window to get sunlight each day.
  • Encourage patients to be physically active each day, but don’t plan too many activities.
  • Avoid providing beverages with caffeine, such as coffee or cola, late in the day.
  • Discourage long naps and dozing late in the day.

Practical Neurology also recommends playing familiar music one hour before usual sundowning onset. The Alzheimer’s Association advocates for maintaining adequate lighting to reduce confusion and cautions, “Do not physically restrain the person; it can make agitation worse.” Instead, they suggest allowing a person who is feeling upset to pace back and forth, with supervision. They suggest finding out whether there is anything the person needs, orienting the person to time of day, and providing calm reassurance.

Behavioral and neurological assessment needed

When sundowning symptoms arise, it is important to conduct both neurological and behavioral assessments, according to Practical Neurology. Blood work to rule out metabolic conditions and medication review are all essential to assessment, in their view. Behavioral assessment can inform the team with a more holistic view of the patient’s experiences, including a focus on patterns and triggers, and determining mental health conditions, such as depression, which influence sundowning symptoms. These assessments provide keys to the most successful strategies for care. In some cases, specific pharmacologic treatments can be valuable, explains Dr. Posar, based on findings from a comprehensive neuropsychiatric assessment.

Person-centered care

As with all dementia care, a focus on the person’s experience is central to solving clinical and behavioral concerns. Learn more about person-centered care for dementia, which is at the heart of the GuideStar Eldercare mission.