Sundowning: What Is It and Which Non-Drug Interventions Help?

Challenging Behaviors Can Increase near the End of the Day. José Antonio Jiménez age fotostock/ Getty Images

What Is Sundowning?

Sundowning is the increased anxiety and agitation that some people with dementia (and occasionally some without dementia) often display in the later afternoon and evening hours. Sundowning behaviors include restlessness, falls, calling out, crying, pacing, wandering, fearfulness, mood swings, paranoia, hallucinations and shadowing.

Prevalance

The Alzheimer's Association estimates that approximately 20% of people with Alzheimer's exhibit sundowning behavior.

However, some research has placed that number as high as 66%, specifically for people with dementia who are living at home.

In Which Stage of Dementia Does Sundowning Behavior Develop?

Sundowning behaviors, along with other challenging behaviors, most often develop in the middle stages of dementia and increase as the disease progresses.

What Causes Sundowning?

There are several theories as to what triggers sundowning. These include the following:

  • Fatigue
  • Over-stimulation
  • Boredom
  • Loneliness
  • Medications wearing off as the day progresses
  • Chronic pain from arthritis or other medical conditions
  • Lighting changes in fall and winter
  • Caregiver stress, fatigue or burnout
  • Shadows from the windows and blinds
  • Hunger
  • Unmet needs

Which Interventions Should Be Used to Help in Sundowning?

Approaches that are individualized to each person are the best way to respond to, prevent and minimize sundowning.Some specific non-drug approaches that may be helpful include the following:

  • Changing the routine

Possible Medications

Some physicians have also prescribed medication to “take the edge off” these behaviors. Medications should always be a second resort after non-drug interventions have been attempted. Medications should not be given to alleviate the caregiver's burden but rather should be focused on minimizing the distress of the person.

Melatonin, acetylcholinesterase inhibitors and antipsychotic medications have all shown some benefit for some people with sundowning behaviors in research studies.

Sources:

Alzheimer's Association. Sleep Issues and Sundowning. Accessed May 25, 2015.  https://www.alz.org/care/alzheimers-dementia-sleep-issues-sundowning.asp

Alzheimer Society Canada. October 11, 2012. Sundowning. http://www.alzheimer.ca/en/Living-with-dementia/Understanding-behaviour/Sundowning

National Institute on Aging. June 2013. Alzheimer’s Disease Education and Referral Center. Alzheimer's Caregiving Tips: Sundowning. http://www.nia.nih.gov/sites/default/files/caregivingtips_sundowning-final_13jun24_0.pdf

Psychiatry Investigation. 2011 Dec; 8(4): 275–287. Sundown Syndrome in Persons with Dementia: An Update. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/

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