Sundowning: Demystifying The Triggers

"Vail Beach Sunset" by Andrew Horowitz

by Paul Raia, Ph.D

Mrs. Richards, a resident at an Alzheimer’s facility, would get agitated and act out every afternoon. At 3 pm every day like clockwork, she would try to get away and yell anxiously, “Let me out of here! Let me out of here!”

Being a mother, Mrs. Richards was remembering the time of day when she had to pick up her children from school. Once we were able to identify her trigger, we were then able to be preemptive and alleviate her anxiety. At 2:30 every day we would tell her that her husband was going to pick up the kids today and then divert her attention into an activity. This successfully resolved her disruptive afternoon routine.

Sundowning is a troublesome behavior that affects many Alzheimer’s patients. Loosely speaking, sundowning is thought of as the worsening in the late afternoon and early evening of behaviors associated with Alzheimer’s. The term does not refer to any specific behavior but, rather, to a time of the day when some people afflicted with the disease become anxious and restless, show anger and hostility, fidget excessively, yell out, and generally become paranoid.

What many do not realize is that sundowning is not a neurological inevitability. It is caused by a variety of triggers, which, once identified, can be alleviated. Let’s consider some of the factors that can play into sundowning.
Fears are heightened by darkness — Some Alzheimer’s patients sundown because the oncoming darkness brings to mind the terrors of early childhood, when darkness ushered in a fear of the unknown. Many people carry this free-floating anxiety into adulthood, but it’s countered by the ability to rationalize away the dread. Alzheimer’s patients lose that ability as the disease progresses.

Visual aspects — Another probable cause of sundowning involves the relationship between Alzheimer’s disease and vision. If you have impaired memory, what you see in your immediate surroundings is your only reality. A cup in the cupboard, behind a closed door, doesn’t exist because you cannot see it and have no memory of it. When a cup is observed on the counter, it exists, at least for that moment. So, in that way, vision can compensate, somewhat, for memory loss. However, vision is also affected by Alzheimer’s disease, and, because there is less light available around the time of sunset, people with Alzheimer’s have to work that much harder to perceive and process the world around them.

Sleep disruption — Sleep figures prominently as a factor related to sundowning. The wake/sleep biorhythm that every person has is disrupted in individuals with Alzheimer’s disease — they lose their sense of time. Prolonged and late-afternoon naps can contribute to their not being able to sleep as much at night and subsequent drowsiness during the day. They could be so out of kilter with their wake-sleep cycle that they are literally half-asleep at certain times of the day. They may be talking or involved in an activity, but their functioning is more akin to sleepwalking, and their emotionality is more profound. Getting overly tired in the late afternoon makes it harder for those with already-diminished cognitive capacity. It becomes a fertile ground for frustration and irascibility.

Restlessness — Not having anything to do, not being engaged in something, is when those with Alzheimer’s become anxious. In fact, we have found that, in nursing homes, problem behavior is almost always due to the lack of activity.

How can we help?

  • Restore the basic wake-sleep cycle. Getting exposure to our sun’s ultraviolet rays helps. Get your loved one outside for at least 20 minutes a day, even if it’s cloudy. If getting outside is a challenge, get them exposure to bright lights indoors, preferably with full-spectrum light bulbs.
  • To that end, make sure they take Vitamin D to help the body metabolize light and increase the amount of melatonin in the brain, which helps adjust their circadian rhythm.
  • Having activities and socialization during the day is important on many levels. For one, being up and active during the day can help your loved one become tired enough to sleep at night. Adult day programs are great for this.
  • The frail person with Alzheimer’s disease should nap in the early afternoon, but not for more than two hours. People with Alzheimer’s often do not wake up quickly. So if they nap in the late afternoon, it can take another 30 to 45 minutes for them to become fully alert. During this time, agitation comes easily.
  • Keep the house bright during the day to signal daytime. Employ timers around the house that turn lamps on before it starts getting dark.
  • Sundowning behavior usually happens at the same time every day. So, one-half hour before your loved one typically sundowns, get them engaged in an activity. This way you are able to disrupt the pattern and hopefully preempt the emotional outburst. Have them help with dinner preparation. Be creative — find a task that is meaningful and allows them to be engaged with the family.

If you need personalized help in developing strategies for the best possible symptom management and communication, we extend our free Care Consultation services to the In Care of Dad community. Call our helpline at 800.272.3900 or click here to get in touch with our trained consultants.

Paul Raia is Vice President, Professional Clinical Services of the Alzheimer’s Association, MA/NH Chapter, and is also the chapter’s Director of Patient Care and Family Support.

The photo titled “Vail Beach Sunset” was taken by Andrew Horowitz.

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