Sundown syndrome: end of the day confusion

Sundown Syndrome or “sundowning” is a state of confusion that occurs at the end of the day and into the night and can lead to pacing or wandering. Sundowning has been compared to Seasonal Affective Disorder which is a common depression caused by less exposure to natural light and usually occurs with the onset of winter. Sundowning occurs in approximately 20% of Alzheimer’s patients and usually peaks in the middle stages and lessens as the disease progresses (Webmd.com). Although Alzheimer’s patients are more susceptible to sundowning, changes in blood pressure, glucose levels after eating as well as individuals with macular degeneration can experience sundowning.

The exact cause of sundown syndrome is unknown (Mayo Clinic). However, studies have suggested that it may occur due to changes in the brain’s circadian patterns. The cluster of nerves which keeps the body’s 24 hour clock has been altered or damaged. Another study done with mice has shown that it may occur due to a change in the brain’s chemistry from the younger mice to the older mice (Webmd.com). A few factors may aggravate the occurrence of sundown syndrome are: fatigue, low lighting, increased shadows, disruption of the body’s internal clock and the difficultly separating reality from dreams (Mayo Clinic). With the inability to understand what he/she is seeing, he/she will often misinterpret what is there. For instance, one story I came across in my research tells the story of a man who thought he was being robbed at home because the sunlight coming through the blinds created stick figures on his walls. He would repeatedly call the police.

The symptoms of sundown syndrome may vary from patient to patient. Majority of patients will experience: confusion, anxiety, aggression, forgetfulness, delirium, agitations, ignoring directions, restlessness and trouble sleeping (Mayo Clinic and Webmd.com). A patient who experiences these symptoms may be compelled to wander or pace and may yell and become combative. Many physical ailments may lead to a patient being more susceptible to sundowning. Severe constipation, poor nourishment, pain, an infection and too many medications.

There are some tips for reducing the occurrence of sundown syndrome (suggested by the Mayo Clinic and Webmd.com):

Activities:

Plan activities for during the day to optimize exposure to the sun and to encourage nighttime sleepiness

Avoid daytime napping

Try to maintain a predictable routine for bedtime, waking, meals and other activities

In the evening, reduce background noise and stimulating activities (i.e. TV viewing)

Healthy Diet:

Limit caffeine and sugar to morning hours

Eat an early dinner

Light snacks before bedtime

Medical Advice:

Check for any conditions which may be contributing factors (i.e. UTIs, sleep apnea)

Regularly check medications to make sure still needed

Good sleeping environment:

Use a night light to reduce agitation that occurs when surroundings are dark or unfamiliar

Play gentle music in the evening or relaxing sounds of nature (i.e. waves) to promote sleepiness

Change bedrooms if needed

Calm reassurance:

Gently remind the patient where he/she is and what time it is.

When in a strange or new setting, bring familiar items (i.e. pictures) to help with relaxation

Due to the stress it puts on caregivers, sundown syndrome is a common cause of caregiver burnout. It is a difficult situation to take care of an individual with Alzheimer’s. My Grandma Ruby suffered from Alzheimer’s disease and it was heartbreaking to see her unable to recognize where she was or who she was with. I’m not sure if she suffered from sundown syndrome but she probably did. Sundown syndrome in combination with other disorders can be terrifying for the sufferer as well as stressful on a caregiver. I think following the above suggestions from the Mayo Clinic and other medical sources can help lessen the effects of sundowning as well as the stress and anxiety it can cause.