Sundowning, or "sundown syndrome," is a name for a phenomenon, common among elderly dementia patients or anyone with a disease affecting the brain, where the person becomes more confused, anxious, and/or agitated in the evenings and at night. Sundowning includes both behavior when the person has not yet gone to bed and when they awake at night. Such events as wandering around, saying they want to "go home" or "find Mother," rearranging and adjusting items around them, pulling or tearing at their clothes, suspicions that other people are mistreating or stealing from them, "shadowing" their caretaker and not leaving them alone, and even hallucinations can be part of sundowning. Obviously these behaviors make things difficult for the people caring for the patient; persistent sundowning problems are high on the list of reasons why Alzheimer's and other dementia patients are placed in nursing homes.

On the other hand, a few people say that the problem is only that the caretakers are more tired late in the day and "blame any new delirium which occurs in an elderly patient, on the fact that that the sun has gone down, and thus is something you don't have to worry about much." (Harris in sci.med archive)) doyle told me of an incident when "I had a young man clearly encephalopathic, and I could not convince the unit, who said he was sundowning." Clearly this is a phenomenon that can be misdiagnosed.

The exact causes of sundowning are still debated. ElderCare Online says, "It used to be thought that sundowning was caused by the lowering light and shorter days. However, research now indicates that being overly tired may have more to do with sundowning." However, other sites still record light therapy, similar to that used in treating Seasonal Affective Disorder, being used to reduce sundowning behavior in cases where the disease may be causing the biological clock to be out of sync with real day/night transition. Other possible causes could be decreased sensory stimulation after dark, with the absence of noises and other sense cues from routine daytime activity, or perceiving that the person/people caring for them are getting tired and becoming anxious. Also, at night when waking from a dream, the dementia patient may have even more disorientation than normal because they can't really separate the dream from reality.

For residents in nursing homes, there may be additional factors; Health and Age says that shift changes, leading to less familiar staff members being around, and sometimes fewer staff to help with problems, can be harder to for residents to deal with. One caretaker also notes that the residents in dementia sections remain strangers to one another, and the evening meal in a common dining room can cause stress and disorientation for them.

Ideas to decrease sundowning include:

  1. afternoon naps to relieve tiredness (on the other hand, napping would be discouraged for someone who tends to be sleepless during the night)
  2. scheduling activities for morning (especially if the person is restless at night -- they can use up their energy earlier in the day) and keeping a consistent routine
  3. reducing irritating stimuli (TV/radio loud, too many people around); several web sites say soft, calm music often calms noticeably
  4. making sure the patient is physically comfortable (not hungry or too hot or cold, etc; this can also include medication for arthritis or other conditions that can worsen as the day goes on, or bladder problems that cause night waking)
  5. limiting caffeine and sweets to early in the day so that their effects will not keep the person awake (and check medication for possible effects on sleep patterns)
  6. good indoor lighting and shutting curtains/blinds to keep the patient from feeling that it is late
  7. caregivers need to speak to the patient calmly and reassuringly, rather than becoming angry or asking for explanations
Sources:
http://www.healthandage.com/Home/gid7=152
http://www.wordspy.com/words/sundowning.asp
http://www.ec-online.net/Knowledge/Articles/sundowntip.html
http://www.alz.org/FamCare/Caregivingchallenges/sleeplessnessandsundowning.htm
http://www.disability.vic.gov.au/dsonline/dsarticles.nsf/pages/Dementia_and_sundowning?OpenDocument
http://www.alznorcal.org/abtalz/socbehav/sundown.asp
http://www.geocities.com/pdcaregiver/SunDown.html
http://www.caregiver.on.ca/cgcihidmsd.html
http://www.angelfire.com/mi4/downs_dementia/Sundowning.html
http://www.alzeci.org/sundowning.html
http://yarchive.net/med/sundowning.html

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