WHAT IS SUNDOWNING AND WHAT CAN BE DONE?

Anyone with acute or chronic confusion may become more confused, restless, agitated and anxious in the late afternoon and especially after dark when the sun goes down or seasonally when there are fewer hours of sunlight.  This may happen whether the person is living at home ore in a facility.  The sundowning behavior can worsen following a move or change in routine.  Individuals with sundowning behavior become more demanding, upset, suspicious, disoriented and see, hear, believe things that aren't real or pace/wander.

Those with Alzheimer's Disease act as if their biological clocks are "reset."  These individuals may stay up all night alert and full of energy despite all interventions to encourage them to sleep in bed; then, they will continually doze on/off during the day.  The reasons for these changes in the sleep-wake cycle in Alzheimer's Disease is not known.

The reason for sundowning behavior is also not known. One theory is that there are fewer environmental clues at night when daylight and eyesight is diminished.  Some scientists believe it may be related to the biological clock in the brain which regulate the amount of hormones and other chemicals important for brain function.  If the biological clock is not properly functioning, the brain itself may not be able to properly function as well.

What can be done for those with abnormalities to the sleep-wake cycle?  It can be a very frustrating problem to deal with, but the following suggestions may be worth a try:

1) ACCOMODATE TO THEM.  Granted, this may be the most difficult and costly approach.  Accommodating to the person's new routine must include keeping them in a locked/secured environment and awake night staff for full supervision as well as ongoing stimulation during their awake periods. They could rest and snooze throughout the day to insure they are adequately rested.

2) MEDICATIONS.  It may be appropriate for the doctor to review all medications to consider discontinuing any non-essential medications which may have an effect on sleep.  Other medications that may reduce anxiety, relax muscles or induce sleep may be considered.

3) ASSESS PAIN.  Pain keeps people from sleeping, or may wake them up from sleep.  With some forms of dementia, communicating or expressing one's pain may be impaired.  Those with complex medical problems in addition to dementia may also be affected by musculoskeletal or other source of pain.  In some cases, a trial of a relatively benign pain medication such as Tylenol may be justified.  If sleep problems are in part due to arthritic pain, aspirin or Tylenol may decrease musculoskeletal pain so that the person can sleep more comfortably.

4) ADDRESS NIGHT TIME TOILETING.  Many older persons awaken many times a night to urinate and then are unable to return back to sleep.  Identify if there might be a urinary infection, provide a bedside urinal or commode to minimize walking through the house activity.  With less physical activity involved to manage night time urination, individuals may fall back to sleep more easily.

5) UTILIZE NIGHT LIGHTS.  Elderly individuals may also have low vision which is exacerbated at night.  A small night light helps to orient and minimize agitation if the individual wakes up and becomes frightened by strange surroundings.  Night lights can also be placed to mark the pathway to the bathroom.

6) KEEP A STANDARD, DAILY ROUTINE.  While caregivers may change from day to day, it is helpful to keep a standard daily routine for any individual with dementia.  A standard daily program for wake-up time, meals, medications, toileting and bedtime routines should be followed by all caregivers to provide consistency.  The daily routine should also include physical activity and other mentally stimulating activities which will help to reset the awake-sleep cycle as well as maintain optimal function. A consistent program reduces anxiety so that an individual will also learn to anticipate what will happen next rather than begin to worry or become anxious wondering when they will eat, get their meds, toilet or go to bed.  Make a written program which is followed by all caregivers 7 days/week.