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Sundowner’s Syndrome

Sundowners Syndrome and Live in Care – Triggers and the Management

Being alive to see the sunset every day is always a cause for celebration, and most people will celebrate that within their hearts because it’s a period you get to relax from the day’s activities – a transition period from a hectic day to a more relaxed period. However, this relaxed situation eludes some, especially elderly people suffering from Alzheimer or some other forms of dementia – the evening period (the period after the sun has set) could be a period of increased anxiety, memory loss, confusion, or anger for them.

Health givers or family members caring for people suffering from dementia may feel exhausted, pained, or frightened because of the troubles these ones face moments after sunset.

Common Causes of Sundowning

Tiredness: Having nothing to do after the dinner hour or exhaustion after end of the day’s job could contribute a lot to sundowning.

Burst of Activities Towards the End of the Day: Research has proven that when there is a burst or rush of activities towards the end of the day, it could result in sundowning because at that moment, there tendency for increased confusion or anxiety.

Winter: For some, winter periods worsens sundowning, meaning that the sundowning syndrome may have a thing to do with Seasonal Affective Disorder (a type of known depression caused by reduced contact with natural sunlight).

Imbalances Internally: Research has also suggested that hormonal imbalances or disturbances in the internal biological clock, which orders understanding between sleeping hours and waking up hours could likewise be a principal factor.

Decrease in Light: As the brightness of the sun goes down, shadows will increase, thus making is more difficult for those with vision problem to see clearly.

An Instance of Behaviour in People with Sundowners Syndrome

Margaret, is a 72-year-old woman diagnosed with an early-stage Alzheimer. Margaret loves to eat her breakfast every morning, and she’s often in a mild spirit every morning while at her Live in Care facility dining room. Although she displays many of the known symptoms of Alzheimer during the morning hours and after having her lunch, like impediments in her speech, short-term memory loss, disorientation, and more, Margaret’s situation is quite manageable because she gets along quite well with other people. However, as the sun goes out, Margaret would change and become moody: sometimes shouting at those around her. And when she goes to sleep, she often rages about those in her past, thereby making it impossible for her and those around her to enjoy a good night sleep.

Sundowning Syndrome is phenomenon that affects around 20% of old people suffering from Alzheimer.

Managing Sundowning Symptoms

The treatment of Sundowner’s Syndrome, just like its cause, is not well established. But there is hope in a number of approaches that have helped calm down sufferers of the condition in the past.

“It’s not like treating blood pressure where you just give a blood pressure medicine,” says Rabins. “It’s hard to generalize about it because there’s not one treatment approach, but I think often when you focus on the individual you can find things that are more likely to work with one person than another.”

Some of the more successful approaches to managing sundowning behavior include:

Establishing a Routine

Routines help sundowners feel safe. Routines minimize surprises and set up daily rhythms that can be relied on. Without a routine that fits your loved one’s need for regular activity and food, he or she may remain in a constant state of anxiety and confusion, their limited cognitive abilities unable to deal with the unpredictability of the day. Schedule more vigorous activities in the morning hours. Don’t schedule more than two major activities a day. As much as possible, discourage napping, especially if your loved one has problems sleeping.

Monitoring Diet

Watch for patterns in behavior linked to certain foods. Avoid giving foods or drinks containing caffeine or large amounts of sugar, especially late in the day.

Controlling Noise

It may be helpful to reduce the noise from televisions, radios and other household entertainment devices beginning in the late afternoon and early evening. Avoid having visitors come in the evening hours. Activities that generate noise should be done as far away from your loved one’s bedroom as possible.

Letting Light In

Light boxes that contain full-spectrum lights (light therapy) have been found to minimize the effects of sundowning and depression. As the evening approaches, keep rooms well-lit so that your loved one can see while moving around and so that the surroundings do not seem to shift because of shadows and loss of color. Night lights often help reduce stress if he or she needs to get up in the night for any reason.


In some cases of sundowning, especially when associated with depression or sleep disorders, medication may be helpful. Consult a physician carefully, for some medications may actually disrupt sleep patterns and energy levels in a way that makes sundowning worse, not better.

Taking Supplements

A few over-the-counter supplements may be of some benefit. (Remember to consult with your loved one’s doctor before giving him or her any dietary supplement.) The herbs ginkgo biloba and St. John’s Wort have assisted people with Alzheimer’s and dementia in the past. Vitamin E has also been found to minimize sundowning in some cases. Melatonin is a hormone in supplement form that helps regulate sleep.

Looking for Behaviour Patterns

Sundowners Syndrome is a condition most often associated with early-stage Alzheimer’s, but has been known to affect the elderly recovering from surgery in hospitals or in unfamiliar environments. Occasionally, the syndrome will affect people in the early morning hours. While the symptoms and causes of Sundowners Syndrome are unique to the individual, researchers agree that it occurs during the transition between daylight and darkness, either early in the morning or late in the afternoon. But the precise cause of sundowners, like the cause of Alzheimer’s disease, remains elusive.

“There is not a clear definition of what sundowners syndrome means,” says Dr. Peter V. Rabins, professor of psychiatry in the geriatric psychiatry and neuropsychiatry division of Johns Hopkins University School of Medicine. “It’s a phrase. Some people would only include agitation in the definition. It is a range of behaviors-something that is not usual for the person. That can range from just being restless to striking out.”

While some with Alzheimer’s express their dementia throughout the day, the behaviors encountered in sundowners syndrome are often more severe and pronounced, and almost always worsen as the sun goes down and natural daylight fades. While one person may express several of the behaviors at the same time, another may exhibit only one of them. Symptoms include rapid mood changes, anger, crying, agitation, pacing, fear, depression, stubbornness, restlessness and rocking, according to Rabin.

Occasionally you will find your loved one “shadowing” you closely from room to room. They may ask you questions and interrupt you before you can answer them. They may ask these questions more than once, but it is important to realize they have no recollection of ever asking them before. They are not purposely trying to aggravate you. They simply do not remember.

The more severe symptoms of Sundowners Syndrome are also the most difficult to manage for those who care for Alzheimer’s patients and may also put others at risk: hallucinations, hiding things, paranoia, violence and wandering. Wandering, especially, is dangerous, besides also being frustrating. Not only can the person not control these behaviors or conditions, if they wander, they often do not know they are wandering and they often do not know how to return home. While it may sound rather indiscreet, it is often a good idea to give your loved one an identification bracelet and even go so far as to lock doors and fence yards with locked gates to keep him or her safe during unsupervised hours. It is never a good idea to leave a loved one with sundowners alone in a car or in a public place while you are shopping or running errands.

According to Rabins, it is not inevitable that a person with Alzheimer’s disease will also develop Sundowners Syndrome. And it is also important to note that Alzheimer’s specifically and dementia in general are not the only precursors to the condition. As mentioned above, it is not uncommon for perfectly healthy elderly people to behave strangely when recovering from surgeries in which anesthesia has been administered, or during protracted hospital stays. These event-oriented psychoses are usually temporary. It is only when a pattern in behaviors at sundown is noticed that a syndrome may be developing.

“When there’s a pattern to it,” says Rabins, “it’s important to look for triggers or something in the environment. Is there something in the patient’s medication? Are their fewer activities? Is there less staffing? There might be things in the environment that may change or things in the patient: biological changes, sleep-wake cycle, hormone secretion problems. There may be things that can be done, for example, to increase the stimulation for some people, but for others it might be decreasing it. Does it happen every day, how long does it last, how severe is it?”

Because it is common, many professional caregivers who care for Alzheimer’s patients are experienced with its range of symptoms and trained to deal with them appropriately.

It is important to remember that Sundowners Syndrome in your loved one is not something he or she can help. They are not purposely becoming agitated or angry or afraid as the afternoon leads to evening. Remaining calm will help you and your loved one get through these sometimes stressful moments.