Sundowner’s syndrome describes the late-day or evening emergence of symptoms such as agitation, increased confusion, wandering, disorientation, aggression, and anxiety. It commonly affects people living with Alzheimer’s disease or other forms of dementia. Clinically referred to as Sundown Syndrome or “sundowning,” the condition can be distressing to patients and caregivers. Although there is no prevention or cure, there are strategies that can help manage and reduce the severity of symptoms.
What Is Sundowner’s Syndrome?
Sundowner’s syndrome, also known as “sundowning,” refers to a cluster of symptoms that typically begin to emerge late in the day or early afternoon. It is a cyclical, delirium-like condition common in people living with Alzheimer’s disease or other types of dementia. The behaviors associated with sundown syndrome typically worsen later in the day when the sun goes down. These behaviors may include agitation, increased confusion, distress, wandering, disorientation, aggression, and anxiety symptoms. 1
Sundowner’s syndrome is not a formal disease or diagnosis; it is a descriptive term for the cluster of behaviors that occur at a specific time of day, particularly in older adults living with Alzheimer’s disease or other dementia. Sundowning tends to begin in the middle and later stages of Alzheimer’s disease, although not all people will experience it.2
Sundowning is not a form of delirium, although it is sometimes referred to as “nocturnal delirium,” with some of the symptoms being similar.3 The main difference between sundown syndrome and delirium is that delirium comes on suddenly and will worsen over hours or days 4, and in older adults with Alzheimer’s or dementia, delirium is usually caused by an infection or as an adverse effect of medication.5
Sundowner’s Syndrome Symptoms
The behavioral and neuropsychiatric signs and symptoms of sundowning occur in the late afternoon, evening, or after sunset. There is a wide variety of symptoms that may be present, and they will be unique to every individual. Symptoms can affect mood, thinking, behavior, personality, and reasoning.2
Common sundowning symptoms include:
Causes of Sundowning
The exact cause of sundown syndrome is unknown. However, it is speculated that the late-day presentation of symptoms, or “nighttime Alzheimer’s,” may be related to damage or changes to the area of the brain that regulates a person’s circadian rhythm in people with Alzheimer’s disease or other dementia. Circadian rhythms respond to light and dark and serve as the body’s natural clock, which loosely follows a 24-hour cycle.5 Some researchers disagree, saying there isn’t enough evidence to support this claim and that further research is necessary.1
While there is no single scientific finding that has been proven to cause sundowning, research supports several theories about what may influence the presentation and severity of sundowning in some people. The main ideas include sleep disorders; inadequate exposure to light; as a response to environmental factors; medications (specifically, the “wearing off” of certain medications); and a result of exacerbating existing medical and psychiatric issues.1
Possible contributing factors of sundown syndrome include:
- Cumulative physical and mental exhaustion from daily activities
- Unmet needs such as hunger or thirst
- Pain
- Poor sleep
- Changes to melatonin levels
- Loss of routine
- Effects of medication wearing off or adverse effects of medication
- The stress of navigating unfamiliar environments
- Hormone levels change throughout the day
- Sensing frustration or exhaustion in caregivers
- Overstimulation
- Lack of exposure to natural light
- Visual or auditory impairment, which can create confusion
10 Tips for Helping Someone With Sundowner’s Syndrome
Learning how to calm anxiety in someone with Sundowner’s syndrome can help reduce the need for medications and therapy. Helping someone adopt lifestyle changes and use self-help techniques takes patience, practice, empathy, and observational skills. Some techniques require a change in a caregiver’s approach. Family and caregivers can implement these changes for themselves and their loved ones struggling with sundowning.
Below are ten ways to help minimize a loved one’s symptoms of sundowners syndrome:
1. Treat the Underlying Issue
People with moderate to advanced Alzheimer’s or dementia may have difficulty communicating their wants and needs, or expressing when something is wrong. Sundowning might be how the person is trying to communicate a need such as hunger, thirst, or untreated pain. It may be a way of expressing discomfort, such as ill-fitting clothing or shoes, or the need to use the bathroom.
2. Identify Triggers
Pay attention to when symptoms begin and if there are any identifiable issues that may have caused the change or worsening of mood and behavior. Certain activities or situations may trigger sundowning, such as a noisy environment, a change in caregiver, a visit from a friend or family member, a medical appointment, or other known anxiety triggers. It’s also possible that the trigger is more subtle, such as an irritating shirt label or shoes that feel too tight, and the inability to communicate is what creates frustration and distress.
3. Rule Out Other Causes
It is possible that an infection, medication, pain, dehydration, or other medical issue is causing the symptoms you are observing. Urinary tract infections are common in older adults, and symptoms can include confusion or delirium.6 It is more common in older adults than in younger patients to have cognitive impairment or delirium as an adverse effect of medication. 7 Talking to a physician about your concerns can be helpful in ruling out other potential causes of mood and behavioral disturbance.
4. Pay Attention to Sleep Schedules
The impact of sleep on mental health extends to sundowning. Fatigue and lack of sleep can worsen sundowning symptoms. Research suggests there is a relationship between agitation and sleep disturbance in older adults, and in general, agitation may be exacerbated by fatigue.8 Sleep disruptions, such as increased waking during the night, frequent napping during the day, and decreased sleep efficiency (which is the total time spent asleep compared to the total time in bed), can all contribute to sundowning. Avoid late-day naps, limit sugar and caffeine intake, and create a dependable bedtime routine.
5. Keep a Predictable Routine
A predictable daily routine can help minimize confusion and anxiety. Pay attention to the timing of meals, naps, and medications, and make changes as necessary. Minimize stressful situations by avoiding surprises and scheduling appointments early in the day. Remember that overscheduling can be mentally and physically exhausting, leading to sundowning.
6. Get Exercise Outdoors
When appropriate, and with a physician’s recommendation, go outside to exercise. The mental health benefits of exercise are numerous and well-supported by research.9 Walking, in particular, has been shown to decrease sundown syndrome. 10 Being outside has benefits, too. Some of these benefits include stress reduction, relaxation, sleep quality, and improved mood. 11 In addition, natural light is connected to circadian rhythms, which may be dysregulated in individuals with Alzheimer’s disease and other dementia.
The sun’s light-and-dark cycle can have a powerful effect on the body’s natural clock. According to the Centers For Disease Control (CDC), getting bright light in the morning, just after waking up, can make a person feel more alert during the day and also have the effect of making a person feel sleepy earlier in the evening.12
7. Reassure, Validate & Redirect
Reassurance can help to calm anxiety and fears. Reassurance can be through words, such as a comforting phrase like, “You are safe here with me,” or, “I will sit with you while you’re upset,” or through calming, and welcomed physical touch. Validation provides recognition or acknowledgment of another person’s feelings. Validation is helpful because it conveys to the person that their feelings are real and they are being heard. “I’m sorry this happened to you. I would feel angry, too.”
Redirection is a way to distract from discomfort by shifting the conversation or activity to something completely different. Redirection is helpful with sundowning because it takes the person’s attention away from the situation that is causing anger, anxiety, or distress. “Why don’t we go to the kitchen and make a snack?”
8. Try Alternative Therapies
Alternative holistic therapies, such as therapeutic massage, soothing music, and essential oils, can help with anxiety and agitation. Massage is used for a variety of medical conditions and has many benefits, including pain and stress reduction, increased relaxation, and improved energy and alertness. A physician should be consulted prior to trying a massage. 13 Research supports the use of music as a non-pharmaceutical intervention to reduce symptoms of sundowning, particularly agitation, and depression. 14
Essential oils, such as lemon balm and lavender, can help with anxiety. It is strongly advised to consult with a physician or integrative medicine specialist to learn more about the appropriate use of essential oils because they can cause irritation or allergic reactions in some people. 15
9. Be Aware of Your Own Mood & Behavior
Caring for a loved one with challenging behaviors can be physically and mentally exhausting. Caregivers experience higher levels of stress, depression, and anxiety than their non-caregiver peers. 16 Be aware of your mood and whether your loved one may be picking up on your own fatigue, frustration, or irritability.
People with Sundowner’s syndrome may become upset when their caregivers appear distressed. Taking a break, even if only for a few minutes outside or in another room, can be helpful. Seeking support from family, friends, or professionals can also help to reduce caregiver burnout. Choosing a therapist to work with may also provide much-needed support and guidance in your caregiving role.
10. Consult With Professionals
Professionals can offer insight and interventions for managing sundowning symptoms, and each can bring a distinct perspective and skill set for the management of negative symptoms. For example, medical doctors and psychiatrists can assess the appropriateness of medication to help with symptoms and advise the best times of day to take it. Clinical dieticians and nutritionists can help make mealtimes more comfortable, boost nutrition, and address appetite issues that may contribute to sundowning.
Treatments for Sundowner’s Syndrome
If your loved one struggles with symptoms of Sundowner’s Syndrome despite trying several coping methods, treatment may be helpful. Therapy and medication can effectively reduce symptoms and improve quality of life.
Therapy
There are therapy options that may be appropriate for people with Alzheimer’s disease or other dementia who experience sundowning. The goal of therapy for people with this type of cognitive impairment is to provide support and symptom reduction. It is different from traditional psychotherapy because of the limitations which result from impaired memory, thinking, and communication.
Some psychotherapy techniques that can help with Sundowner’s syndrome include:
- Reminiscence Therapy: Reminiscence therapy involves talking about memories or experiences from the past. It targets certain parts of the brain which can store long-term memories and uses all of the senses. A therapist could use a photograph or song to prompt discussion.
- Art Therapy: Art Therapy promotes expression and communication, which can slow the progression of cognitive decline linked with Alzheimer’s disease and other types of dementia.
- Music Therapy: Music therapy uses music-based experiences and interactions to improve mood and lower anxiety.
- Mindfulness-Based Cognitive Therapy (MBCT): Mindfulness-based cognitive therapy involves directing awareness to the present moment, and it can be helpful in relieving psychological distress.
Seeking therapy for Sundowner’s syndrome requires a careful look at the options in your area. Using this therapist directory can help you find a professional who understands the older adult population and how to treat dementia conditions such as Sundowner’s syndrome.
Medication for Sundowner’s Syndrome
Sometimes, medication can help with symptoms of sundowning. 2 However, as with all medication, it is important to weigh the risks and benefits. Pharmaceutical treatment for sundowning may be only marginally beneficial, and there are potential adverse effects that may occur from use.17
Medications that can be used to reduce symptoms of sundowner’s syndrome:
- Antipsychotics: Antipsychotics are commonly prescribed for agitation and psychosis in patients with Alzheimer’s disease or other dementia.
- Acetylcholinesterase inhibitors: Acetylcholinesterase inhibitors are used to slow cognitive decline.
- Melatonin: Melatonin affects sleep regulation, mood, and behavior. It can decrease agitation.8
- Antidepressants: Some antidepressants can be used to manage sleep disturbances because of their sedative effects.
Final Thoughts
If your loved one is struggling with sundowner’s syndrome, remember you’re not alone. Although there is no prevention or cure for sundowner’s syndrome, there are strategies that can help you to manage and reduce the severity of symptoms. Speaking with a therapist specializing in older adults or caregiving can improve how you feel.
Sundowner’s Syndrome Infographics
