“But losing everything is like the sun going down on me.” –Elton John and Bernie Taupin
Elton John didn’t record the song “Don’t Let the Sun Go Down on Me” with sundowning in mind, but this last line of the chorus is especially poignant.
What is sundowning, or sundowner’s syndrome? First, what it is not: it is not a disease or diagnosis unto itself. It is a constellation of symptoms that may occur in patients with a diagnosis of dementia, such as Alzheimer’s disease, in the late afternoon and into the evening.
Those symptoms might include: confusion, agitation, anxiety, wandering, or pacing.
I first learned of sundowning while a medical student doing a surgery rotation. Our team was following a woman in her eighties who was becoming increasingly agitated while in the intensive care unit (ICU), especially in the evenings. Her nurses told the team that they believed the patient was exhibiting sundowning. I was given the task of researching this topic and presenting my findings to the team.
My research was essentially what we know today, defined above. For our patient, who had an underlying diagnosis of dementia, her stay in the ICU triggered her confusion and combativeness. The continuous activity, noise, and light that sometimes necessarily accompany the ICU, had disrupted her natural sleep-wake cycle. Patients without a form of dementia can sometimes exhibit sundowning when confined to the ICU for long periods. Patients with dementia, who already have an altered sensorium, are even more affected.
Though sundowning can occur in an ICU, it most often occurs in the home of patients with Alzheimer’s disease or other dementias. The medical community is not completely sure why this happens, but it may be due to disturbed bio-rhythms. The internal clock that tells us when to be wakeful and when it is time to sleep seems to be adversely affected in dementia syndromes, throwing off the normal wake-sleep cycle.
If a person naps during the day, or is not physically active, or does not eat at regular intervals, an already disordered internal clock can go haywire.
(However, if the onset of sundowning comes on suddenly, it may be a sign of a urinary tract infection or another acute illness.)
So how can a caregiver combat sundowning in their loved one? First, it’s important to establish a routine for waking, eating, and sleeping. Try to avoid naps. Avoid caffeine ingestion in the afternoon. Make sure there is some physical and mental stimulation throughout the day. These are all commonplace ideas that we should all adhere to, I know, but it really is important to have this routine for your loved one.
As late afternoon approaches, and natural light wanes in their homes, some people like to let the evening settle into darkness. One of the best ways to combat sundowning is to keep the lights bright inside the house at this time. The long shadows cast during this time of day can be confusing to your loved one as they try to decipher what it is they are seeing. Keeping the lights on minimizes shadows.
In a hospital setting, ask the staff to keep nighttime disruptions to a minimum, and adhere to your loved one’s home routine as much as possible.
There are medications that can be used to calm an agitated patient if non-medical measures are not working. They are fraught with complications, though, and should not be employed lightly. A good neurologist or geriatric psychiatrist will know the best pharmaceutical approach.
Good night!