Sundowning

Sundowning

Sundowning is a psychological phenomenon that causes increased confusion and restlessness in patients with some form of dementia, particularly those with Alzheimer's disease or mixed dementia. The term "sundowning" was coined due to the timing of the patient's confusion, which usually occurs in the evening or while the sun is setting. Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia. Patients are generally able to understand that this behavioral pattern is abnormal. Sundowning seems to subside with the progression of a patient's dementia. Research shows that 20–45% of Alzheimer's patients will experience some sort of sundowning confusion.

Honeymoon Bay Sunset

Symptoms

Symptoms of sundowning are not limited to but may include:

• Increased general confusion as natural light begins to fade and increased shadows appear.
• Agitation and mood swings. Patients may become frustrated with their own confusion as well as aggravated by noise. Yelling and becoming increasingly upset with their caregiver is not uncommon.
• Mental and physical fatigue increase with the setting of the sun. This fatigue can play a role in the patient's irritability.
• Tremors may increase and become uncontrollable.
• A patient may experience an increase in restlessness while trying to sleep. Restlessness can often lead to pacing and/or wandering which can be potentially harmful for a patient in a confused state.

Causes

While the specific causes of sundowning have not been empirically proven, some evidence suggests that circadian rhythm disruption enhances sundowning behaviors.

Disturbances in circadian rhythms

It is thought that with the development of plaques and tangles associated with Alzheimer's disease, there might be a disruption within the suprachiasmatic nucleus (SCN). The suprachiasmatic nucleus is associated with regulating our sleep patterns by maintaining our circadian rhythms. These rhythms are also strongly associated with external light and dark cues. A disruption within the SCN would seem to be an area that could cause the types of confusion paired with sundowning. However, finding evidence for this is difficult due to the need for an autopsy to correctly diagnose Alzheimer's in a patient. Once a patient has died, they have already surpassed the level of dementia and brain damage that would be associated with sundowning. This theory is supported by the effectiveness of melatonin, a natural hormone, to decrease behavioral symptoms associated with sundowning.

Treatment

Treatment for sundowning may include:

• A consistent sleeping schedule and daily routine that the patient is comfortable with can reduce confusion and agitation.
• Incorporating increased daily activity into the patient's schedule can help promote an earlier bedtime and need for sleep.
• Checking for over-napping. Patients may wish to take naps during the day, but unintentionally getting too much sleep will affect nighttime sleep. Physical activity is a treatment for Alzheimer's and a way to encourage night sleep.
• Limiting caffeine intake, particularly at night when sleep is needed.
• Letting patients choose their own sleeping arrangements each night, wherever they feel most comfortable sleeping, as well as allowing for a dim light to occupy the room to alleviate confusion associated with an unfamiliar place.
• Some evidence supports the use of melatonin to induce sleep.

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