What is Sundowning?

Persons with acute or chronic confusion become more confused, restless, and insecure late in the day and especially after dark. This happens whether they are living at home or in a facility, but most often, it is worse after a move or change in the patient’s routines. She may become more demanding, restless, upset, suspicious, disoriented and even see, hear or believe things that aren’t real, especially at night.

What Causes Sundowning?

No one is sure what causes Sundowning, although it seems to result from brain diseases - whether acute(treatable) or chronic (irreversible). Alzheimer’s patients tire more easily, even from minimal demands on their thinking ability, and they become more restless and hard to manage when tired. It’s as if their ability to cope with a confusing environment has been used up. All stimuli, because the patient can’t sort out sounds or activities, has an add-on stressful effect.

Sundowning may relate to lack of sensory stimulation after dark. At night they are fewer cues in the environment, with the dim light and absence of noises from routine daytime activity. Those routine noises are a major source of security for Ad patients, many of whom sleep well only during the day and in chairs close to nursing stations. A Sundowning, restless patient also may be hungry, uncomfortable(too tight clothes?), in pain or needing to urinate, all of which she can only express through restlessness. AD patients may regress to childlike behavior and thinking patterns as the disease progresses. As she understands less about what’s happening to her, she becomes more frightened of things like the dark or being left alone. She becomes more frantic in trying to restore her sense of familiarity or security. Many families caring for AD patients say the patients become more anxious late in the day about "going home, finding my mother" (all those things indicating a need for security and protection).

Keep the patient active in the morning and encourage her to rest after lunch. If fatigues is making the Sundowning worse, an early afternoon rest might restore her composure.

Don’t physically restrain her. That tends to make AS patients worse- she may scream, squirm , or become even angrier and more resistant.
Instead, let her pace back and forth where she can be observed. If one can, fall in step with her and offer her a brief moment of companionship and distraction from her mumblings. Taking her outdoors for a walk would also help-fresh air seems to clear the minds and reduce restlessness in Ad patients. When you pass her, reach out and smile, pat her or say, "It’s good to see you."

Don’t argue or condemn her for "wanting to die." It’s probably a phrase that got stuck in her mind and she can’t help repeating it. She’s looking for attention. Reassurance is the best response. "We love you and we’ll help you."

Give her something to fiddle with in her hands to distract her from pulling on or tearing her cloths. Perhaps she could be asked to hold something "for you" which keeps her hands too busy to fiddle with anything else. If she pulls her skirt up regularly in public, get her some pull on slacks.

Some patients are comforted by stuffed animals, real animals, hearing familiar tunes, or an opportunity to do a favorite pastime, i.e. window shopping at the mall looking at cars on used car lots or whatever.

Don’t ask her to make decisions, or ask her what’s wrong. If you make decisions, she’s relieved of that taxing responsibility.

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