Individuals suffering from acute or chronic confusion become more confused, restless and insecure late in the day, especially after dark. This happens whether living at home or in a facility. Usually the confusion is worse after a move or change in routine. Sundowners become more demanding, upset, suspicious, disoriented; they see, hear, believe things that aren't real, and they may wander all night.

Many individuals with Alzheimer's disease act as if their biological clocks are "reset." These individuals stay up all night despite the pleas of the caregiver for them to go to bed, and will then continually doze off during the day. The reasons for these changes in the sleep-wake cycle are not known.

Here are some suggestions that may be worth trying:

1. Medications may influence the sleep-wake cycle. It may be appropriate for the attending physician to discontinue nonessential medications or change to an alternative medication which may not have as dramatic an effect on sleep.
2. Individuals in pain often cannot sleep. Persons with AD may have difficulty communicating their pain. A physical examination may identify some unexpected sources of pain. In unclear cases, a trial of an over the counter pain medication (e.g. tylenol) may be justified.
3. Many older people awaken many times at night to urinate and are unable to return to sleep. Sometimes using a bedside urinal or commode is less upsetting than a walk in the dark house to the bathroom. With less emotional upset, the diagnosed person may fall back to sleep more easily.
4. A light kept on all night may help orient persons with AD and may keep them from becoming agitated if they awaken and cannot identify their surroundings.
5. Be certain that the diagnosed person gets enough exercise during the day. Many people with AD have extraordinary needs to pace for hours. If possible, pacing should not be restricted. At the very least, one to two brisk walks during the day should be encouraged.
6. Try to keep the individual with AD from napping during the day. People who sleep all day are less likely to sleep at night.
7. Avoid coffee, soft drinks, and tea for several hours before bedtime. These beverages contain caffeine and may interfere with sleep.
8. Depressed people often have difficulty sleeping. Depression appropriate drug and other kinds of therapy may improve sleep. Many antidepressant drugs tend to make patients drowsy and are given before bed to help a person sleep.
9. Persons with AD will not sleep in their beds, but will readily fall asleep in a favorite chair or on a couch. Letting the patient sleep in a chair or on a couch is better than not sleeping at all.
10. Often the major problem in a family is not that the person with AD isn't sleeping at night, but that the caregiver is exhausted. It may be possible to make part of the house so safe that the person with AD can be up and pacing while his caregiver sleeps in a separate room. When sleeping problems are especially severe other family members may need to provide temporary supervision at night so that the primary caregiver can sleep.
11. The alteration in a sleep-wake cycle is often not permanent. Persons with AD may revert to earlier patterns or may sleep for increasing periods of time.
12. When other measures are tried and fail, a short trial of sleeping medication is reasonable. Unfortunately, such treatment often does not work. The diagnosed person may still not sleep at night and be even more confused during the day. Nonetheless, when families are desperate, a trial of sleeping pills may be indicated.
13. Major tranquilizers may sometimes help patients sleep. Judicious use of these drugs may "take the edge off" difficult behaviors and stabilize volatile home situations.

Proper management of sleep disorders may require the coordinated efforts of family members as well as physicians, social workers, nurses and other helping professionals. Some other suggestions are:

• plan activities of the day so that there is less to do in late afternoon
• schedule appointments and trips for the earlier part of the day
• play quiet music in the late afternoon instead of loud television
• try to make the patient feel secure and well-protected
• never restrain the patient unless absolutely necessary
• do not argue with the patient
• do not ask the patient to explain what is bothering him/her (he doesn't know and cannot tell you)
• if the patient is restless, try to get him/her interested in some quiet activity such as folding towels

Try to remember that the person with AD does not have control over his behavior; his annoying behavior is the inability of his brain to sort out a confusing environment.

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