Sundowner’s Syndrome—Causes, Symptoms, Suggestions

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Sundowner’s Syndrome, Sundowning or nocturnal delirium can be defined as a marked increase in confusion, disorientation and possibly agitation in an elderly or severely cognitively impaired subject at sunset or when daylight is reduced.

Sundowner’s syndromes can also be considered a mood disorder or even a sleep disorder. Sufferers experience periods of extreme agitation and confusion during the late afternoon or early evening hours, leading to irritability towards caregivers. It was once believed that sundowner’s syndrome was a result of missed day/night light cues, hence the sudden onset at sundown. Current research points towards more organic causes such as drug interactions or stress associated with lower cognitive function.

The symptoms of sundowning are not unlike those of delirium except that sundowning is associated with the cases that suddenly occur in the late afternoons or early evenings. Assessment for sundowning therefore is the same as for delirium.

The triggers for sundowning seem to vary from individual to individual but they can be traced to psychological, environmental, and physiological factors. Traumatic psychological events can play a significant role in dementia patients becoming confused. Events like loss of a significant other, functioning, independence in the recent few months or an experience of a crisis or a recent move could be traumatic enough that the patient becomes confused or agitated. Noise in the environment or frustration from getting to the bathroom could trigger some of the symptoms associated with sundowning.

Loss of visual acuity in particular which may follow as a product of aging and/or a neurologically compromised brain, may with inadequate lighting fail to allow the patient to orient themselves and thus confusion and possibly agitation will follow. In such a situation, the symptoms can be managed by having the patient in a well lit room especially in the late afternoons.

Dementia patients have impaired cognitive deficits and a non structured or irregular routine will lead to more confusion. Dementia patients may therefore benefit from a structured and consistent environment. Assessing the patient's environment for continuity of care including the times at which he or she receives meals, medications, as well as sleep will be of importance. Structure and routine create a feeling of safety and comfort, while being in familiar surroundings helps keep feelings of anxiety and confusion at bay.

Managing Sundowner’s Syndrome

There are no cures for sundowning but by identifying the underlying triggers, sundowning can be managed for dementia patients. In some cases, by treating underlying issues, the symptoms can be reversed.

What works for one individual may not work for another. Management of sundowning is therefore effective if the underlying triggers are first identified and effectiveness of various techniques is assessed to find an effective one.

According to the Alzheimer’s Foundation of America some of the techniques that are effective include the following:

  • Allow for light exposure in the early morning to help set internal clock.
  • Discourage day-time napping to regulate sleep cycle.
  • Encourage exercise throughout the day to expend excess energy.
  • Limit caffeine intake, particularly in the evening to avoid potential Sundowner’s symptoms.
  • Plan activities for the daytime so there is sufficient time to adjust to night.
  • Have a quiet nighttime activity ready and a private space for relaxing.
  • Consider purchasing a bedside commode. Leaving his or her bed to use the restroom can start the cycle all over again, making it hard to get back to sleep.
  • Schedule regular medical appointments to ensure he or she is not in any physical pain and to check for worsening Sundowner’s symptoms.
  • Take precautions to provide a safe space for him or her at night so that you can get a solid night’s rest, even if he or she needs to stay awake and wander.

No matter the situation, every case can benefit from a kinder and gentler approach. Dementia patients already have a deficit in cognitive functioning. When dementia patients become agitated, they are not just acting out. By talking to them in a softer tone and engaging them in a conversation to find out the triggers for the behavior, we can often alleviate the problem. Listening, patience and caring can go a long way in improving the quality of life of an Alzheimer’s patient.

While we are it, we need to make the environment safer for the patient. Removing unsafe objects, clutters and securing the patient’s environment can help prevent complications that can result from sundowning.

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