Tips on Sundowning in Alzheimer's Patients

by Edyth Ann Knox, ElderCare Online

Experts say that all types of agitating behaviors are forms of communication. Your loved one is trying to tell you something even though the disease has robbed them of other ways (i.e., talking) of telling you. Perhaps your loved one is frightened or fatigued and does not know how to express it in words. Some experts believe that agitation behavior is "the inability the deal with stress."

"Sundowning" is a state of increased agitation, activity and negative behaviors which happen late in the day through the evening hours. It used to be thought that sundowning was caused by the lowering light and shorter days. However, research now indicates that being overly tired may have more to do with sundowning. Here are some suggestions on how to minimize the negative behaviors associated with sundowning:

1) Make sure that your Loved One is well-rested: I know that this is easier said then done. It does help though if you can get your Loved One to take a nap just before their normal period of sundowning. If they can not or will not nap, an hour quiet time (reduced stimulation and activity) will work. I used to sit Milly down in her recliner, turn off the TV, turn on some soft music and then I would sit next to her doing a quiet activity such as cross stitch or crocheting. We sat quietly for an hour and talked or just relaxed. I found that she rested much better and would even dose off if I took a nap/break with her. I was more relaxed also!

2) Limit outings and activities to the morning hours: Generally the individual with Alzheimer’s Disease is better able to tolerate outings, activities and increased stimulus during the earlier part of the day. Plan your trips to the grocery store, involvement with kids, visits to day care and so forth during the earlier part of the day. This should be followed with a time of decreased stimulus and quiet time to allow your Loved One to wind down and relax.

3) Decrease the length and amount of stimulus: Even during the earlier part of the day the individual with Alzheimer’s Disease can only tolerate so much stimulation and commotion. Take steps to eliminate over-stimulation such as television, children, any noise making item, quick movements and many things going on at one time. Sometimes excessive stimulation can not be avoided. When that happens, allow your Loved One to have a quiet area to retreat to.

4) Identify and minimize physical discomfort: Other types of physical discomfort can also play a part in sundowning. Hunger, being wet or soiled, feeling cold/hot and other sources of discomfort can increase agitation, especially in the late afternoon and early evening. Light snacking during the day can be helpful. Apples and other fruits can help replace lost energy – even if your Loved One is pacing back and forth, that does not mean they have an endless supply of energy. Make sure that your Loved One’s personal needs are attended to and that the climate is at a comfortable level.

5) Identify and treat medical ailments: Many ailments can contribute to sundowning and agitation. Arthritis can be one of the most common causes. An over-the-counter painkiller as recommended by your Loved One’s physician before the time of sundowning might be of great benefit. Urinary Tract Infections(UTI), flus/colds, asthma, allergies and other conditions are all medical ailments that can contribute to sundowning. It is always a good idea that when your Loved One first begins to exhibit sundowning or when sundowning becomes common to take them to the doctor to make sure that there is nothing ailing her.

6) Be observant to possible causes: Many times there are triggers to agitation leading to sundowning. One time, we bought our kids a video game so that they had something to play with. We found that the noise from the video game would set Milly off as soon as they started playing. We placed the video game in a room that was out of the way and she could not hear it and it really helped decrease the sundowning. Providing the kids with a separate private area helped both with them as well. Mirrors also became a trigger as well as a picture of Milly's daughter. Watching to see what is going on, what events are happening and who is present prior to sundowning can help reveal some causes (and solutions).

Sometimes no matter what we do sundowning will happen. If we can not prevent it we can help lessen it or at least make it less unpleasant for our Loved Ones and those around them.

7) Provide a private "time out" space for your Loved One: Early on, we made sure that the kids and us all had private off-limits areas but it became obvious Milly had to have hers too. Milly did retreat to her room if things became too much so it became her natural private area. Her room was off limits to kids and general traffic. I was the only one who did enter there and even then I limited it to certain times. There were times that Milly had to get away from us as much as we had to get away from her, which brings me to the next step.

8) Clear the house: There were times that nothing we did would ease Milly during one of her most aggressive sundowning episodes. I would often send my husband and the kids to the movies or to some outing, turn off unneeded lights, turn off the TV/radios and either go to my quiet corner or go sit outside for a moment. I always made sure the house was safe for Milly; I never did leave her; and I was always close by. I would then change my hair by tying it up if it was down, letting it down if it was up, change my blouse and re-enter the general living area where Milly was turning up the lights in the room. Milly most often would see me as a friendly face and greet me happily.

9) Check with the doctor: If sundowning is particularly troublesome, you may need some extra help with prescription medication. Talk with the doctor to let him know of the behaviors, time of day and how your Loved One is behaving before sundowning. He may be able to help you by prescribing a medication to help ease the symptoms. Medication is a last resort and may take several attempts with different drugs and doses to find the right one that will work for your Loved One. If the medication does not help, do not become discouraged, relay the information to the doctor and he may either adjust the dosing or change the medication. Always ask the doctor to start with the smallest dose possible. Medication is only meant to take the "edge" off the behavior, it is not meant to make your Loved One dopey or groggy, though some medications may make your Loved One sleepy the first few days.

10) Keep things simple: Keep the surroundings as simple as possible. Be sure your Loved One’s walking paths are clear from clutter and obstacles. Low furniture such as coffee tables and foot stools can make it difficult for your Loved One and a become a source of frustration. Keep knickknacks to a minimum and the tops of tables, television shelves and other surfaces as clear as possible. Mirrors and pictures can often become unfriendly visitors that the individual with Alzheimer’s Disease can not understand. Complicated, noisy appliances are also frustrating to them. Avoid changing things once you have things simplified. Changes of any kind are extremely frustrating.

Recommended Books:
Alzheimer's Early Stages: First Steps in Caring and Treatment by Daniel Kuhn et al.
The 36-Hour Day : A Family Guide to Caring for Persons With Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life by Nancy L. Mace et al.
There's Still a Person in There : The Complete Guide to Treating and Coping With Alzheimer's by Michael Castleman et al.

© 2001 Prism Innovations, Inc. All Rights Reserved.

Edyth Ann Knox was the 24/7 caregiver for her mother-in-law, Milly, for over a decade. As an early adopter of online communities for caregivers, she has earned the respect and friendship of numerous other wired caregivers. She brings years of experience as a practical caregiver, wise mentor and easy-to-laugh friend to new and experienced caregivers alike. She publishes a personal website at http://alzheimer-cg.homepage.com/index.html.  Edyth Ann is also a Contributing Editor to ElderCare Online at http://www.ec-online.net, an online community for people caring for aging loved ones, especially those coping with Alzheimer's Disease. ElderCare Online offers a comprehensive library of practical articles, educational modules and supportive discussion groups.

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