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What exactly is sundowning?  The definition of sundowning, according to the International Psychogeriatric Association, is “the occurrence and exacerbation of BPSD in the afternoon and evening”.  (The IPA Complete Guides to BPSD – Specialists Guide, Module 2: Clinical Issues, 2.13)    These BPSD can include anxiety, agitation, aggression, pacing, wandering, resistance to care, screaming, yelling, and hallucinations. (Canevelli et al, 2016). Beyond this expensive list, there is a great discrepancy in definition.   Regardless, there are currently no randomized, controlled trials investigating treatments, medications, or strategies regarding the phenomenon of sundowning and no standardized ways to assess or screen for sundowning.  A wide variety of factors may precipitate, trigger, or accentuate its occurrence.

 

Sundowning can occur in elders who do not have dementia.  It happens more often in fall and winter is known to be linked to the body’s natural circadian rhythms.  These day and night fluctuations appear to be regulated in the hypothalamus.  Damage to this area of the brain can cause changes in blood glucose levels, blood pressure, and body temperature.  Levels of cortisol increase in stressful situation and have been associated with sundowning.  Worsening of symptoms and initial emergence of sundowning can occur with lessened light exposure, some medications, hunger, absence of a daily routine, and afternoon fatigue (Canevelli et al, 2016).  Sundowning is also associated with sleep disturbance.   Increased prevalence in behavioral issues in early evening has been linked to changes in sleep patterns (partial arousal from REM sleep, sleep apnea, seasonal circadian changes in sleep patterns), and environmental changes in light or temperature that reset the internal body clock (Reynolds, 1991). 

 

Melatonin, which decreases in aging and is even more reduced in those with AD (Canevelli et al, 2016), plays a role in sundowning.  This makes sense as the release of melatonin also appears to occur from an area within the hypothalamus.  Melatonin studies in the general population examine its effects on sleep quality and overall daytime behavior and functioning.  The results of these studies show some effect on decreasing or eliminating sundowning symptoms.  The use of melatonin supplements has shown a significant decrease in sundown agitation over a period as short as three weeks in several studies (Table 2, p 5 of Canevelli et al, 2016). 

Normal sleep changes that occur with aging include reduced REM and slow wave sleep, increased nighttime wakefulness and daytime napping.  These are exaggerated in dementia and problems can increase with the progression of the disease (Vitiello and Prinz, 1989). Restless leg syndrome, loneliness, lack of stimulation, and diminished physical and social cues may also contribute to sleep difficulties and sundowning.  No one causative factor, however, has been specifically linked to sundowning. 

 

Institutional carers report that sundowning is extremely disruptive.   What can be done to address this phenomenon?  As always, non-pharmacological interventions should be attempted first. 

 

Increasing the amount of sunlight exposure may be helpful. 

Exercise or plan more challenging activities during the day.  (Khachiyants et al, 2011) (Desai & Grossberg, 2001)

 

• Minimize unnecessary noise in the early afternoon, including visitors, loudspeakers, or conversation, banging dishes, etc.  

• Eliminate or restrict excessive caffeine, sugar, or junk food consumption early in the day.  

• Discourage afternoon napping by providing structured, quiet activity such as taking a walk, listening to music, working on a puzzle, or playing a card game.

• Draw curtains to eliminate confusing shadows and turn on lights before sunset. Provide a nightlight in the person’s room, bathroom, hallway, etc. 

• Provide a stable routine/schedule.  This includes a daily bedtime routine. 

• Bedtime routine should involve a reduction in sound—the TV should be turned down or off.  Soothing music may be played.  Reduce light, but not to the point that darkness provokes anxiety in some clients.  A familiar scent may be used as a trigger that bedtime is near.  A pleasant activity—reading a book, cradling a stuffed animal or doll, coloring, folding towels, etc. can be included in the routine.  (https://dailycaring.com/7-more-ways-to-manage-dementia-sundowning-symptoms)  Most important in this ritual:  the same steps should be used prior to bedtime each evening.  It will cue the IWD and help them prepare for retiring.  This by itself can reduce anxiety and agitation.  If possible, change into bedclothes prior to these steps as changing can be very stressful to some with dementia (and might be related to body temperature regulation).       

• Avoid unnecessary stimulation in the evening.

• Decrease nighttime disruptions (Desai & Grossberg, 2001).

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Pharmacological interventions have not been studied specifically for sundowning.  OTC sleeping pills are not recommended and can be hazardous to health as many have anticholinergic effects and patients can develop tolerance (Desai & Grossberg, 2001). 

 

Sources:

Canevelli M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, Bruno G.  Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.  Front Med. 2016;3(73):1-7.

 

Desai A and Grossberg G. Recognition and management of behavioral disturbances in dementia.  J Clin Psychiatry 2001;3(3):93-109.

 

Khachiyants N, Trinkle D, Son SJ, Kim KY.  Sundown syndrome in persons with dementia: an update.  Psychiatry Investig. 2011;(8(4):275-87

 

Reynolds CF. Sleep disorders.  In:  Sadavoy J, Lazuarus LW, Jarvik LF, eds.   Comprehensive Review of Geriatric Psychiatry.   Washington, DC:  American Psychiatric Press; 1991:403-418.