Sundown Syndrome in the Elderly

Sundown Syndrome is not a new phenomenon. Carers have noted that the symptoms of dementia or Alzheimer’s disease seem to get worse as the day progresses. Evening shift staff in care homes have reported that the degree of agitation and confusion amongst patients is notably higher after sunset, giving rise to the name Sundown Syndrome or Sundowning.

The early signs of Sundown Syndrome

The earliest signs of the onset of this condition can be subtle and difficult to recognise for those new to Sundown Syndrome. These include paranoid delusions of being criticised or judged. For example, the sufferer may start to feel they are being watched and that their movements are known to neighbours.

As the condition progresses, they may become more confused, becoming more agitated towards the end of the day. At its worst, the sufferer may experience hallucinations - possibly caused by the effects of chemical imbalances in the brain affecting the centres that handle visual and auditory processing.

The hallucinations can be very realistic, and sufferers may be convinced that they have had visitors or that people are shouting at them.

Another distressing symptom is confusion of the diurnal / nocturnal rhythms, i.e. not knowing whether it is night or day. The sufferer may decide to get up in the middle of the night in order to go for a walk. Such nocturnal wandering is one of the main reasons that is cited for sufferers being admitted into care homes.

Causes of Sundown Syndrome

The medical community is divided on what causes Sundown Syndrome. Some believe that it is the cumulative effect of sensory stimulation during the day and others believe that it could be connected with fatigue or stress. Others suggest that it is hormonally related and another theory is that it is due to anxiety caused by reduced ability to see as well in the dark.

Another piece of research suggests that it may be linked to disturbance in the day/night rhythms caused by altered patterns of sleep and wakefulness. They advise that using a full spectrum light bulb (e.g. 2000 lux) at a distance of approximately one metre from the sufferer first thing in the morning for half an hour can help to reset the body’s clock.

Hydration is Important

Keeping the body hydrated is very important. Many elderly people strictly control the amount that they drink because they don't want to have to get up in the night. Becoming dehydrated effects the brain and is more likely to bring on an attack of Sundown Syndrome. It is important to encourage the sufferer to have regular drinks throughout the day.

Choice of drinks is important too. Water is best as it hydrates correctly, whereas fizzy drinks containing E numbers and artificial sweeteners may not have the desired effect.

Care of Sundown Syndrome

The following are some suggestions that can help minimise the symptoms:

• Reassure and keep the sufferer calm
• Warm and soothing drinks (warm milk, chamomile tea) at evening time
• Avoid over-tiredness
• Frequent and regular naps and rest periods
• Close the drapes before sunset
• Minimise stress
• Explain that the things they see/hear are just hallucinations and can’t harm them

REFERENCES

M. L. McGonigal-Kenney and D. Schutte. "Non-pharmacologic management of agitated behaviors in persons with Alzheimer disease and other chronic dementing illnesses." University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core, National Guideline Clearinghouse, 2004.

Teicher MH et al. The phototherapy light vision: more than meets the eye. Am J Psychiatry 1995;1528,1197-202.

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