Sundowning Syndrome: Caregiver’s Guide

July 16th, 2014

Perhaps you’ve never heard of sundown syndrome. I hadn’t either, until my father began to fall in the evenings and at night. I noticed that he didn’t fall in the mornings and that he reached the height of his agitation at the end of the day.

My father’s primary care physician advised that I watch for symptoms of “sundown syndrome.” Also called “sundowner syndrome” or “sundowning,” this is when symptoms that accompany dementia or Alzheimer’s disease occur in a patient as the sun starts sinking in the sky. While sundowner’s is prevalent among those with dementia, it is a separate condition. It sometimes appears in those who have not been diagnosed with dementia or Alzheimer’s or who may have been hiding those conditions.

What Is Sundown Syndrome?

Sundown syndrome is a description rather than a diagnosis. You won’t find it in the latest Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Still, it’s real enough for the National Institutes of Health and many other medical organizations and associations to acknowledge its existence. You’ll find many references to it in clinical literature. That said, the medical community has not yet arrived at an exact clinical definition, because there’s more disagreement than agreement on various aspects of the syndrome.

Symptoms and Causes of Sundown Syndrome

A paper published by the Korean Neuropsychiatric Association in Psychiatry Investigation states that “[Sundown syndrome] is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition.” The paper found that sundowner’s is one reason why so many seniors are placed in nursing and assisted living facilities.

Symptoms that occur at the end of the day and lead into night can include one or more of the following:

  • Agitation
  • Confusion
  • Anxiety
  • Drowsiness
  • Aggression
  • Ataxia. The Mayo Clinic defines ataxia is as “a lack of muscle control during voluntary movements, such as walking or picking up objects. A sign of an underlying condition, ataxia can affect movement, speech, eye movement, and swallowing.”

If a senior with sundown syndrome displays these symptoms during the day, the symptoms may become exaggerated at the end of the day.

A Place for Mom notes: “Some researchers believe the flurry of activity toward the end of the day as the facility’s staff changes shifts may lead to anxiety and confusion.” Fatigue and low light at the end of the day may play a role in late-day disorientation, as well as an imbalance in the body’s circadian rhythm. With fewer daylight hours in the winter, seasonal affective disorder (SAD) can exacerbate the condition. There’s little agreement in the medical community on the cause, and it could manifest as any combination of these conditions. It can also occur when the senior is in an unfamiliar environment, such as a hospital.

Coping with Sundown Syndrome

A Place for Mom offers the following suggestions:

  • Establish a routine.
  • Eliminate naps.
  • Let in natural light and add full-spectrum lighting.
  • Reduce noise levels, particularly close to the senior’s bedroom.
  • Talk with your loved one’s doctor about medication and supplementation. The Korean Neuropsychiatric Association study found that in addition to behavioral modification, certain treatment options may help.

If your senior’s doctor doesn’t acknowledge sundown syndrome, find another doctor. It’s a real phenomenon, and you are not imagining the symptoms. Trust your judgment as a caregiver, and take care of yourself and your senior loved one.