Sundowning: Basic Strategies for the Caregiver

In January 2021, my in-laws were packing to move so they could be closer to us in Texas. They’d lived in their house since 2003, and now they were downsizing into an apartment in an independent living community. Chris, Faith and I had gone to Memphis to help with the packing. We knew my father-in-law had been diagnosed with Alzheimer’s nearly a year before, so we weren’t surprised when, in his confusion, he gave us a little push-back as we sorted through their household items.

What did surprise us was the degree of agitation he began to display every afternoon anywhere between one and three o’clock. Up to that time every day, he was usually very cooperative, putting boxes together, even reinforcing their bottoms so the heavier items could be secure; but every single day as the afternoon wore on, he became increasingly irritable and grouchy. He would angrily spout off about money, vehemently arguing about the value of a particular item, and he would move around the house with a scowl on his face that made you want to get out of his way.

One of the worst times was when Chris was taking a work call in a back bedroom of their house. His dad burst through the door yelling about the approximate value of a set of tools he believed had been stolen. I was desperately trying to coax him out of the room as Chris was explaining to the people on the call what was happening.

And just what, exactly, was happening? What was happening was that my father-in-law was Sundowning, a term which, according to the Mayo Clinic, refers to “a state of confusion occurring in the late afternoon and spanning into the night.” It isn’t a disease in and of itself, but rather a group of symptoms that affect patients with Alzheimer’s.

The exact cause is unknown, but it is generally reported that one in five Alzheimer’s patients will experience Sundowning at some point. The National Institute on Aging suggests a possible cause may be tied to the changes in the brain—a natural result of Alzheimer’s Disease—which can affect a person’s “biological clock,” and this can lead to problems with the patient’s sleep-wake cycles. While agitation is one of the typical (one might even say “garden variety”) dementia symptoms, the level of agitation and other symptoms that accompany Sundowning seem to be kicked up a notch. The patient may be:

• Anxious
• Restless
• Irritable
• Confused
• Disoriented
• Demanding
• Suspicious
• Yelling
• Pacing
• Hallucinating
• Or experiencing mood swings

Being able to recognize Sundowning is one thing, but determining a reasonable course of action is what caregivers really want; what can be done about it?

Turn Lamps on Early—Before the Sun Goes Down

As evening approaches, the house slowly begins to get dark. Before you know it, you can barely see around the room. This gradual, creeping darkness, and the shadowy spaces that are created by it, can be very unsettling for the Alzheimer’s patient. Some research suggests that turning on the lights before the room starts getting dark may reduce the agitation and confusion of the person who is Sundowning.

Keep the Afternoon and Evening Activities to a Minimum

Late afternoon and early evening will often find people coming in from work and scurrying around to fix dinner. If the caregiver is also a mom or dad to teens, the house may feel like one big revolving door as kids come and go in the haze of homework and sporting events. This level of activity may contribute to increased agitation in the Alzheimer’s patient. If possible, let the caregiver or another family member take the patient for a short walk. This can allow their nervous energy to be spent physically, and it gives the other family members time to complete their activities.

Consider Limiting Caffeine, Tobacco and Alcohol

If possible, try to set a time shortly after lunch to serve as a “cut-off point” for the use of these products. Both caffeine and tobacco are considered stimulants, and while alcohol is primarily a depressant, upon its initial intake it can also have some stimulant effects. Confining the use of these products to the earlier hours of the day may help the Alzheimer’s patient reduce the jittery or “wired” feelings they experience as the evening approaches.

Engage The Mind

If a Sundowning episode begins, calmly seek to engage the patient’s mind with an activity that is soothing to them. They might enjoy listening to a favorite piece of music, or they may calm down when looking at a photo album. You might also try to put on a favorite movie they’ve enjoyed in the past.

It may take several tries to find the right thing to settle the Alzheimer’s patient down once the agitation has started, but positive re-direction can help restore a peaceful, orderly environment. It’ll be a win for both the patient and the caregiver.