Alzheimer’s Challenges at the End of the Day

Jeff D. Williamson, M.D., chief of gerontology and geriatric medicine at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
Jeff D. Williamson, M.D., chief of gerontology and geriatric medicine at Wake Forest Baptist Medical Center, Winston-Salem, N.C.

People with dementia often have certain problems when it gets dark at the end of the day and stays dark through the night. This problem is called “sundowning.” The problems that get worse include increased confusion, anxiety, agitation, and not being able to get to sleep and stay asleep.

“Sundowning is a very common problem for Alzheimer’s patients and, of course, for caregivers,” says Jeff D. Williamson, M.D., chief of gerontology and geriatric medicine at Wake Forest Baptist Medical Center in Winston-Salem, N.C. “It’s very challenging to manage.”

Sundowning Symptoms
As anyone who has cared for someone with Alzheimer’s disease (AD) knows, the patient will have good days and bad days. According to the National Institute on Aging (NIA), some of the personality changes that may intensify with sundowning late in the day or during the night include the following:

  • Getting upset, worried, and angry more easily
  • Acting depressed or not interested in things
  • Hiding things or believing other people are hiding things
  • Imagining things that aren’t there
  • Wandering away from home
  • Pacing a lot of the time
  • Showing unusual sexual behavior
  • Hitting you or other people
  • Misunderstanding what he or she sees or hears

Health-related problems other than AD can contribute to behavioral changes:

  • Illness or pain
  • New medications
  • Lack of sleep
  • Infections, constipation, hunger, or thirst
  • Poor eyesight or hearing
  • Alcohol abuse
  • Too much caffeine

Problems in their surroundings are also contributors for the caregiver to consider:

  • Being in a place he or she doesn’t know well.
  • Too much noise, such as TV, radio, or many people talking at once. Noise can cause confusion or frustration.
  • Stepping from one type of flooring to another. The change in texture or the way the floor looks may make the person think he or she needs to take a step down.
  • Misunderstanding signs. Some signs may cause confusion. For example, one person with AD thought a sign reading “Wet Floor” meant he should urinate on the floor.
  • Mirrors. Someone with AD may think that a mirror image is another person in the room.
Sundown can present challenges for loved ones with Alzheimer’s.
Sundown can present challenges for loved ones with Alzheimer’s.

Almost all Alzheimer’s patients will have some manifestation of sundowning, notes Dr. Williamson. “So, it’s important that caregivers understand that sundowning is not caused by something they did or didn’t do,” he says. “But there are some strategies to get through this.”

According to Dr. Williamson and NIA research, there are certain behavioral strategies that can help caregivers with sundowning:

  • Having a daily routine may help. Calmly reassuring and giving cues to orient the person who has dementia is also helpful in the evening and closer to bedtime. Try to keep them going to bed at the same time every night.
  • Doing calm activities at the end of the day and before bedtime may help the person with dementia sleep better at night. If they are active during the day, these calm activities can make them tired and more able to sleep.
  • Avoid loud noises and activity in the home at night, so the person does not wake up once they are asleep.
  • Do NOT restrain a person with dementia when they are in bed. If you are using a hospital bed that has guardrails in the home, putting the rails up may help keep the person from wandering at night.
  • Always talk with your healthcare provider before giving the patient store-bought sleep medicines. Many sleep aids can make confusion worse.

Take the person to places where they can move around and exercise during the day, such as shopping malls. If the person who has dementia has an angry outburst, try not to touch or restrain them. Touch or restrain them only if you need to for safety. Instead, try to stay calm and distract them during outbursts. Do not take their behavior personally.

When to Call the Doctor
In addition to behavioral steps that canhelp with sundowning, there are medication issues that can be a factor, according to Dr. Williamson.

“Depression is often an underrecognized part of sundowning,” he says, “And the patient may not be able to articulate it. There are antidepressants and anti-anxiety medicines that a physician may recommend. So, it’s important that you talk to your healthcare provider, especially when you have questions about medications.”

On the other hand, sometimes currently prescribed medicines or over-the-counter products may be creating or contributing to sundowning symptoms. Talk to the patient’s doctor any time you think that medicines may be the cause of changes in the behavior of someone who has dementia, Dr. Williamson recommends.

When Caregivers Need Help
Children of an Alzheimer’s patient often wonder how they can help the primary caregiver—especially when the caregiver is a mother or father. This is especially important when an Alzheimer’s patient is showing signs of sundowning, which is even more stressful on caregivers.

“I find a lot of caregivers are embarrassed to ask for help,” says Dr. Williamson. “It’s a fork in the road for some families. Children can offer to help by volunteering to stay with the patient for short periods while the primary caregiver gets a break. Church members and social club members who know the patient can do that, as well.

“And there are times when a person can be a better caregiver with the person they love by regularly taking the patient to an Alzheimer’s care center while they take a break,” says Dr. Williamson. “Families shouldn’t feel guilty about these things. Caregivers should realize that this is a good thing.”