Understanding Sundowning

On today's blog post, we will be talking about a commonly brought up and asked about topic— sundowning, also known as Sundowning Syndrome.  You may also hear people refer to it as Sundowners. Now, this will be a two part blog. In this first part, we will be defining sundowning and its potential contributing factors.


I personally believe that to best respond to sundowning, you have to have a basic foundational knowledge regarding why it may be happening to begin with. That will give you a good reference point for where to start. In the second part of the blog, we will talk about practical strategies that you can do and implement to decrease behaviors that may be associated with sundowning. Though it may be tempting to just wait or skip ahead to the strategies, I really do think that you will find this blog post interesting and helpful.


So, if you're ready, let's go ahead and get started. I want to first start by giving you a quick example of sundowning that was shared by a caregiver. OK, so it says, "My mom is very alert in the day. But as night comes, she starts with the frustration, crying, anger, talking to herself for very long periods of time. And then, in the middle of the night seeing things. I am so tired I don't know what to do."


Now, can any of you guys relate to the situation that this caregiver is going through? I'm sure many of you can or at least have a unique situation of your own going on. So, what exactly is sundowning? The good thing about the name is that it kind of defines itself. Essentially what sundowning is, is the exacerbation of behavioral symptoms that worsens in the afternoon or evening hours. So basically, as the sun goes down — sun.....downing. It's most often seen in elderly people with or without dementia or those with some type of cognitive impairment. And again, you're going to notice this near the hours of sunset and the behavior changes can continue into the night. The most distinctive characteristic of sundowning is going to be the timing of these behaviors.

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Now some of these behaviors can include things like increased:

• Confusion and disorientation
• Anxiety
• Agitation
• Aggression
• Wandering
• Yelling
• Ignoring or difficulty following directions
• Delusions or hallucination

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There can be several contributing factors to sundowning. And unfortunately, because sundowning is not well understood, it has been indicated as a common cause of the institutionalization of older people with dementia. And, people with dementia are often overmedicated because of sundowning. So, let's talk about some of the factors that have been associated with the occurrence of sundowning.  

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There are:

• Neurobiological factors
• Pharmacological factors
• Physiological factors
• Medical factors
• Environmental factors

I don't want you to get too caught up in what falls under which category, because honestly, depending on the source you reference, they will group them a bit differently as some categories can overlap.


Now, just to give you a heads up, there will be some fancy terms and a little blah, blah, blah, but I'm going to try to break it down the best I can for you.

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Neurobiological Factors

Neurobiological factors are factors referring to the impact of the nervous system. Now, there are no causative factors that have been clearly identified per say. Remember, I said that sundowning is still largely misunderstood and this goes for the medical community as well. But, there have been several hypotheses proposed. So, some of those include degeneration of the suprachiasmatic nucleus, which is thought to be concerned with the regulation of physiological circadian rhythms—that internal clock; decreased melatonin production; disruption in circadian rhythms; impaired cholinergic neurotransmission, which refers to the binding of acetylcholine to acetylcholine receptors. To little acetylcholine, is believed to cause a decline in cognitive abilities and memory.

So, if you didn't know, many of the drugs prescribed to manage some of the symptoms associated with dementia like Aricept, Exelon and Galantamine work by preventing an enzyme called acetylcholinesterase from breaking down acetylcholine, which allows for higher levels of acetylcholine to remain in the brain—which is good. But of course, we know that the effectiveness of these medications vary from person to person. The final neurobiological factor that I'll mention is the dysregulation of the HPA axis. The HPA axis is just an easier way to say the hypothalamic pituitary adrenal axis. It's basically like our central stress response system. It's this intertwining of the central nervous system with the endocrine system. So, the proper functioning of the axis is crucial in helping us deal with stressors. When this system is not functioning properly, what you may see are things like fatigue, difficulty sleeping, brain fog, low appetite and other things like that.  

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Pharmacological Factors  

Pharmacological factors would include things like antipsychotics, anticholinergic antidepressants, hypnotics. It's not so important to remember all these different medications. But, it's important to remember that every medication has the potential of causing side effects—some more than others. Some medications can cause restlessness, confusion, worsening cognition, and even induce emotional and behavioral changes. These are definitely things that you want to keep in mind and why it's so important to always keep a medication log, especially for when your partner has changes in medications like a new medication being added or a dosage or frequency being changed or medications discontinued. It will be so much easier to see if changes in your partner's behavior may be linked to some medication change.

Physiological Factors  

Physiological factors are factors related to the body and its physical and chemical processes or functions. Some examples of physiological factors are:

• Fatigue
• Hunger
• Unmet physical needs
• Psychological needs
• Changes in body temperature changes
• Changes in blood pressure

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Now, I don't know about you, but when I'm hungry or when I'm tired, I do not function at 100%. I'm like a completely different person. If I'm hungry, I'm honestly not the most patient. I'm probably not the most nicest person either—just being honest. If I'm tired, I can't think straight sometimes. And if I stay up too late, I start speaking a little gibberish, slurring my words. And so, this is not too far off from what is happening during sundowning if the cause is more physiological in nature. When the state of your body is different, the way you act can be different. Right?  

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For example, when someone has a fever, they may have things like cold sweats or a headache. But, we also know that when a person has a fever, it can cause confusion and irritability. So that's a good example of when the state of the body is different, our behaviors can be different as well. Another example is when, say, someone's having fluctuations in their blood sugar and this can be whether you have diabetes or not, you'll notice that the person will start acting a little bit different with those changes. So, changes in blood sugar levels and the body results and changes in the way that the person behaves. Does that make sense?  

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Medical Factors  

Medical factors are factors such as:

• Pain
• Depression
• Visual or hearing impairments
• Sensory deprivation
• Sleep disorders
• Mood disorders
• Cognitive deficits

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Now, these factors can all influence a person's behavior irrespective of the time of day, as can other things we mentioned. But, they can also worsen as day goes on and as the person gets more tired, OK?  

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Environmental Factors

With environmental factors think:

• Inadequate exposure to light
• Lack of attention
• Clutter
• Overstimulation

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I want to give you a quick example of how the environment can play a role in sundowning. A few months ago, I was working with an older gentleman who had dementia. And to be quite honest, the home was really cluttered. There was pretty much stuff everywhere, especially in the living room and bedroom. And, the home didn't have the greatest natural light because the windows were small and curtained. So, the only light they really had to work with were the yellow lights from the ceiling fan and then the light from a small lamp that they had in the corner. Now, the clutter already had him quite anxious during the day. He would always say, "I don't know why all these people are here." And then, he'd point at the piles of laundry or the stack of papers or the boxes that were in the home. But at night, as the sun went down, his anxiety worsened as the light in the home was even more poor, now receiving only dim light from the ceiling fan and the little lamp they had in the corner. Now, he became more afraid to fall. He was quite agitated, too, as he didn't understand why they were still so many people in his house. And then, he'd start fussing at his wife, telling her to tell them to go home. And, he got increasingly frustrated as she did nothing about it, because, of course, the only way for those people to have gone home was for her to clean up the house. As you can see from this example, his behavior was largely induced by the environment.

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So you have to be really mindful of the environment as it can be filled with so many triggers in and outside of sundowning.

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Take Aways

So what do I really want you to take away from this? The most important takeaway from this blog is not that there are neurobiological, pharmacological, physiological, medical, environmental factors or what so have you, but more so that there are many things, either in combination or in acting alone, that can be contributing to sundowning. Just as with any behavior, there can be so many factors that are contributing to it.  

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With sundowning, it's our job to try to figure out what is triggering the behavior as the day falls in to night and then finding ways to intervene at that level. So that's what we'll be talking about in the next blog. In the meantime, if your partner is sundowning and if you're down for participating, I want you to try to keep a 5-day log of your partner's activities from the time that they wake up until the time that they go to bed, OK?

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And so some of the things that I want you to pay special attention to are the time that they woke up and when they were sleeping, was it restful or not? Because that might be important depending on your person. Other things I want you to pay attention to is the activities or lack thereof that they participated in the food and water if they consumed or didn't consume. Did they take a nap or did they miss their nap? If they're used to taking naps, that they take their medications as scheduled, that they have adequate exposure to sunlight or bright light during the day? And what complaints or requests did they have, if any?  

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I also want you to make additional notes about the environment, including people, clutter, noise levels. The next goal will be to identify the time or time range that the behaviors start. So when do the behaviors kind of come up a notch, you know?


Then, I want you to think about what is currently going on around that time, as well as what they used to do at that time before they were diagnosed with dementia. So for some people, they may have been picking up their child from school, maybe getting off of work or going into work if they worked late or shifts. They might be about to start cooking at that time or what so have you. What you may notice is that their need or desire to do what they've always done, although they might not be doing it any longer, will kick in around that time and kind of lead to this downward spiral because they feel this need to do something. Sometimes they'll tell you, I need to do this, I need to do that. Sometimes they just start pacing and wandering because they feel like they should be doing something.

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So let's do this for five days. So essentially keep a diary of the happenings of the day and you're going to want to keep time stamps as well. They don't have to be super specific. You can round, you can do whatever's easiest for you so it's not super stressful. But just keep a diary and I will meet you back here next blog post. We'll talk about analyzing your results, kind of what you found in your diary that you were keeping for 5 days and practical ways to address sundowning behaviors.

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