Sudden behavior changes are common in Alzheimer’s patients. Patients may become agitated, suspicious, or even aggressive, often in the late afternoon or early evening. Unless properly managed, this behavior can drag on into the night, leaving patients and caregivers exhausted.
Because these episodes occur frequently around the end of the day, doctors refer to them as sundown syndrome, or simply “sundowning.” Understanding what sundown syndrome is and how to respond helps families and assisted living homes caring for victims of the disease.
What causes sundown syndrome?
Medical researchers don’t fully understand the roots of sundown syndrome. Because it is usually triggered by fading light, they think that Alzheimer’s may impact the body’s circadian rhythm. This is the internal clock that governs the sleep-wake cycle.
Several other factors can influence undesired behaviors as well, such as:
Urinary tract infections are notorious for exacerbating sundown symptoms. Cognitive decline makes it harder for patients to control their bladder, while simultaneously lessening bowel urges.
As Alzheimer’s progresses, patients gradually lose the ability to clean themselves, paving the way for infections. Unable to understand why they are in pain, patients grow increasingly agitated, confused, and belligerent. For this reason, when dealing with problem behaviors, caregivers should start by looking for an infection.
What is the best way to manage sundown syndrome?
Before an episode
Caregivers can take steps to prevent or minimize sundowning.
Establish a routine: Creating a familiar flow to the day reduces agitation and confusion. Because some major activities, like doctor’s appointments, cannot be avoided, never schedule more than two on the same date.
Avoid hustle and bustle late in the day: Turn down the volume on the television, radio, and sound speakers. Avoid having visitors over in the evening. At the end of the day, relieve stress by playing soft music or nature sounds.
Close the blinds and turn up the lights: Installing full-spectrum light boxes has also been shown to reduce incidents.
Make sure patients get enough rest: Do not let patients smoke or drink alcohol and limit caffeine and sugar to the morning. Serve a big lunch, but a small dinner, 500 calories or less (prolonged digestion interferes with sleep). Prevent patients from napping as much as possible. If they must sleep, keep it short and never later than four hours before bedtime.
Buy a nightlight: For sundown patients, waking up in a dark place can be frightening and confusing, so something as simple as an LED nightlight can help provide a sense of calm and familiarity.
If symptoms grow worse, it may be time to consider medication. Like any other disease, Alzheimer’s progresses in stages, and medication is sometimes necessary to manage symptoms. However, the goal of medication is not to sedate the patient, but to keep them calm, happy, and functional. To find the right balance, physicians need to remain up-to-date about any changes in the patient’s condition.
After sundown symptoms start
As soon as caregivers notice a patient is sundowning, they need to intervene quickly, before the patient becomes aggressive and starts hitting, pushing, shouting, or name-calling. This is not only distressing to the patient but puts other people at risk, especially if it occurs in an assisted living home.
But caregivers can employ simple, effective techniques to help patients, meeting them where they are with calm, compassion, and care.
During an episode:
For caregivers, the most important thing is to remain calm. They should not raise their voice or demand an explanation. Scolding (frowning, pointing fingers, putting their hands on their hips) will only escalate the situation. Reasoning with patients is also counterproductive.
In many cases, aggression is caused by sensory overload. Respect personal space and stay an arm’s length away. Make sure no one has been hurt. Wait for the patient to calm down before trying to redirect them. Take them to a quiet room away from everyone else to afford them space to settle down.
Start by assuring them they are safe. Listen to what they are saying. Pay attention to their feelings. Give simple answers. Suspicion is often triggered by a lost or misplaced possession, so offer to help them find it. If the patient keeps losing the same item over and over (e.g., toothbrush, eyeglasses, keys), keep several spares on hand.
Say comforting words and use a quiet tone (i.e., “May I help you?” “You’re safe.” “Everything is fine.”), and listen to what the patient is saying. Are they hungry, thirsty, constipated, or in pain? Are their clothes too tight or too loose? Redirect with a simple art project. Put on soothing music. Use gentle touch (i.e., hugs, holding hands). Show them old photographs and encourage them to talk about their memories. If they are still agitated, try taking them for a walk or playing a game.
Walk with them. Hold their hand. Offer them a snack. Keep their path clear of obstacles, so they can’t trip. Redirect their nervous energy by giving them a simple task, like sorting spoons or wiping down the table.
Always make sure the supplies you need are ready ahead of time (i.e., toothbrush, nail clippers, soap, shampoo). Explain what they will be doing in simple terms. Don’t ask if they want to do the activity; simply tell them it is time to do the activity. If they become combative, step back for a few minutes before trying again.
Approaching advancing care needs
Alzheimer’s Disease requires complex care, beyond what a family can typically provide on their own. Assisted living homes ease the burden, with support services, medical care, and 24-hour supervision, but caregivers in larger environments cannot provide such close monitoring and sometimes fail to redirect in time.
Smaller homes such as Verona Court are normally ideal for patients with more advanced memory care issues, because they provide a better care ratio.
Verona Court’s residency is capped at six residents, with memory care specialists plus two full-time caregivers onsite at all times, affording staff the opportunity to get to know each individual and the nuances of their personalities. Knowing patients well helps caregivers anticipate problem behavior and take measures to prevent or minimize it.