Updated 05 February 2014

When Alzheimer’s patients become impossible

People with Alzheimer’s disease are commonly affected by a phenomenon known as “sundowning” or “sundown syndrome” – when symptoms such as restlessness, agitation, disorientation, aggression, anxiety and confusion become worse in the afternoon.

As a caregiver, it’s important to understand why this occurs and how best to deal with the phenomenon.

What is sundowning?

Sundowning is most commonly associated with Alzheimer's, but also occurs in people with mixed dementia (where characteristics of both Alzheimer’s disease and vascular dementia are present) and Parkinson’s disease.

Sundowning is always cause for concern: it is a common cause of institutionalisation of older dementia patients and often predicts faster cognitive decline in Alzheimer's patients.

People who experience sundown syndrome typically experience behavioural problems in the late afternoon, evening or at night, hence the term.

Apart from the symptoms mentioned above, the affected person may also experience mood swings, an abnormally demanding attitude, suspiciousness, and visual and auditory hallucinations.

What causes sundowning?

Sundowning is one of the many effects of dementia that experts do not yet fully understand.

However, many experts believe that dementia may cause damage to the body’s internal clock (the so-called “circadian rhythm”). The result is a change in behaviour and mood as the evening draws closer.

Treatment options

A variety of treatment options have been found to help keep the symptoms associated with sundowning in check.

Available options include:

•             Light therapy (regular exposure to bright light, including the sun)

•             Melatonin supplementation (a hormone made by the pineal gland in the brain, which helps control sleep and wake cycles)

•             Acetylcholinesterase inhibitor drugs (it’s believed that the “cholinergic” pathways in the brain are compromised by Alzheimer’s disease)

•             N-methyl-d-aspartate receptor antagonists (this group of drugs work by regulating the activity of a chemical messenger involved in memory and learning)

•             Antipsychotics

•             Behaviour modification

Change in behaviour discussion

It’s important to always discuss a change in behaviour with the patient’s attending doctor, who will be able to check whether there’s a physical cause. Sometimes changing the dosage or the time that medication is given can help relieve symptoms.

In her book Care of Alzheimer’s Patients: A Manual for Nursing Home Staff, Lisa Gwyther also offers the following tips:

•             If fatigue is making the sundowning worse, an early afternoon rest might help. Keep the person active in the morning and encourage a rest after lunch.

•             Early evening activities that are familiar from an earlier time in the person’s life may be helpful. Closing the curtains, a pre-dinner drink or assisting with preparing dinner or setting the table may be helpful.

•             Don’t physically restrain the person. Let them pace where they’re safe. A walk outdoors can help reduce restlessness.

Visit for more of Gwyther’s tips.

Read more:

Principles for Alzheimer’s care

Caring for parents with dementia a struggle

At-home test may spot early Alzheimer's






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