People living with Alzheimer’s disease are commonly affected by a phenomenon known as “sundowning” or “sundown syndrome” – when neuropsychiatric symptoms such as restlessness, agitation, disorientation, aggression, anxiety and confusion worsen as the day progresses.

As a caregiver, it’s important to understand why this occurs and how best to deal with the phenomenon – or it may take its physical and emotional toll on you too.

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

But no matter what the underlying condition, sundowning is always cause for concern: one study shows that agitation from sundowning is a common cause of institutionalisation of older dementia patients; another shows the phenomenon is a predictor of faster cognitive decline in people with Alzheimer’s disease.

People who experience sundown syndrome typically experience behavioural problems in the late afternoon, evening or at night, hence the term. It seems to occur more frequently during the middle stages of Alzheimer’s disease, when patients are generally still able to understand that this behavioural pattern is abnormal.

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. Right now, the exact mechanics are still poorly understood.

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

Environmental and social factors may also play a role.

Treatment options
A variety of treatment options have been found to help keep the symptoms associated with sundowning in check, but research is ongoing.

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

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. Arrange for a thorough medical examination and discuss the person’s medication with the doctor. 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 www.fightdementia.org.au for more of Gwyther’s tips.

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