Sundown Syndrome
A Primer
By Lois G. Tager, BS, MEd, CSA
L
ori was returning with her father from Florida. He
was coming home to live with his daughter and her
family. Lori’s dad had cognitive losses, but was aware
that he was going to California and was quite excited
to do so. They had spent a long day traveling, with a
two-hour road trip to the airport, plane delays, and a
six-hour flight to California, but Lori’s dad was happy
and content. Lori was pleased that the trip was going so
much easier then she had imagined.
Then her Dad fell asleep on the plane. When they arrived at the gate, she gently woke him. To her surprise,
this gentle, affable man was now glued to his seat and
refused to leave the plane. When he fell asleep it was
daytime, with lots of sun shining through the window.
When he woke, it was dark and dreary with much commotion and other passengers waking up and moving
about. Welcome to sundowning.
Sundown syndrome, sometimes referred to as sundowning or sunsetting, describes the onset of behaviors such
as agitation, confusion, and irritability. These behaviors
are often found in people who have cognitive losses or
Alzheimer’s disease, although some research suggests
that they can also be found in seniors simply because of
age-related changes. These behaviors can be seen at any
time of the day, but caregivers and mental health facilities report behavioral changes when the sun starts to set
in late afternoon or early evening. Others have reported
that sundown syndrome can continue on through the
evening and, in rare cases, throughout the night.
Although experts do not know the exact cause of sundown syndrome, many believe there are numerous
contributing factors. Research also describes a specific
set of involved behaviors: confusion, anxiety, agitation,
or disorientation. Continued research into sundown syndrome is still required, but there are some steps that you
can take to help those who show its behavioral signs.
A Daunting Problem
Indications of sundown syndrome present differently
from person to person. Many people hallucinate,
believing that others are in the room when no one else is
present, or imagine that someone is stealing from them.
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CSA Journal 46 • May 2010
At a Glance
We often think of winding down at the end of the
day as a relaxing time. But for people with varying
degrees of cognitive losses, the time around sunset
usually brings agitation, confusion, and disorientation. The cause of this difficult time, known as sundown syndrome, is largely unknown; how to solve
the problem is another mystery. What we do know is
that extrinsic factors can make it worse, and behavior
modification techniques sometimes help to mitigate
the intensity of the behaviors. Sundown syndrome
is very real to those who experience it, and continued research should be directed to discover both its
cause and treatment.
Dr. Maria Sullivan, associate professor of clinical psychiatry at Columbia University and the New York State Psychiatric Institute, explains that “all elderly people exhibit
some age-related cognitive decline, even if it cannot
be termed cognitive losses. Therefore, even a minimal
degeneration may predispose someone to sundown
syndrome.” Dr. Sullivan also reports that the “primary
symptoms that she observed, besides confusion and agitation, are benign visual hallucinations” (Vanda, 2010).
Hallucinations that accompany sundown syndrome can
present the caregiver with daunting problems.
Consider the story of Jayne. Jayne’s sister, who lives
3,000 miles away, was shocked to receive an angry
phone call. “I just know that Mary is stealing my makeup!” claimed Jayne. Her sister knew Mary well; she had
been in the family for 20 years, taking care of various
family members, and it was very unlikely that she was
taking Jayne’s make-up. The next week, Jayne called
again to say she had fired Mary and no longer needed
anyone to take care of her or her home. “I’m just fine!”
she said.
Refusing to allow another person into the home to help
with caretaking can be a major problem. When caregivers do find help outside of the family, the senior who
has sundown syndrome repeatedly fires that person.
This problem is often exacerbated by hallucinations,
such as the example here, in which Jayne believed her
caregiver was stealing.
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A Range of Theories
Some experts believe that sundowning is caused by
physical and mental exhaustion after a long day. Others
believe that planned physical activity is key to avoiding
sundown syndrome. Some think that new medications
play a role, perhaps causing confusion and disorientation. There are many contradicting opinions and,
unfortunately, no real answers as to why sundowning
happens. However, most experts agree that the degree
of light and the time of day play a distinctive role in
the level of agitation and disruptive behavior that are
exhibited.
According to an article on sundowning at Caring.com,
scientists have not been able to pinpoint the cause or
causes of sundown syndrome. However, “studies have
shown an association between sundown syndrome and
changes in the internal biological clock among people
with cognitive losses. The internal clock—governed by
the circadian rhythms—controls sleeping and waking,
and is connected to how active we are at different times
of the day, and influences changes in the body that
regulate behavior.” Perhaps this internal clock shifts in
people who have cognitive losses, thus making them
more prone to sundowning (Udesky, 2010).
The article goes on to state, “Researchers also theorize that hunger, a drop in blood pressure after a meal
(which temporarily takes oxygen away from the brain)
or changes in glucose levels in the blood from eating
in people with diabetes” can precipitate confusion and
agitation. Other factors that might influence behavior
relate to the person’s hearing and vision. When a person has difficulty seeing, changes in light might affect
how he or she sees at the onset of twilight. The article
suggests that “placing a full-spectrum fluorescent lamp
near the person in the morning or at sunset may help
get their biological clock reset” (Udesky, 2010).
A Helping Hand
Although there is no single known cause of sundown
syndrome, we do know some simple ways to mitigate
its effects and to make the experience less traumatic for
the person who has it, as well as his or her caretakers:
• Try to plan structured activities, such as bathing
(often a difficult task) early in the day, when a loved
one is most alert.
• Try taking a walk, or find a gentle exercise in which
both the senior and caregiver can participate.
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• Redirect the affected person’s attention to a familiar
activity.
• Turn off the television, which many experts believe
can cause confusion.
• Soft classical music might have a calming effect.
• Establish a familiar routine, and encourage the
senior to help with simple tasks such as setting the
table for dinner or folding clothes.
Most importantly, speak in gentle, loving tones, and
avoid confrontation. If the sundowning behavior
becomes aggressive, dangerous, or self-destructive, be
sure to contact a medical professional. In such instances, medication might help minimize the behavior. Senior care centers can be extremely valuable in assisting
with exercise and the diversion of day-to-day activities.
The Complete Guide to Alzheimer’s Proofing Your Home,
by Mark Warner, suggests that “once it has been determined that there is no real or serious cause for discomfort or agitation, redirecting one’s attention to more
pleasant thoughts or activities may be one of the best
solutions” (Warner, 1998). Warner suggests installing a
false telephone or battery-operated doorbell that can
be used to divert a family member’s attention during
difficult moments. Warner uses the following example,
during which a caretaker uses a false telephone to stage
a phone conversation and divert her mother’s attention
from the bathing process:
“Hello? Mom, it’s Judy calling to see how you are doing.
Hi, Judy, how are you?” The caretaker washes under her
mother’s arms. “Oh, Mom is just great.” Speaking to her
mother: “Rinse off here, Mom. Is that the baby I hear in
the background? ... Mom, turn so I can wash your back.
Okay, I guess you have to go ... Let’s rinse off a little
now. I’ll tell Mom that you called. Bye, Bye.” Speaking again to her mother: “Mom, that was Judy. She is
thrilled that you are doing so well. She wanted to talk to
you, but the baby is crying. She’s going to call you later.
Now give me your foot.”
Because long-term memory usually outlasts other types
of memory, talking about family members or savoring a
special event in the senior’s life often has a calming effect on a person experiencing sundowning. If the senior
loved to sing, start a song that will be familiar, and then
sing along together. Focus your attention and speak
slowly, quietly, and directly to calm and soothe.
Some episodes of agitation will be unavoidable. When
possible, place comfortable chairs close to each other
CSA Journal 46 • May 2010
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and guide the senior to sit down with you to regroup.
Reminisce about the past or look through family albums. Such activities are often enough of a distraction
to change the agitated behavior.
Redirection and Reassurance
Sundown syndrome is common in people who have
cognitive losses. This syndrome demonstrates confusion, agitation, and hallucinations. Often the behavior
is precipitated by the setting of the sun or reduction in
light within the environment, and can be aggravated by
extraneous noises from television, families returning
home, or an increase in noise levels within the surroundings, as well as by certain medications. Researchers continue to search for the cause, but until we know
precisely why sundown syndrome affects so many
people, we must rely on techniques such as distraction,
redirection, and reassurance.
References
Bowlby Sifton, Carol. 2004. Navigating the Alzheimer’s Journey –
A Compass for Care-giving. Health Professions Press, Inc.
Jong, Nikki. 2008. Treating Sundowner’s Syndrome: Top Ten Behavior
Management Strategies. Associated Content. September 30, 2008.
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CSA Journal 46 • May 2010
http://www.associatedcontent.com/article/1065893/treating_
sundowners_syndrome_top_10.html?cat=5 (accessed January 30,
2010).
Mace, Nancy L. Rabins. 2001. The 36 – Hour Day. Warner Books, The John
Hopkins University Press.
Udesky, Laurie. 2010. What To Do When Someone Shows Signs of
Sundown Syndrome, Caring.com. http://www.caring.com/articles/
sundown-syndrome (accessed January 30, 2010).
Vanda. 2010. Sundowning Syndrome, CareConnection.com. http://
www.healthcentral.com/caregiver/index-159674-5_pf.html (accessed January 14, 2010).
Warner, Mark L. 1998. The Complete Guide to Alzheimer’s – Proofing
Your Home, Purdue University Press.
Lois G. Tager is the Director of Geriatric Care Management for the Law firm of Roy W. Litherland in
Campbell, CA. She has worked with the Alzheimer’s
Association as a facilitator to caregiver groups for the
past seven years. Ms. Tager has personal experience
as a consultant for her sister who had early-onset
Alzheimer’s disease; she also took care of her father,
who had cognitive losses. Ms. Tager has a B.S. from Boston University,
and an M.Ed from Providence College, specializing in counseling.
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