What Is the Best Treatment for Sundowning? A Comprehensive Guide

Sundowning affects up to two-thirds of individuals with Alzheimer's disease and other dementias, causing confusion, agitation, and anxiety in the late afternoon and evening. Understanding what is the best treatment for sundowning requires a multi-pronged approach that addresses both environmental triggers and the individual's underlying needs, often with the guidance of a healthcare professional.

Quick Summary

The most effective approach for managing sundowning involves a combination of consistent routines, strategic environmental adjustments like light therapy, and behavioral techniques to reduce evening stimulation. Treatment is highly individualized and may incorporate non-medication strategies before considering pharmacological options under medical supervision.

Key Points

• Routine is paramount: A consistent daily routine helps regulate the internal clock and reduces confusion, preventing or lessening the severity of sundowning episodes.

• Optimize light exposure: Maximize natural light during the day and use bright indoor lighting to reduce shadows in the evening, as this helps reinforce the sleep-wake cycle.

• Minimize evening stimulation: Limit loud noises, visitors, and stressful activities in the late afternoon and evening to create a calm and soothing environment.

• Explore behavioral and sensory therapies: Utilize music therapy, aromatherapy, or multisensory activities as safe, non-pharmacological methods to calm and distract during episodes.

• Consider medication with caution: Pharmacological treatments like melatonin or, in severe cases, antipsychotics are options but should only be pursued under medical supervision due to potential side effects.

Understanding Sundowning and Its Causes

Sundowning, or sundown syndrome, is a group of symptoms that occur in individuals with dementia as daylight begins to fade. These symptoms can include increased confusion, anxiety, agitation, aggression, and wandering. While the exact cause is not fully understood, it is believed to be linked to disruptions in the body's internal clock (circadian rhythm), fatigue, changes in lighting, and difficulty distinguishing between dreams and reality. Caregivers need a comprehensive toolkit to manage this challenging condition.

Non-Pharmacological Interventions: The Foundation of Treatment

For most people experiencing sundowning, behavioral and environmental modifications are the first and most crucial line of defense. These strategies focus on creating a stable, predictable, and calming atmosphere to minimize triggers.

Establishing a Predictable Daily Routine

• Maintain Consistency: A structured daily routine for waking, meals, and bedtime helps regulate the body's internal clock. Predictability can reduce confusion and anxiety for someone with dementia.
• Plan Daytime Activity: Encourage physical and cognitive activity during the day to promote better nighttime sleep. This can include short walks, simple puzzles, or folding laundry. However, avoid overexertion, which can increase fatigue and worsen evening symptoms.
• Manage Napping: Limit daytime naps, especially in the late afternoon. If a nap is necessary, keep it short (20-30 minutes) and schedule it earlier in the day.

Environmental Adjustments

• Control Lighting: As afternoon turns to evening, ensure rooms are well-lit to eliminate shadows, which can cause fear and confusion. Light therapy, using a bright light in the morning, has shown promise in regulating circadian rhythms and improving sleep quality.
• Reduce Stimulation: Minimize background noise from sources like television and keep the environment quiet and calm in the late afternoon. Limit the number of visitors and avoid stressful activities like bathing during this time.
• Create a Soothing Atmosphere: Play familiar, gentle music or natural sounds, like ocean waves, to create a relaxing ambiance. Keeping familiar objects, such as photographs or a favorite blanket, nearby can also be comforting.

Immediate Response Techniques

When an episode of sundowning occurs, how a caregiver responds can make a significant difference.

• Stay Calm and Reassure: Use a calm voice and reassure the individual that they are safe. Avoid arguing or confronting their fears, as this can escalate the situation.
• Distraction and Redirection: Use a favorite object, snack, or simple activity to redirect their attention. Examples include offering a warm drink or looking at a photo album together.
• Address Unmet Needs: Sundowning can sometimes signal an unmet need like hunger, thirst, pain, or the need to use the restroom. Gently ask questions or check for non-verbal cues.

Pharmacological Options: When to Consider Medication

In some cases, non-pharmacological methods may not be enough, and a doctor may recommend medication. This should always be a last resort and used with extreme caution, as some medications have significant side effects in older adults.

• Melatonin: A naturally occurring hormone that regulates the sleep-wake cycle, melatonin supplements may be recommended to help reset the individual's sleep patterns. Studies suggest it can help ease sundowning, especially when combined with daytime light exposure.
• Antipsychotics: In severe cases involving aggression, hallucinations, or extreme agitation, a healthcare provider might prescribe an atypical antipsychotic, such as brexpiprazole (Rexulti). These drugs have risks, including an increased risk of stroke in older adults with dementia, and should be used with close medical supervision.
• Antidepressants or Anxiolytics: Anti-anxiety or antidepressant medications may be used to address underlying anxiety or depression contributing to sundowning.

Comparing Treatment Approaches

Feature	Non-Pharmacological Strategies	Pharmacological Strategies
Effectiveness	Often highly effective, especially when consistently applied to prevent episodes.	Can be effective for managing severe symptoms that don't respond to other methods.
Risks/Side Effects	Minimal risk, focused on safety and creating a supportive environment.	Potential for significant side effects, including increased risk of stroke with certain medications.
Role in Care	Foundational and proactive; helps prevent sundowning before it starts.	Reactive and targeted; used for specific, severe symptoms under medical guidance.
Examples	Maintaining routines, light therapy, calming music, distraction.	Melatonin, antidepressants, anxiolytics, antipsychotics.

The Importance of Caregiver Support

Caring for someone with sundowning can be emotionally and physically draining. Caregivers must also prioritize their own well-being.

• Seek Support Groups: Connecting with other caregivers facing similar challenges can provide a vital emotional outlet and a source of practical advice.
• Practice Self-Care: It's essential for caregivers to schedule their own rest and personal time to avoid burnout. A well-rested caregiver is better equipped to handle difficult situations calmly.
• Consult Professionals: Don't hesitate to seek professional guidance from a doctor or a dementia care specialist. They can help identify underlying medical issues, such as a urinary tract infection or pain, that might be exacerbating symptoms.

Conclusion

Ultimately, there is no single "best" treatment for sundowning. The most effective strategy involves a personalized, integrated approach that starts with preventive non-pharmacological methods. By establishing consistent routines, adjusting the environment, and responding calmly to episodes, caregivers can significantly reduce the frequency and severity of sundowning symptoms. Medications should be considered carefully and only after other options have been explored, and always in consultation with a healthcare professional. For more in-depth information, the National Institute on Aging offers valuable resources on managing dementia-related behaviors, including sundowning (see link below). Understanding and addressing the individual's unique needs is key to navigating this challenging aspect of dementia care and creating a more peaceful environment for everyone involved.

Managing behavioral symptoms in dementia

Frequently Asked Questions

What time does sundowning typically start?

Sundowning symptoms usually begin in the late afternoon and can continue into the evening and night. The exact timing can vary from person to person, often triggered by the transition from daylight to darkness.

Does melatonin help with sundowning?

Yes, some research suggests that a low dose of melatonin can be helpful for easing sundowning symptoms, particularly when combined with daytime exposure to bright light. Melatonin helps regulate the sleep-wake cycle.

How can caregivers manage sundowning behaviors when they happen?

During a sundowning episode, caregivers should stay calm, use a soothing voice, and avoid arguing. Distraction techniques, such as offering a snack or playing soft music, are often effective in redirecting the person's attention and calming them.

Are there any medications to avoid for sundowning?

Yes, some over-the-counter sleep aids and certain medications can worsen confusion in people with dementia. It is important to avoid or use certain medications with caution, such as benzodiazepines, and always consult a healthcare professional before administering any new medication or supplement.

Can diet and exercise impact sundowning?

Yes. A regular intake of food and fluids, avoiding caffeine and large meals in the evening, can help. Daily physical activity, such as a walk, can also improve sleep patterns and reduce late-day restlessness.

What environmental changes can help with sundowning?

Environmental adjustments include ensuring adequate lighting in the evening to reduce shadows, minimizing noise and clutter, and using familiar, comforting objects. Creating a quiet, calm space can help reduce agitation.

Does sundowning ever go away?

As sundowning is a behavioral symptom of an underlying condition like dementia, there is no cure. However, with consistent management strategies, the frequency and severity of episodes can often be significantly reduced, improving the quality of life for the individual and their caregiver.