Challenging Behaviors for the Caregiver

Sundowning

What is Sundowning?

Persons with acute or chronic confusion become more confused, restless, and insecure late in the day and especially after dark. This happens whether they are living at home or in a facility, but most often, it is worse after a move or change in the patientís routines. She may become more demanding, restless, upset, suspicious, disoriented and even see, hear or believe things that arenít real, especially at night.

 

What Causes Sundowning?

 

No one is sure what causes Sundowning, although it seems to result from brain diseases - whether acute(treatable) or chronic (irreversible). Alzheimerís patients tire more easily, even from minimal demands on their thinking ability, and they become more restless and hard to manage when tired. Itís as if their ability to cope with a confusing environment has been used up. All stimuli, because the patient canít sort out sounds or activities, has an add-on stressful effect.

Sundowning may relate to lack of sensory stimulation after dark. At night they are fewer cues in the environment, with the dim light and absence of noises from routine daytime activity. Those routine noises are a major source of security for Ad patients, many of whom sleep well only during the day and in chairs close to nursing stations. A Sundowning, restless patient also may be hungry, uncomfortable(too tight clothes?), in pain or needing to urinate, all of which she can only express through restlessness. AD patients may regress to childlike behavior and thinking patterns as the disease progresses. As she understands less about whatís happening to her, she becomes more frightened of things like the dark or being left alone. She becomes more frantic in trying to restore her sense of familiarity or security. Many families caring for AD patients say the patients become more anxious late in the day about "going home, finding my mother" (all those things indicating a need for security and protection).

Helping Strategies

Keep the patient active in the morning and encourage her to rest after lunch. If fatigues is making the Sundowning worse, an early afternoon rest might restore her composure.

Donít physically restrain her. That tends to make AS patients worse- she may scream, squirm , or become even angrier and more resistant.
Instead, let her pace back and forth where she can be observed. If one can, fall in step with her and offer her a brief moment of companionship and distraction from her mumblings. Taking her outdoors for a walk would also help-fresh air seems to clear the minds and reduce restlessness in Ad patients. When you pass her, reach out and smile, pat her or say, "Itís good to see you."

Donít argue or condemn her for "wanting to die." Itís probably a phrase that got stuck in her mind and she canít help repeating it. Sheís looking for attention. Reassurance is the best response. "We love you and weíll help you."

Give her something to fiddle with in her hands to distract her from pulling on or tearing her cloths. Perhaps she could be asked to hold something "for you" which keeps her hands too busy to fiddle with anything else. If she pulls her skirt up regularly in public, get her some pull on slacks.

Some patients are comforted by stuffed animals, real animals, hearing familiar tunes, or an opportunity to do a favorite pastime, i.e. window shopping at the mall looking at cars on used car lots or whatever.

Donít ask her to make decisions, or ask her whatís wrong. If you make decisions, sheís relieved of that taxing responsibility.

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