‘Sundowning’ and Other Behaviors

Sundowning behavioral changes begin without warning

Sundowning is a term that relates to a condition experienced by people with dementia.  During Sundowning, the person exhibits behaviors such as irritability, belligerence, abusiveness toward people around them, agitation and general excitability.  Trying to argue with them or correct them does not work.  Instead look at the environment.  Is it noisy?  Are they tired?  Are they safe?  Was there something that could have triggered the behavior?  Correct anything that may be bothering them.  Allow them to have some space to decompress.  You may want to move out of their sight to the next room.  Appeal to their senses with aromatherapy oils such as lavendar, and other soothing fragrances.  Use hand lotions and soft music.  Redirect them to something they like to do, i.e., bake cookies, take a nap, watch their favorite DVD or listen to their favorite music.  My clients have gone for a walk and when they returned, had forgotten the incident even occurred. Their caregivers may have still been shaking in their boots, however.

As a Geriatric Care Manager, one of my clients was a woman who had Alzheimer’s disease and was a retired nurse.  During an excursion for doctor’s appointments and other errands, she began to Sundown and was able to describe her experience as each phase was unfolding. That taught me to never plan doctor’s appointments at the end of the day.  The term is called Sundowning because it often happens later in the day.  However, one day the caregiver called me and what she described when she came on her shift sounded like Sundowning but it was early morning.  As I was  contemplating it, it occurred to me that we had had several days of low cloud cover and no sun.  I suggested that the caregiver open the drapes and turn on the lights everywhere so that she had more light.  That took care of the situation.  Lighting seems to play a key part because during the time that people with dementia Sundown, it is later in the day.  Even residential care facilities are now being designed with more skylights and direct sun to help alleviate that condition.

What can be done to minimize conditions triggering sundowning behaviors

It has appeared as if there is a certain amount of excitability that a person with Alzheimer’s can handle and after it is reached, behavior deteriorates.  I advise caregivers to make sure they provide peaceful environments; help them to read the newspaper; provide exercise, fresh air, good nutrition and social interaction.  The retired nurse that I mentioned had a fantastic sense of humor and could keep everyone laughing.  However, after a trip to the bank (5 minutes away), she could no longer remember where she had been.  People who cannot remember what has happened 5 minutes before are very vulnerable. They cannot self report what is happening in their life.  Do they appear agitated? Be on the lookout for differences in behavior that may indicate something is happening with caregivers that they cannot verbalize.  Make unplanned visits to monitor caregivers at different times of the day.  Ask caregivers record nurse’s notes so that you can monitor what is happening each day.  Include eating patterns, meds taken and any unusual behaviors.

In one experience with my mother, we were having a family reunion.  She came into the gathering in which her grandchildren were dancing to the “Macarena”.  She complained that it was too loud.  She eventually went back to her room.  It put a blight on the occasion.  We had not recognized that this would be too much for her.

Paranoia is common in dementia

Dementia patients will sometimes become paranoid and accuse people of taking their things.  That happens because they misplace their items and can’t find them.  Post pictures of where things belong so that they know where to look.  Place pictures of loved ones next to the speed dial number on the phone so they can call their favorite people.  Have everyone write on the calendar when they came over so that they will know that someone has been visiting.  Include them in chores that they may have done all their lives such as folding clothes, dusting, setting and clearing the table.  See what they are capable of handling on their own and allow them to do as much as possible.  It is advisable for the caregiver to supervise taking of medications.

A person with dementia knows that they are no longer in control of their environment and it frightens them.  Asking them to remember something is fruitless and beyond their capability.  Plan to clean out their refrigerator for them to remove items that are beyond their prime.  Anything out of sight will not be remembered any longer.  You may have to disconnect the toaster oven, oven, coffee pot and other items that could be forgotten and start a fire.  Get them a carafe to store coffee in their room.

In the later stages of dementia, they will not be capable of using a remote to change channels; making a phone call; choosing items on a menu; or handling their own hygiene.  My mother stood like a child and allowed me to dress her.  That would never have happened earlier.  She also lost inhibition when it came to discussing sexual experiences.  She had a boyfriend and gave me more information than I wanted regarding their relationship.  In the end, I believe that they mostly held hands and kissed.  He had a stroke and left the facility.  Because of HIPAA, the staff never told her what happened to him.  She just knew that he didn’t come around any more.  While I was visiting, I asked about him and they said he had had a stroke and was in a higher care facility.  My mother spoke up and said,”Oh!  Is that what happened to him?”.  It seemed sad to me that it took so long for her to have closure.

The Issue of consent in dementia patients

There is the issue of consent.  Staff in that facility tried to discourage relationships.  Many feel that a person with dementia does not have the ability to give consent.  It is my experience that often they have good days and bad days.  Their sexuality has not gone away because they are less mentally available.  It is definitely a discussion worth having.  Giving affection is important to the individual.  They must know that they are still valued and be given respect and accorded dignity. My mother always had a stuffed gorilla that she could hug.  She said that after Dad died, that was what she missed most…the hugs.

Many times in the evenings, sleeping patterns are interrupted and a person with dementia gets up and starts rummaging around.  It is good to provide some drawers with items with which they can rummage.  Choose hats and clothes from a former era, and different textures.  If a person was involved in a specific career, try to choose items from that career.  It will trigger memories.  In Alzheimer’s dementia, short term memory is most affected.  They will be able to remember things from earlier in their life.  Keep photo albums handy to peruse.  Think of visual items that can convey what you would most like them to know, i.e. use a stop sign to indicate they are not to go past a certain door.  From previous experience, they will intuitively know to turn around and not go there.  A caregiver can also use babyproofing items to stop them from leaving the house unawares or getting into cabinets where cleaning supplies are stored.  Alarms are now available too to prevent a dementia person from leaving without the caregiver’s knowledge.

Make sure that they have some form of identification on them in case they begin to wander and cannot remember how to get home.  Many enjoy walking but as the disease progresses, they lose their sense of space and time.  They may not remember where they live or what their name is. It is a good idea to place their name inside the label of all their clothes so if they get lost, someone knows who they are.  The Alzheimer’s Association (http://www.alz.org) offers Medic Alert and Safety bracelets or dog tags which can help identify them if they are lost without giving away too much information.

Music, if it was enjoyed when they did not have dementia, can still be enjoyed by someone with dementia even when they are in the final stages.  Soothing, relaxing music will help calm their anxieties.

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