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Treating Sundowner's Syndrome: Top 10 Behavior Management Strategies

By Nikki Jong
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Although there are countless theories, researchers understand very little about the causes of Sundowner’s Syndrome, a condition often associated with Alzheimer’s disease and dementia. As with any other syndrome, it is the signs and symptoms which occur together that characterize the condition. However, the symptoms are different for each individual and can encompass behaviors ranging from agitation, confusion and irritability to paranoia and hallucinations. And despite the moniker, many people with Sundowner’s Syndrome suffer symptoms in the early morning hours, not when the sun goes down. So without knowing the causes of Sundowner’s Syndrome, how can you treat the condition?

There is currently no “cure” for Sundowner’s Syndrome, but it can be treated. The best way to treat a person with Sundowner’s Syndrome is through behavior management strategies. In the debate about the probable causes of Sundowner’s Syndrome, research points to fatigue, cognitive decline, internal imbalances, drug interactions and stress. Targeting the underlying causes and triggers of Sundowner’s Syndrome through behavior management strategies will help you achieve more headway. Following are the top ten behavior management strategies.

1. Establish a routine. As Alzheimer's and dementia progresses, the patient’s ability to reason and perform normal daily activities diminishes. Different functions and capabilities are lost, creating confusion and frustration. Establishing a routine of behavior management strategies will not only help you monitor the patient’s functioning, but it will also be extremely beneficial to the patient. Structure and routine create a feeling of safety and comfort, while being in familiar surroundings helps keep feelings of anxiety and confusion at bay.

2. Schedule structured activities. Planning activities early in the day will help maximize the chance of engaging the elder’s interest, and reduce the incidence of agitation. Those who experience sundowning symptoms in the afternoon and evening are likely to have more energy and clarity to focus during morning hours, so rigorous activities, particularly exercise, is ideal early in the day. Exercise, one of the more effective behavior management strategies, will also help the patient expend excess energy and aid in sleeping at night. Quiet nighttime activities can help the patient focus any nervous energy before bed.

3. Use redirection techniques. A person with Sundowner’s Syndrome may exhibit uncharacteristic behaviors, such as using foul language, acting out violently, or simply acting more emotional than the situation warrants. As a part of the behavior management strategies, ask specific questions to understand why the patient is agitated. Speak in soothing tones and try to calm the patient, diverting his or her attention from the cause of the stress to something more pleasant. The primary goal of redirection techniques is to reduce stress and tension. Use the opportunity to try and engage the patient in a new activity.

4. Practice patience.Whether you are a family caregiver, a home care worker or a medical professional, dealing with a patient suffering from Sundowner’s Syndrome isn’t easy. A sundowning patient may wander, shadow you, and repeatedly ask the same questions, forgetting each previous interaction. A patient may experience hallucinations, seeing people or things that are not there. Experts agree that it’s best not to correct the person you’re caring for, as it will only create heightened stress and tension. He or she is likely to become upset that you are challenging their “reality.”

Validation therapy used in conjunction with other behavior management strategies, may incorporate redirection, but it is also about recognizing the legitimacy of the patient’s feelings and emotions even if the behavior doesn’t make sense to you. The patient’s anxiety can be exacerbated by confrontation or even simple disagreement. Asking specific questions to understand how certain actions or situations make the patient feel is a good lead-in. After listening to the patient, show your support with a validating response such as, “I understand why you feel that way.”

5. Make sure basic needs are met. It’s important to ensure the patient’s physical comfort, and you can start by making sure that basic needs are met. Is the patient eating enough? Is the patient in any pain? If the patient is incontinent, are those needs being looked after? A bedside commode may be helpful so the patient won’t have to navigate the path to the bathroom at night. With regard to fatigue, experts disagree on whether daytime napping should be encouraged or discouraged. Some believe that it may lessen the fatigue that occurs at the end of the day. Others think that napping can cause difficulty sleeping at night, disrupting the body’s internal clock, and contributing to a cycle of sleeplessness and fatigue. You’ll have to see what works best for your patient when integrating these behavior management strategies into the routine.

6. Monitor the patient’s diet. Watch for behavior patterns that can be linked to the patient’s diet. Limit sugary foods and caffeinated beverages, particularly after midday. If a full bladder causes nighttime incontinence or a continual need to rise during the night, restrict liquids for a few hours before bed.

7. Provide peace and quiet. Patients with Sundowner’s Syndrome are very sensitive to outside stimuli. Noise, even levels that are acceptable to the rest of us, can be distracting and upsetting to someone who is sundowning. Before symptoms of Sundowner’s Syndrome begin to occur, shut off televisions, radios, dishwashers and other noisy appliances. Also encourage visitors to come earlier in the day, rather than in the afternoon or evening. In keeping with established behavior management strategies, noise-generating activities should take place as far away from the patient as possible. Reserve a private space for the patient to relax, away from noise and people. Removing the factors that cause overstimulation will help if the patient has been provoked.

8. Turn on the lights. Exposing the patient to light in the early morning will help set the internal clock. Open blinds or drapes, and turn on the lights if the room is still dim. Use the same approach during daylight hours, making sure the patient’s environment is well lit. Some experts advocate light therapy as a part of the other behavior management strategies to help reset the body’s internal clock; it may also help alleviate symptoms related to mood and sleep disorders. Keeping the environment well-lit in the evening may be helpful as well. A comfortable, familiar environment can easily become unfamiliar and unsettling when it is dark and shadowy. Use night lights so that the patient will be able to see if he or she wakes up during the night.

9. Consult with the patient’s doctor. Schedule regular appointments with the patient’s doctor to discuss pain management as well as options for treating the underlying conditions that may be causing the patient to sundown. Some natural supplements have been reported to be beneficial to individuals with Sundowner’s Syndrome. These dietary supplements are used to improve cognitive function, improve circulation in the body and brain, encourage sleep, stimulate re-growth of damaged nerve networks, neutralize free radicals and boost overall brain health. However, natural supplements may interact negatively with each other and there may be contraindications with the patient’s existing medications. They should only be taken under medical advice and supervision.

If natural supplements don’t help, medication may be helpful when used with other behavior management strategies. Make sure the patient’s doctor understands the patient’s symptoms so that the prescribed medications do not negatively impact sleep patterns and energy levels, which could worsen the sundowning. Some cases of Sundowner’s Syndrome have been successfully treated with antipsychotic medication. However, one major side effect is sedation, which can also make the situation worse, so discuss this possibility with the patient’s doctor. Other drugs used to treat patients with Sundowner’s Syndrome include cholinesterase inhibitors, psychotropic medications, mood stabilizers, anti-anxiety medications and antidepressants.

10. Make the home safe for the patient. If you’re caring for the patient at home, secure the house so that the patient will be safe if he or she wanders at night. You may need to take extra precautions to accommodate certain sundowning behaviors, ensuring that the entire home is a safe environment, including the bedrooms, bathroom, kitchen, living areas and any outdoor space. Sundowning behaviors can change and develop over time, so you’ll need to reevaluate the safety of the home periodically.

Finally, be creative in your behavior management strategies for patients with Sundowner’s Syndrome. In attempting to find solutions, try more than one thing, and focus on the individual. Some behavior management strategies are more likely to work with one patient than another. Continue trying a combination of efforts until you find the right course of action for your situation.

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