'Sundowning' is real, but not really understood
DEAR DOCTOR K:
My wife is in her late 70s. Lately she appears very tired and agitated in the evenings. I talked to a doctor friend who said she might be "sundowning." What is sundowning, and what can we do about it?
Some older people have trouble concentrating, grow agitated or even confused, and become especially fatigued at the end of the day. This phenomenon is known as "sundowning" because its effects tend to coincide with sunset -- usually occurring in the late afternoon into the evening, then settling down late at night.
Sundowning behavior commonly occurs in people with Alzheimer's disease, but it can also occur in older people without Alzheimer's disease or other types of dementia.
Sundowning is more likely to occur in an unfamiliar environment in a dark place. I had a patient who never experienced sundowning at home, but sometimes when she and her husband traveled, it would happen in a hotel room at night. Sundowning occurs quite often in hospitalized patients. It can lead to problems such as falls and fractured bones as people get out of bed in their confusion and trip over something.
Sundowning isn't an illness; it's a temporary condition, and we don't entirely understand what causes it. One explanation is that by late afternoon, some older people have difficulty coping with the accumulation of stresses that build over the course of the day.
Here are some ways you and your wife can alleviate the effects of sundowning:
-- Keep a daily log and jot down events that seem to trigger symptoms. For instance, too much noise or the act of preparing dinner could be a trigger. Once you and your wife recognize these triggers, you can work on ways to avoid them.
-- Stick to a regular schedule. Take walks or exercise at the same time each day, preferably early in the day. Eat an early dinner and go to sleep at the same time each night.
-- Schedule appointments, trips and activities in the morning. Limit obligations in the late afternoon hours.
-- Take a late afternoon rest. Just putting her feet up and closing her eyes for a short respite can help preserve your wife's energy and prevent end-of-day fatigue.
-- Prevent overstimulation by reducing noise from televisions or stereos.
-- Reduce food and beverages that contain caffeine, or restrict them to early morning hours. Caffeine can stay in your system for as long as 16 hours and interrupt your sleep. Poor quality sleep may also contribute to sundowning.
-- When she begins to feel symptoms, she should either rest or do something familiar that relaxes her, such as knitting or reading the newspaper.
If the problem is ongoing, have your doctor review the medications she is taking to be sure that they're not causing the problem.
Sundowning is more common in older people than you might think. Fortunately, it's not usually a sign of a serious underlying problem. But it can lead to problems, like falls and fractures, so try some of the things that you and she can do yourselves. If they don't help, ask her doctor if testing of her intellectual function might be required. But I'll bet that won't prove necessary.
(Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.)
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