"You can count on it like
clockwork," Linda says, as her mother marches with a
determined air into the kitchen with her overcoat.
"Where's my purse! I have to go! Now!" Alice demands.
"Where are you going, Alice?" I ask.
"I have to go! I have to be there! I need to go home! Right
now!" Alice mumbles as she tries to push past me and out
the dead-bolted door of the house she's lived in with her
daughter for more than 10 years.
During the day Alice is fine. She dresses herself and eats
without assistance. She'll help Linda fold laundry, or dust. She
enjoys the occasional joke, and she loves to get out in the car.
She dozes contentedly in her chair off and on.
By late afternoon, though, Alice changes. Increasingly she
becomes more agitated. She rummages through things, tossing them
wildly about as if she's looking for something she can't
articulate. Sometimes she gets aggressive. Other times she's
inconsolable with a grief she can't explain, wailing and
wringing her hands. She doesn't seem to want to be touched. It's
a fight to get her ready for bed, and she's up and down all
night. Linda is exhausted and desperate.
Alice is sundowning.
Sundowning is aptly named after the time of day - late afternoon
or evening - when people with Alzheimer's or other dementias
often become upset, agitated, suspicious, paranoid, and
generally difficult. Not infrequently, sundowners don't sleep
well at night. Many will pace incessantly. Often they seem to
get their days and nights mixed up - sleeping well in a chair
during the day, but wakeful and up at night. Often sundowning is
worse after a change in daily routine or after a move.
The theory used to be that sundowning was caused by the
reduction of light in the evening. Now it appears more likely
that being tired at the end of the day probably has a lot to do
with sundowning behavior.
Individuals with dementia are using their energy reserves simply
getting through the day. Even the smallest, most
"routine" activity is a demand on their thinking
ability. By the late afternoon their reserves are used up, and
they no longer have the ability to cope with what, for them, is
a confusing environment. Every new stimulus, even hunger or a
need to use the bathroom, adds to the accumulated stress.
The research continues. But, no matter what the cause,
caregivers need strategies to manage sundowning behaviors.
First, and foremost, a thorough medical examination and a
medication review is essential. In some cases, an adjustment in
the kind or dosage of medication, or the time of day it's being
taken, can make a big difference.
Work with the doctor to treat any medical conditions. Arthritis
pain is often a contributor, and a pain reliever given in the
afternoon might make all the difference. Urinary tract
infections very often contribute to sundowning. Allergies, skin
irritations, even a slight cold can make things worse.
Anticipate and prevent as much physical discomfort as you can.
Schedule regular trips to the bathroom or change undergarments.
Keep the house at a comfortable temperature and check to see if
a sweater is needed (or needs to be removed). Check to see that
socks aren't wrinkled inside shoes and that waistbands aren't
too tight.
Plan activities or trips out of the house for the morning hours,
when the sundowner is usually at his or her best. Avoid too much
stimulation in the afternoon.
Try to plan no more than one activity or trip out each day. Even
early in the day, too much going on can be overwhelming, and
will to problems later.
Limit the amount of noise and activity at home. If the
dishwasher is running, the vacuum is roaring, the television is
on, and the dog is barking, there is too much going on at once
for the dementia victim to process.
Create private spaces. If you can't avoid a certain amount of
normal chaos, provide a safe and quiet place for your sundowner
to retreat to. Create "off limits" private areas with
doors you can lock for yourself and other family members, too.
Watch for patterns. If you can identify things that seem to set
off agitation, maybe you can modify your behavior or routine. If
bathing is a battle in the evening, try bathing in the morning
instead.
Clear out clutter. Cluttered classrooms have been proven to
increase hyperactivity in children. A cluttered home will have
the same effect on a sundowner. Clear off tables and other
surfaces. Move breakables and collectibles to a safe off limits
room. Take away small tables, throw rugs, and anything else that
could trip up a pacer. Make a safe walking area where your
sundowner can work off built up energy.
Turn on the lights. If your sundowner tends to see or hear
things that aren't there, dark places can be scary. Sometimes a
soft light left on in the bedroom helps reduce shadows and fears
at night.
Encourage a rest period for an hour or so just before the time
sundowning usually starts. If being overtired contributes to
sundowning, some quiet time to regroup may help. If she resists
lying down on the bed for a nap, try a quiet hour in a
comfortable chair or recliner with calming music (no TV).
If all else fails, go back to the doctor. You may need a new
medication or a change in the dose. It might take several tries
to find something that helps.
Remember that this, too, shall pass. If you feel that it's
becoming more than you can handle right now, call for help.
Reach out to family members. Look into respite care. Talk to an
eldercare specialist for more ideas and resources. Take care of
yourself. Your sundowner needs you, even if he doesn't know it
or won't admit it.
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