Johns Hopkins Health Alerts | Memory | Coping Strategies for Alzheimer's Disease Behavioral Problems

Some people with Alzheimer’s disease experience a worsening of agitation and confusion in the afternoon and early evening. Here are some practical strategies you can try.

Becoming agitated in the late afternoon or early evening is a common phenomenon among people with Alzheimer’s disease. In fact, a special word -- “sundowning” -- is used to describe this behavior. Sundowning can take the form of behaviors not seen during other times of day, or it may represent a worsening of ongoing daily behaviors.

Exactly what causes sundowning is unclear. Possible explanations include fatigue at the end of the day, being overwhelmed by too much sensory input, lack of stimulation (not enough activities or attention), and becoming confused in dim light. Sleep problems, such as sleep apnea and disturbances in the sleep/wake cycle (circadian rhythm), may also play a role. The behavior seems to be more common among Alzheimer’s disease patients who live in nursing homes. Of course, not everyone with Alzheimer’s disease experiences sundowning, and some individuals have more behavior problems early in the day rather than later.

How to cope with Alzheimer’s disease and sundowning

If you are caring for someone with Alzheimer’s disease who experiences sundowning, think about what might be triggering the episodes and take steps to minimize those triggers. For example:

1. Exhaustion -- A patient with Alzheimer’s disease may be tired in the evening from a day of trying to make sense of his environment. Plan the person’s day so that fewer demands, such as bathing, are placed on him in the evening.
2. Too much input -– For an Alzheimer’s disease patient, noise, glare, and distractions can contribute to agitation. If sundowning coincides with a busy time in your household, try to reduce the number of activities going on, or move the Alzheimer’s patient to a quieter area of the house.
3. Too little input -- Some people with Alzheimer’s disease are used to having constant attention and will become agitated when you turn to other responsibilities, such as returning phone calls. Try giving the person a simple task to do nearby, or enlist another family member to spend time with her.
4. Inadequate lighting -- An Alzheimer’s disease patient who cannot see clearly because of dim light may become confused and visualize objects that aren’t there, so make sure the house is well lit in the evening.
5. The role of sleep -- People with Alzheimer’s disease suffer disproportionately from sleep disturbances, including sleep apnea. Helping the person get a good night’s sleep can reduce daytime sleepiness and may reduce disruption of the circadian rhythm, a common problem in elderly people.
6. Medication -- Because Aricept and other cholinesterase inhibitors sometimes have a stimulant effect, try giving them in the mornings if the person is not sleeping well.
7. Light therapy -- Inadequate exposure to light can contribute to sundowning. Getting the person outdoors during the day or placing the person’s chair next to a sunny window can remedy this problem.
8. Activity -- Because inactivity can lead to sundowning, try to schedule an activity the person has always enjoyed -- such as going to the store or meeting friends -- on most afternoons.
9. Distraction -- Sometimes, distracting the person can help control sundowning. Try engaging the person in a conversation about a topic he or she finds important, such as family, hobbies, or politics.

Johns Hopkins Health Alerts | Memory | Coping Strategies for Alzheimer's Disease Behavioral Problems