Alzheimer's disease and 'sundowning' - what you need to know

People with Alzheimer's disease often experience a worsening of symptoms during the late afternoon and evening, which experts refer to as sundowning or sundown syndrome.

You may not be able to prevent sundowning entirely, but there are things you can do to reduce the worst of its effects – so that you and your loved one are better able to cope.

See also: Eight hidden signs of dementia

See also: People 'frequently misdiagnosed with common types of dementia'

Symptoms
If you're caring for someone with Alzehimer's disease, you may notice that they become increasingly agitated, confused and demanding as the light fades, and generally improve by morning.

When someone is experiencing sundowning, they may be:

• Disoriented
• Suspicious
• Agitated
• Restless
• Confused
• Demanding
• Irritable
• Aggressive

They may also experience mood swings and be more likely to suffer from hallucinations. These aren't always frightening - sometimes a person with Alzheimer's will set the table or talk to someone who isn't there, and it brings them comfort.

What causes sundowning
Scientists aren't exactly sure why sundowning occurs. The main theory is that Alzheimer's disease affects a person's inner body clock, interfering with the part of the brain that differentiates between waking and sleeping.

There are a number of factors which can make sundowning more likely. Being overly tired, hungry or thirsty, bored, depressed or in pain can all increase the risk of sundowning.

The environment of someone with Alzheimer's disease can also play a part. For example, less light and more shadows in the house can cause anxiety and fear.

How to help prevent it
Studies have shown that putting a full-spectrum fluorescent lamp about one meter from the person suffering from sundown syndrome and within their visual field for a couple of hours in the morning can help to re-set their biological clock, which in turn will make them less agitated at sundown. Try switching it on while your loved one is watching TV or engaged in some other daily activity.

It can help to look for patterns and note any obvious triggers which you can then avoid. Keeping to a daily routine, with regular times for waking up, meals and sleep can help.

People with Alzhemier's can be suspicious of new people and any changes to their routine. If you need to schedule an appointment – such as seeing their doctor, or want to go on an outing, make sure you schedule this for the morning when they are at their best.

Ensuring your loved one gets enough sleep can help to avoid the effects of sundowning. That's much easier said than done, but there are things you can do. For example, smoking, drinking alcohol and caffeine are all best avoided as they will interfere with sleep.

Daytime naps are sometimes unavoidable, but try to keep these brief and ensure they are at least four hours before bed time.

The resulting drop in blood pressure after eating a big meal can make symptoms worse. Make lunch the main meal of the day and ensure evening meals are light are easy to digest. If the person is agitated because they're hungry, try serving food earlier or offering them a snack or drink until dinner is ready.

Darkness and shadows can trigger confusion and fear, so before twilight, close the curtains and turn on the lights. Cover 'hallucinogenic props' like wardrobe mirrors, ensure curtains are not moving in the wind, and modify lighting so that it does not throw shadows.

Keep the room temperature comfortable, limit loud noises and do an activity that's relaxing. For example, you might want to listen to calming music, read, or look through a memory box together.

How to react
Caring for someone with Alzhemier's disease can be emotionally, physically and mentally draining – and it's normal to feel tired and frustrated at the end of the day. Your loved one may pick up on your change in tone and behaviour, even if you do your best to hide it. Try to be aware of your emotions and get extra help – join a support group, speak to relatives, or your GP.

When the person you're concerned about is sundowing, try to stay calm and ask if they need anything. Don't argue or try to convince them they are mistaken – use distraction techniques when possible and reassure them that everything is ok.

If they become restless and need to pace, don't stop them. Instead, use locks on doors and windows, a gate to block the stairs if necessary, and ensure anything sharp is put safely away. Trying to prevent them from moving around is likely to make them feel more frustrated. Consider investing in a baby monitor or motion detectors to alert you when your loved one is moving around.

Try to speak in a calm, reassuring voice and let the person know that you're listening by holding their hand or stroking their arm for a few minutes. A little reassurance ca n go a long way in keeping someone calm.

When to see your GP
If sundowning is a problem, it's worth speaking to your doctor for advice. They will be able to check that any medications given to relax or sleep don't confuse more confusion the next day.

Take care of yourself
Sundowning can make it difficult for you to get restful sleep, so consider asking a friend or relative to fill in for you - or contact a health care service to provide backup. Take daytime naps and breaks whenever you can and join a caregiver's support group for support and advice.

You may not get much time to yourself, but it's important to eat well and exercise and spend some time with friends – you need to take proper care of yourself in order to be there for your loved one.