Sundowning is a phenomenon by which the person with Alzheimer's disesae may become highly agitated, active, confused, combative, anxious and/or restless in the late afternoon or evening. This behaviour can be quite out of the ordinary and be very difficult for caregivers. My father went through a phase last summer when he would not settle down at night. If he had had his way, we would have been wheeling the streets in his wheelchair half the night!

There is no conclusive evidence about sundowning Some professionals attributite to one thing; other professionals to another. Some theories:

1. Decreasing levels of light may be disorienting. The lower light provides fewer clues as to the person's surroundings and shadows may be frightening.

2. The person may feel they are supposed to "go home" around this time.

3. The person may be fatigued by the end of the day and thus be more easily frustrated.

4. Comforting noise (music, talking) may not be present and may cause panic.

5. Shift changes in facilities often occur at this time and the increase in activity may cause confusion.

6. The person may be afraid of the dark and may be making noises to fill up the emptiness.

7. The brain centres that trigger waking and sleeping schedules may be damaged by Alzheimer's.

8. At this time of day the caregiver may be tired as well and may be subtly communicating their fatigue and frustration to the confused person.

What a Caregiver Can Do to Minimize Sundowning

1. Leave lights on and close blinds to shut out the darkness. Leave a nite light on and make sure there is a well-lit path to the bathroom.

2. Try to reduce activity around the person at sundown so they are not overstimulated.

3. Try to be well rested yourself.

4. Reduce the person's caffeine intake.

5. Try to get the person to take an afternoon nap to see if this reduces fatigue and resulting agitation at sundown.

6. Try a soothing bath before bedtime.

7. Encourage more activity earlier in the day to use up energy and reduce stress.

According to a Wonderful 'Gerinet' Social Worker, Whit

I see a fair amount of this in demented nursing home residents, and used to approach it pretty superficially, seeing the main challenge as identifying the correct medication and then the secondary challenge as getting that med into the resident an hour or so before the time when he or she generally escalated.

Of course medications often can and do help with this, as with other kinds of agitation -- particularly where it is possible to tease out an agitated depression from the tangle of dementia symptoms; you get lucky sometimes and the diurnal escalations disappear once the patient is on the right antidepressant. But a slightly broader view opens up some other options.

For example, what happens mid-afternoon in nursing homes?

1. Exodus: everybody on the 7-3 shift goes home. For those who are confused about the identities of their caregivers or about the location they find themselves in (in fact, even for those who are simply angry about these things), this exodus can feel like a major trauma. I have always felt nurses and aides needed to be trained in "how to leave" without inflicting any more pain than necessary on folks who may be regressed enough to experience their departure as an abandonment, an insult, or even a taunt. The same can apply to family visits -- so many residents spend all week anticipating them, then "crash" when the visitor goes home. Rarely do residents get a chance to address feelings of renewed loss and fresh incarceration.

2. Sunset: particularly in the winter in the north, the afternoons can be just about lightless. I have heard of studies documenting the benefits of phototherapy in reducing "sundowning" but I haven't seen them.

3. Evening meal: in my experience most nursing homes give supper very early (4:30 or 5 p.m.) and place heavy value on having people eat together unless death is imminent. With demented folks who often see each other as complete strangers or else reincarnations of missing relatives, I have never quite understood the reasoning here -- are we trying to recreate ye olde family meal from 1920, knowing nothing about the individual resident's personal experience of those days? Maybe she dreaded supper back then. Maybe she and her sister fought all the time. Maybe dad was always drunk, or abusive, etc. Along with more flexible dietary options (like not being required to sit down to a standard-issue meal with so many things on the tray you must have all your faculties intact even to understand what you're seeing), I'd like to see a re-examination of how and where people eat as part of an effort to reduce late-afternoon and early-evening stress.

A related story involving auditory stimulation: Susan, one of my patients, has severe global aphasia and generally begins to cry out in early afternoon. She appears to be reacting to the excessive social and visual stimulation of being parked, after lunch, right at the nursing station where there are many other people, lots of comings and goings, and lots of noise. My efforts to get Susan relocated to a quieter spot have not worked. Even homeopathic doses of medications seem to oversedate her.

My demonstration to nursing that you can soothe her very effectively by brushing her hair for 10 minutes was met with "isn't that interesting!" but it's been hard to get any follow up. But a newly-hired nurse made a brilliant move: she put her Walkman on Susan's head and tuned in a schlocky FM "soft-rock" station. Susan's screaming stopped instantly. She sat for the entire afternoon, conscious but"hypnotized." It took some time to get the family to buy Susan a Walkman of her own, but we are literally reducing her psychiatric medications as a result of this technique, which so is working miraculously.

(By the way, I've seen dramatic results in calming down a room full of demented, bickering seniors by turning off the TV in the common room and putting something soothing, orderly and graceful -- like Handel or Bach -- on the stereo.)