Our residents living with Alzheimer’s or other dementias may find it difficult to control their behaviors at day’s end, which we know colloquially as “sundowning” because of the prevalence of the behavior as the sun sets.
According to the Alzheimer’s Association, as many as 20% of people with dementia experience Sundown Syndrome. The behaviors might include:
- Mood swings
- Energy surge
- Increased confusion
The behaviors can include pacing, rocking, screaming, crying, disorientation, resistance, anger, aggression and violence. The sufferer may feel the need to go somewhere or do something without actually knowing what or why. “What’s the plan?” “What should I be doing?”
What’s the trigger for these behaviors? There are lots of theories, but most agree that it has to do with fatigue as the light dims. For those of you on your feet all day, don’t you get tired? When you’re tired, aren’t you a little more irritated? Imagine your resident who’s been walking all day and his feet hurt and his knees hurt, and where’s my wife, and where’s my dinner? He’s going to act out. The light dimming may also trigger feeling unsafe and insecure and just wanting to go home.
How can we manage the symptoms and bring comfort to our residents? No one wants to see anyone suffer, and working with them to mitigate the distress works for everyone. I’m embarrassed to remember how we managed those suffering from Sundown Syndrome when I was new to healthcare many, many decades ago.
Back then, we used physical or chemical restraints on just about any behavior problem. Waist restraints, vest restraints, wrist restraints. And we didn’t just tie our elderly into their chairs; we tied them to the chairs, then tied the chairs to the hall rail. This is a vision that’s burned into my brain. The ignorance and coldness that contributed to that practice because “we’re allowed” is unconscionable.
Observe and minimize triggers. Watch your residents for fatigue. Is she falling asleep in her chair? Time to lie down for a nap. Is the unit noisy at shift change? Is the TV on too loud? Change the habits on the unit and lower the lights, allow for afternoon naps, and keep the noise at library level.
Maintain routines and structure. Ask your activities department to schedule the big stuff in the morning and maybe have more passive activities (e.g., movies) in the afternoon.
Simplify surroundings. Too much sensory stimulation, whether auditory, visual or tactile, can push the resident into disruptive behaviors. Their brains are being challenged by their dementia, don’t force them to process beyond their capacity.
Modify the sleep environment. Keep their room calm and comfortable. Many experts recommend a sleep environment at 67-70⁰ F. Keep the lights low but not dark. A completely black room can increase hallucinations while decreasing orientation and balance.
Validate, validate, validate. When your resident gets anxious because she has to pick up the kids from school, don’t say, “Your kids are grown, and they don’t go to school anymore.” Instead, say, “You love your kids, don’t you? What are their names? I bet you’re a good mom”, and keep her talking about her kids and her family. You will be surprised how quickly she calms down because she’s talking about the thing that makes her happy.
Try music. The Music and Memory program, initiated in 2006 by social worker Dan Cohen, discovered that music touches a part of the brain that is primal and brings the resident back to the person they were before dementia. Check out the film Alive Inside to see some remarkable transformations initiated by music.
As Elton John sang, “I can’t light no more of your darkness/ All my pictures seem to fade to black and white/ I’m growin’ tired, and time stands still before me/ Frozen here on the ladder of my life.”
Allowing our residents to grow old calmly and peacefully is the best we can do for them as they ascend the ladder of their lives. It’s the best we can do for all of us.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.
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