Sundowning: Understand The Causes, and Tips to Make it Better

What causes sundowning, and is there anything you can do to decrease the effect? Listen and get show notes: https://bit.ly/3CbLHET

Sundowning is a behavior change in people who become agitated, uncooperative, hallucinate, pace, or have increased confusion as the sun goes down.  It has been found that these behaviors do not only occur for elders with dementia, but also older adults without the disease, young people, and older dogs.

In this Episode:

• 01:44 - Recipe: Mississippi Chicken
• 02:13 - Notable Deaths from 2024
• 05:13 - Sundowning - What is It?
• 08:38 - Things that Make Sundowning Behavior Worse
• 09:17 - What Can Help Sundowning?
• 10:43 - Can Dogs Get Sundowning Behaviors?
• 14:33 - Ranata Suzuki - One Piece of Advice to Hold
• 16:00 - Outro

Understanding Sundowning
The behaviors that are associated with sundowning are confusion, anxiety, agitation or aggressiveness with increased motor activity (e.g. pacing, wandering), and yelling, all of which get worse as the sun is going down. So what causes sundowning? Read more below.

The Link to Circadian Rhythm
The current thinking is that these sundowning behaviors occur at sunset is because of an impairment of the circadian rhythm from damage to the sleep-promoting center in the hypothalamus and decreased production of melatonin. Listen to learn more about the cause and why it is important.

Is There a Way to Help Decrease Sundowning?
We talk about several ways to help, from adjusting light exposure through the day, to adjusting the environment and activities, to possible medications. We also talk about additional physical conditions that can contribute to sundowning that you can watch for such as urinary tract infections and dehydration. Listen to the podcast for a detailed list of ideas.

Related Episodes:

• S3E50: Caring for a Partner with Dementia
• S2E7: Nonpharmacological Management of Dementia
• S3E47: Frontotemporal Dementia Part 1 – What Is FTD?
• S4E16: Understanding Vascular Dementia, the Second-Most Common Form
• S1E48: Alzheimer’s Disease
• S5E37: Memory and Alzheimer’s Disease
• S2E1: Lewy Body Disease
• S1E34: Huntington’s Disease

Chapters

• 0:00 Intro
• 1:44 Recipe: Mississippi Chicken
• 2:13 Notable Deaths from 2024
• 5:13 Sundowning – What is It?
• 8:38 Things that Make Sundowning Behavior Worse
• 9:17 What Can Help Sundowning?
• 10:43 Can Dogs Get Sundowning Behaviors?
• 14:33 Ranata Suzuki – One Piece of Advice to Hold...
• 16:00 Outro

Transcript

Sundowning Understand The Causes AndM Tips To Make It Better

This podcast does not provide medical nor legal advice. Please listen to the complete disclosure at the end of the recording. Hello and welcome to Everyone Dies, the podcast where we talk about serious illness, dying, death, and bereavement.

I'm Marianne Matzo, nurse practitioner, and I use my experience from working as a nurse for 46 years to help answer your questions about what happens at the end of life. And I'm Charlie Navarette, an actor in New York City, and here to offer an every-person viewpoint to our podcast. We are both here because we believe that the more you know, the better prepared you are to make difficult, end-of-life decisions.

Welcome to this week's show. Please relax, get yourself a cup of Theraflu, or I'm sure many of you are having symptoms by now, and a cookie or six, and thank you for spending the next hour with Charlie B. as we talk about sundowning. Like the BBC, we see our shows offering entertainment, enlightenment, and education, and divide that into three halves to address each of these goals.

Our main topic is in the second half, so feel free to fast forward to that baleful din-free zone. In the first half, Charlie has our recipe of the week and notable deaths from 2024. In the second half, I'm going to update you about the syndrome called sundowning and offer you some of the latest thinking on the subject.

And in the third half, Charlie has advice for Renata Suzuki. So sundowning, I mean, does the sun ever come up anymore? Um, in some parts of the world, I notice it has. Our travels this week take us to Mississippi.

Our recipe this week is Mississippi chicken, where chicken is the star with peppers, adding tang and texture. Made in a crock pot, this chicken is so tender it falls apart. And the dish is hearty, savory, and altogether comforting.

It's that comfort that will make this your new favorite funeral lunch offering. Bon appetit. Now, one of the many philosophical principles we have here at Everyone Dies is, eh, better late than never.

So, before we close out January, we have for you a list of notable deaths from 2024. Actor Donald Sutherland. Louis Gossett Jr., the first black man to win an Oscar for Supporting Actor.

Quincy Jones, trumpeter, bandleader, record producer, composer, arranger, who also produced Michael Jackson's Thriller, the best-selling album of all time. Nikki Giovanni, poet, commentator, and activist. Pete Rose, also known as Charlie Hustle, one of the greatest baseball players, but never showed remorse for gambling as a player, nor his behavior off the field.

Linda Lavin, Broadway actress and star of TV's Alice. Singer, songwriter, and actor Chris Christopherson. His most famous song is Me and My Bobby McGee.

Oscar winner and the Dowager Countess of Granton in the series Downton Abbey, Dame Maggie Smith. NBA star Bill Walton. Dr. Ruth Westheimer, also known as Dr. Ruth.

Holocaust survivor, former sniper, sex therapist, and talk show host. Also pioneering talk show host Phil Donahue, who spoke about a wide range of topics, including clergy sexual abuse, before major media discussed it. Great baseball center fielder Willie Mays, who began his career in the Negro Leagues.

Phil Lesch, founding member of the Grateful Dead. Ricky Henderson, one of the greatest leadoff hitters in baseball. Trina Robbins.

Trina was a pioneering feminist cartoonist and writer. She was the Trina of the Joni Mitchell song, Ladies of the Canyon. May they rest in peace.

Please go to our webpage for this week's recipe and additional resources for this program. Everyone Dies is offered at no cost, but is not free to produce. Please contribute what you can.

Your tax-deductible gift will go directly to supporting our non-profit journalism, so that we can remain accessible to everyone. You can also donate at www.everyonedies.org. That's every, the number one, dies.org. Or at our site on Patreon, www.patreon.com. And search for Everyone Dies. Marianne.

Thanks, Charlie. Anyone who's cared for a person living with dementia has likely observed behaviors known as sundowning. We can easily recall older adults with dementia becoming agitated, uncooperative, hallucinating, pacing, having increased confusion that can happen as the sun goes down.

These behaviors were first talked about in professional literature in 1941 when, quote, senile patients were put in a dark room and within an hour became delirious and agitated. At that time, it was called dark room delirium. These behaviors were named sundowning in 1987 following a study by Evans where she gave standardized confusion inventories to older adults in the morning and evening who were living in a nursing home.

She observed that as evening approached, there were more restless and agitated behaviors in those elders who had a greater degree of dementia and greater mental impairment. Since 1987, there's not been a standardized definition of sundowning developed and adapted by scientists, nor is it an actual diagnosis. And we've found that these behaviors do not only occur for people with dementia, but also older adults without disease.

Some young people and older dogs. Typical early signs of delirium include sundowning, withdrawal, irritability, new forgetfulness or befuddlement, and or new onset of incontinence. Later signs include outbursts of anger, hostility, or abusive behavior.

Confusion, agitation, or restlessness is usually worse at night when a person can become disoriented to place, person, date, and time. Recent studies in large literature reviews have proposed that this definition of sundowners is a cyclic delirium-like condition of older persons that lasts for a few hours and occurs around the sunset hour where no direct physical problem or other medical condition exists. The behaviors that are associated with sundowning are confusion, anxiety, agitation, or aggressiveness with increased motor activity like pacing or wandering and yelling.

All of which get worse as the sun goes down. The current thinking is that these behaviors occur at sunset is because of an impairment in the circadian rhythm from damage to the sleep-promoting center of the hypothalamus and decreased production of melatonin. Melatonin is the hormone that regulates circadian rhythm.

Circadian dysregulation can occur when there is not enough exposure to light during the day. If the person is inside, low lighting and increased shadows can heighten late-day confusion. The environment also changes toward the end of the day.

There's less exposure to light and in long-term care environments, there's a lowering of the noise level and fewer activities going on. People who take their medications in the morning may find that the drug level is lower or there's a change in blood sugar levels before dinner. Pain medication may be wearing off so people may have an increased pain level.

Any or all of these factors can increase agitation for a person. There are things that can take a toll on an older person's body and make sundowning behaviors worse. These are not getting enough sleep, being in pain, depressed or stressed, constipation, having a urinary tract infection, too much activity or too many people around, dehydration, and low lighting in the room.

If you're caring for someone who's sundowning, you could make a checklist for yourself and see which factors you could fix or prevent from occurring to lower the chance of aggravating the situation as the sun is setting. Possible treatments to prevent sundowning would be to correct circadian disruption with melatonin, and some studies have suggested risperidol, which is an antipsychotic, or donathpazol, known as Aricept, to treat Alzheimer's disease. Environmental treatments are getting more sunlight during the day or using light boxes to get the correct wavelength of light.

The ideal time for this is between 9.30 in the morning and 11.30. Plan midday pain medication so the person is comfortable and not in pain as the sun is setting. Activity is also a good treatment. As the sun is setting, people are often doing other things, like making dinner, and there's not enough distraction for the older adult.

Plan activities for this time, or if they're able to help you with dinner, offer a reasonable task that they can do with you. Give them a basket of clothes to fold. It doesn't matter how well they're folded, or if you have a few baskets of things to be folded so there is something useful to do in distracting during these witching hours.

Play music that they like and sing along. Leave the lights on bright so there are no shadows to misinterpret. You can use Skype or FaceTime to let them talk to family members or friends, or have them scroll through Facebook videos as a form of distraction.

Now, I mentioned older dogs can have sundowning behaviors, and it looks like it does in people. The sundowning is part of a canine cognitive dysfunction, and the symptoms occur in 68% of dogs by the age of 16, or to put it another way, nearly two-thirds of 15- to 16-year-old dogs have some level of dementia. Signs of dementia in dogs are disorientation, changes in social behavior, changes in sleep patterns, potty accidents in the house, and increased anxiety and changes in activity and appetite.

The current thinking is that sundowning results from a change in the circadian rhythm. There's no scientific evidence regarding what is the cause of this change. So, until studies with stronger methods and larger sample sizes are conducted, we're left with knowing that sundowning occurs and what things can be done to lower the burden of the behaviors in the older adults and caregivers.

Charlie, have you ever seen anybody have sundowning behaviors? No, this is really fascinating. I've never heard of this. I mean, I get the idea of sundowning.

I don't know, I keep thinking of some movie, or maybe it was a documentary. No, I never heard of that. It's interesting.

Also, to hear you talk about pets. Wow, I don't know what to say to that. No, it's really fascinating, sundowning.

Well, if you do have older pets and they're doing some strange kind of behaviors, instead of saying, well, time to put them down, and I don't know, maybe it is. But I know when we had Dimple Rose, she died when she was 15 and a half. And probably around when she turned 15, she started to be incontinent of urine.

And this was a dog who could hold her bladder until she burst. She was just not going to pee in the house. But she started doing it.

And so we put diapers on her. And she was perfectly fine with a diaper, which this is a woman who never would have been fine with a diaper. So she wore diapers so that we took it off when she went out to go do her business or just walk around the yard.

But she also had some different changes in behaviors in terms of walking around, kind of getting lost, that kind of thing. And I remember saying to David at the time, it's like, I wonder if dogs can sundown, because I didn't really know that they could, because her behavior was like that. And then she would settle.

But she'd have this like witching hour for a couple of hours as the sun went down, where she would be a little bit, you know, pacing, a little bit more aggravated. And then she would settle. Okay.

So you mentioned dogs. I mean, did it happen with cats or, I don't know, a horse? What have you seen? I don't know. I'm from Detroit.

I don't see many horses. Gordon Lightfoot. Remember his song, Sundown? Yes.

Yeah, I mean, the metaphor in that's just perfect to what you're talking about. So moving on. In our third half, as we are striding into the new year, here is some advice to consider from Renata Suzuki.

If I could offer you one piece of advice to hold, a life half-lived, if I could give you one piece of advice to hold in your heart, it would be to appreciate every second you have with the things that you love, be they places, objects, or people, because there is a last time for everything, and you don't always know when it's the last time, when you're in it. There will be a last time you see a sunrise, a last time you taste ice cream, and a last time you smell a rose. There will be a last time you enter every room, a last time you hold every pet, and a last time you hear a loved one's voice.

Sometimes we know we are in those moments and we can savor every second of them, but so often we don't know until that moment is gone and it's too late to go back and relive it. So hold on to those moments while you have them, live inside them, appreciate them to their fullest, every time, so you'll never regret taking them for granted one day when they're gone. Please stay tuned for the continuing saga of Everyone Dies, and thank you for listening.

This is Charlie Navarette, and the last words of the Dowager Countess, played by Dame Maggie Smith on the series Downton Abbey, stop that noise. I can't hear myself die. And I'm Marian Masso, and we'll see you next week.

Remember, every day is a gift. This podcast does not provide medical advice. All discussion on this podcast, such as treatments, dosages, outcomes, charts, patient profiles, advice, messages, and any other discussion are for informational purposes only, and are not a substitute for professional medical advice or treatment.

Always seek the advice of your primary care practitioner or other qualified health providers with any questions that you may have regarding your health. Never disregard professional medical advice or delay in seeking it because of something you have heard from this podcast. If you think you may have a medical emergency, call your doctor or 911 immediately.

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