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Caregiver Training Blog

Risk Factors for Sundowning

The first step in lessening the number of episodes or severity of sundowning syndrome is minimizing risk factors for the person with the condition, which is characterized by confused or agitated behavior at nightfall. 

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If you can help identify someone's risk factors for sundowning, you can take steps to reduce them. Reduction of risk factors will hopefully help lessen or eliminate episodes of the syndrome, or reduce their severity. This can equate to improvements in quality of life for the person experiencing the condition — and their caregivers.

So what are the risk factors for sundowning? This is a hot topic in the medical field right now. Some factors believed to increase someone’s risk factors for sundowning include:

  • Age
  • Fatigue
  • Damage to a part of the brain called the suprachiasmatic nuclei (SCN)
  • Environmental conditions
  • Medication and medical conditions
  • Circadian disregulation

Sleep and Damage to the SCN

People spend a third of their lives in the physiologic state of sleep, and restful sleep is like a powerful medicine. Sleep — or lack of it — can impact those who experience sundowning.

As those with dementia age, damage begins to occur to SCN, which is positioned very deep in the brain beneath the hypothalamus. Data indicates that this is a sleep-promoting center, and that it is affected by light and temperature, along with certain kinds of neurotransmitters, like melatonin.

Our brain produces melatonin, and evidence indicates that melatonin helps induce and maintain sleep. Melatonin is a protein that is triggered by darkness, so as darkness falls, we get more of it. As light occurs, it fades out. People lose melatonin as they age.

Some experts believe a risk factor for sundowning syndrome may be damage to the SCN, causing a loss of volume and neurons. With this damage cellular physiology and metabolism is also lost.

Unfortunately, it is not yet known how to avoid damage to the SCN, but that could be on the horizon.

Environmental Conditions

Another risk factor believed to affect sundowning is a person’s environment, such as noise, lighting and other distractions. If you visit a memory care unit at a nursing home at 9 a.m. and then 5 p.m., you’ll notice differences in these ambient factors. The lighting will be different, the staff will likely have changed and unique noises may be present.

At night, residents will have a different level of exposure to artificial or natural light. Shadows may appear. Residents may be exhausted or depleted from daytime activities. Noises like bed alarms, medical devices and medication dispensations may cause disruptions. Any of these elements may trigger sundowning.

Medication and Medical Conditions

Medication may also be a risk factor for sundowning. Medications are dispensed in different dosages, and may have differing concentrations throughout the day. So people that are getting morning medicines may experience a drop in concentration by 4 p.m.

A patient’s medical conditions may also impact sundowning. Imagine someone with congestive heart failure, arthritis and type 2 diabetes that causes their blood sugar levels to swing. Imagine they’ve had a hip replacement and a knee replacement. Even if they wake up feeling refreshed and full of energy, they may begin to experience pain as the day wears on. This could contribute to an episode of sundowning.

Circadian Dysregulation

Some of the current medical thinking is that sundowning may have a lot to do with circadian dysregulation. This means that the circadian rhythm — or the 24-hour process that living beings undergo, which can be affected by light and temperature — becomes misaligned somehow.

One of the theories is that perhaps dementia patients experiencing sundowning syndrome are getting inadequate exposure to light early in the day. And this could be coupled with damage to the SCN and decreased melatonin production. Then later in the day, lighting becomes lower and shadows appear. If you already have a baseline of confusion, these other factors can turn it up a notch.

For more information on caring for a person with sundowning, including coping strategies, read our online guide to sundowning syndrome.

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