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Sundowning and sleep in Alzheimer's disease

June 27, 2018 0 Comments

sundowning sleep alzheimer's

by Tamara Sellman RPSGT CCSH for Advanced Cardiovascular Sleep Disorders Center]

If you have a loved one with Alzheimer’s disease, you might have noticed their behavior changes at the end of the day.

“Sundowning” describes behavior in which a person with Alzheimer’s experiences anxiety, agitation, and confusion later in the afternoon or evening.

It can also describe changes in sleepiness at the end of the day: many times, a person who is sundowning struggles to fall asleep and may become extremely restless at bedtime when they should be relaxing. They may begin to pace or wander at night, which can place them at higher risk for injury.

What is the relationship between sundowning and sleep?

Sundowning is a marker of circadian dysregulation. In other world’s a person with Alzheimer’s who is “sundowning” is experiencing shifts in their sleep-wake cycle that can lead to daytime sleepiness, insomnia, and behavior disturbances such as mood swings.

According to the Alzheimer’s Association, “Experts estimate that in late stages of Alzheimer’s, individuals spend about 40 percent of their time in bed at night awake and a significant part of their daytime sleeping. In extreme cases, people may have a complete reversal of the usual daytime wakefulness-nighttime sleep pattern.”

While sundowning is the result of imbalances in both circadian rhythms and brain chemistry, physical and external stresses can worsen periods of sundowning in those with Alzheimer’s, such as when they:

  • Don’t have appropriate lighting to help their circadian systems know the different between night and day; shadows and too bright light can be very confusing for people with Alzheimer’s
  • Experience mental or physical exhaustion at the end of the day
  • Shift away from a normal circadian pattern, forcing a change in the “body clock” (such as when traveling across time zones)
  • Don’t get enough sleep, or feel the need for less sleep
  • Struggle to differentiate from dreams and reality during the sleeping period
  • Misinterpret the intent or content of the gestures and expressions of their loved ones

How to help your loved one if they are sundowning

  • You don’t need to do this on your own. Talk to your loved one’s doctor about any sleep disturbances you have noticed, including resistance to bedtime and confusion about the time of day.
  • Pay attention for signs of other sleep disturbances. Sleep disorders like restless leg syndrome, nocturia, or sleep apnea are common in the elderly and may be contributing to a worsening of Alzheimer’s symptoms if they aren’t being treated.
  • Make sure their living environment is comfortable by ensuring rooms are adequately lit and their sleeping space is kept at a temperature that’s comfortable to them.
  • Stick to a schedule. Circadian rhythms are best maintained by following a routine bedtime, wake up time, and meal times.
  • First thing in the morning, take them outside. Exposure to morning sunlight, even if only for 10 minutes, can be an effective way to strengthen normal circadian rhythms.
  • A more active daytime leads to a more restful nighttime. Too many naps or sedentary behavior during the day can lead to insomnia or delayed sleep onset due to lack of “sleep drive.” However, make sure the activities are easy, pleasant, and stress free.
  • Avoid certain “creature comforts” (alcohol, cigarettes, coffee) at bedtime, as they can severely disrupt sleep and worsen sundowning.
  • If your loved one experiences pain from another condition (such as neuropathy, arthritis, or migraine), work with their doctor to find the safest, most effective ways to manage pain. Pain is one of the biggest obstacles to a good night’s sleep.
  • Review any medications your loved one might be taking with a doctor or pharmacist to determine whether they might be the cause of sleeplessness at night.
  • Think safety. Consider nightlights, special door locks, or sensors to help protect against falls and injuries caused by wandering during the evening. Keep the home well lit in the evening.
  • Keep your loved one away from stimulating television programming, computer games, or backlit electronic devices, which can be arousing as well as disrupt one’s circadian shift to wake to sleep.

Expect to look at nonpharmaceutical treatments for sleep problems at first. If your loved one doesn’t respond initially to nondrug approaches, their doctor may prescribe medication to help alleviate sundowning, if necessary.


 “Alzheimer’s Caregiving: Tips for coping with sundowning.” National Institute of Aging, 2017 May 17. Retrieved from the Internet on June 21, 2018.

“Sleep Issues and Sundowning.” Alzheimer’s Association Caregiver Center, n.d. Retrieved from the Internet on June 21, 2018.

 “Treatments for Sleep Changes.” Alzheimer’s Association, n.d. Retrieved from the Internet on June 21, 2018.

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