Ask the Doctors

Dear Doctor: My husband was in the hospital recently, and at night he would get quite agitated. He yelled, took off his clothes and tried to pull out his IV. He had to be secured to his bed to keep him from leaving. But in the morning, he'd be fine and couldn't remember anything from the night before. What's happening? How can I help?

Dear Reader: What you've described is a few of a group of behaviors commonly known as sundowning, or sundowner, syndrome. It's a descriptive term, not a psychiatric diagnosis. However, it's broadly recognized as anxiety, confusion or agitation that is triggered by the onset of waning daylight. Sundowning can begin anywhere from late afternoon to late evening, and usually resolves in the morning, with the return of daylight.

In addition to the symptoms that you mentioned, people may have mood swings, become demanding, suspicious or even paranoid, hallucinate, hear voices, pace or become unaware of time and place. While sundowning is most commonly observed in people with dementia, impaired cognition and Alzheimer's disease, it can also affect individuals who are institutionalized.

Exactly what causes these behaviors to develop isn't yet known. However, in addition to the low light and emerging shadows that give the syndrome its name, triggers can include fatigue, sleeplessness, lack of mental stimulation, disrupted circadian rhythms and the presence of an infection, such as a urinary tract infection.

To see your loved one vanish into the throes of sundowning is upsetting and painful. But once an episode has begun, neither logic nor coaxing can help. Don't try to talk or reason the person out of their fears. If they are hallucinating, don't try to bring them into the present. The best thing you can do is stay calm and be reassuring.

Over the long term, approaches to managing this behavior include:

-- Set up a daily routine with consistent waking and bed times, and regular mealtimes. This will form a predictable framework that can help the individual feel safe.

-- Schedule any taxing activities for early in the day, when the person is at their best. Try not to do more than one or two significant activities, like a doctor's appointment, a shopping trip, or visits from friends or relatives, per day.

-- Watch the diet for any possible triggers. If it turns out that caffeine and sugar cause problems, consider eliminating them, or limit them to earlier in the day.

-- As daylight fades, turn on lots of lights and close the curtains. Limiting noise can also be helpful.

-- Check with your family doctor to see whether a supplement like melatonin may help with sleep cycles.

We are keenly aware of the mental and emotional challenges of being the caregiver at a time like this. That's why we think it's so important that you take time -- make the time -- to care for yourself as well. Take regular breaks, enlist outside help and see a counselor to help process what you're going through. It will bolster your own health and will help you to be an even more effective caregiver.

And if any of you readers have successful strategies we haven't mentioned that you'd like to share, we'd love to hear from you.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

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