“Sundowning or Body Clocks?” Sundowning Quite a few people are sensitive to the waning light in late afternoon; when this affects people with Alzheimer’s or related dementias, it’s known as sundown syndrome or sundowning. In some cases sundowning causes agitation, a change in personality, or increased confusion. In cases of serious agitation diagnosed as sundowning, it is quite common to prescribe an anti-anxiety medication. Before we medicate people to change their behavior, I believe we need to explore other possibilities. In my experience more often than not, these behaviors have been reactions to people’s internal body clocks rather than reaction to late day light. Body Clocks We all have more or less active body clocks. We wake up a few minutes before the alarm goes off - or we get antsy at dinnertime, whether we’re hungry or not. Most of us spend most of our lives in regular routines. Just because a person has “retired” from a job that she held most of her life, doesn’t necessarily mean her body is aware of her new life of leisure and come her old “quitting time” she may have the urge to “go home,” or she may feel incomplete until she has “closed the books” or “punched out.” What to do? If the person in your care exhibits distorted or serious changes in behavior in the late afternoon, I recommend that you explore the possibility that she’s reacting to old body clock impulses, before assuming this to be sundowning. If you cannot identify an exact cause, try to use a diversion that relates to her former life: if she was a bookkeeper, give her a spread sheet or if she worked in retail hand her a cash box with change to be counted. (Whether or not she actually engages in the project, be sure to thank her for her help.) You may have to use a loving lie to help her out of her distress. A loving lie may sound deceiptful to you, but as you'll see by the examples below, it becomes her truth as it is based on her reality at the moment. Marge Marge had been from moved her own apartment to the secure Alzheimer’s wing of her facility. There had been no attempt to gently transition her into this restrictive environment. She recognized right away that this was a secure unit (locked.) and was understandably devastated. Daytime was not bad, all things considered; she was confused and unhappy, but tried her best to fit in, but in mid-afternoon she was at the locked door trying in vain to work the code on the keypad. When her attempts failed she started pounding on the door and yelling for someone to open it. Several minutes later she had collapsed into a pile on the floor, sobbing. The staff tried valiantly to coerce her back into the common room with no luck. Finally two aides dragged her away from the door. Once they had gotten her into the common room, it took considerable time and effort from both of them to calm her down. During the day Marge continued to adjust quite well. She was by nature a social person and during that first week, she was quick to make friends with the other residents. However, by mid-afternoon she was back at the locked door and her agitation increased. By the end of the week, we knew we had to intervene one way or another. We decided to start by assuming this was a body clock reaction rather than sundowning. A conversation with her daughter bore this out. She revealed that when she and her siblings were young, Marge would routinely pick up them up from school every afternoon. This information immediately explained her outbursts. We suspected that the stress of the move had activated her old body clock and sent her into this altered reality. In her mind, she was a young mother and her children were stranded in front of the school and this locked exit was preventing her from reaching them. No wonder she was panicked and hysterical. The Loving Lie: Once we understood her history, we decided to use a loving lie to help her. The following afternoon when Marge was once again pounding on the door, we “relayed” a message from her friend who had called just then. We told her that her friend would pick up all the children from school today. Sensing that Marge wouldn’t want any favors from anybody, we decided to add that her friend expected Marge to pick them up tomorrow. She reacted with immediate relief, reverted back to her “present” self, and readily accepted our invitation to join the others in a cup of tea. We used our loving lie for the next couple of weeks until one afternoon when she simply stayed in the common room and shared tea with the others. She seemed to have forgotten all about the school, the children, and the exit door. I took this as a sign that she finally felt safe in her new environment. *** Betsy Like Marge, Betsy was social and easygoing. She cheerfully participated in activities. However, around 4 o’clock in the afternoon her personality changed. On better days she would simply be sullen and distant; on the worst days she would become restless, fidgety, and agitated, sometimes to the point of tears. This had been going on for weeks and it had been assumed to be sundowning. When she was particularly agitated, we tried to distract her and get her involved in activities. It might work for a few minutes, but before long she would start pacing around the serving counter. Because her behavior was so specific, we decided to explore the body clock possibility. We learned that her husband was a stickler for rigid schedules and during the fifty years of their marriage Betsy had served dinner daily at six o’clock sharp. Once we learned this, her agitation made sense. In her mind, Betsy needed to prepare dinner and there was nothing for her to work with. The dining room in the dementia wing had a small kitchen, but it was only used to hold the meals brought down from the main facility kitchen. Ideally, we would have asked Betsy to help with food preparation, but unfortunately all the meals arrived fully prepared. We did ask her to help set the table, but that only worked to accelerate her agitation. We had to find another solution. The Loving Lie: We told Betsy that someone else was doing the cooking tonight, because she deserved a day off after all those years of making dinner every single night. She accepted our story with no hesitation. She welcomed the break, which was understandable; apparently her husband was quite controlling and had run a tight ship, including the household. We used slight variations of this theme for the next several days whenever we needed to help her relax. By the end of the second week her restlessness was gone and she was happily interacting with the other residents right up till dinnertime.