Experts say that all types of agitating behaviors are forms of communication. A client may be trying to tell you something even though the disease has robbed him/her of other ways (i.e., talking) of telling you. Perhaps the client is frightened or fatigued and does not know how to express it in words. Some experts believe that agitation behavior is "the inability to deal with stress."

"Sundowning" is a state of increased agitation, activity and negative behaviors, which happen late in the day through the evening hours. It used to be thought that sundowning was caused by the lowering light and shorter days. However, research now indicates that being overly tired may have more to do with sundowning. Here are some suggestions on how to minimize the negative behaviors associated with sundowning:

1. Make sure the client is well rested, although this may be easier said than done. It can help if you can get your client to take a nap just before their normal period of sundowning. If they cannot or will not nap, a period of quiet time (reduced stimulation and activity) may work. A proposed scenario may be to sit client down in comfortable chair/recliner, turn off the TV, turn on some soft music and then sit next to client doing a quiet activity such as crossword puzzle. Maybe sit quietly for an hour and talk or just relax. The client may rest much better and might even dose off. You might feel more relaxed also!



2. Limit outings and activities to the morning hours. Generally the individual with Alzheimer￿s Disease is better able to tolerate outings, activities and increased stimulus during the earlier part of the day. Plan any trips to the grocery store, involvement with children, visits and so forth during the earlier part of the day. This should be followed with a time of decreased stimulus and quiet time to allow the client to wind down and relax.



3. Decrease the length and amount of stimulus. Even during the earlier part of the day the individual with Alzheimer￿s Disease can only tolerate so much stimulation and commotion. Take steps to eliminate over-stimulation such as television, children, and any noise making item, quick movements and many things going on at one time. Sometimes excessive stimulation cannot be avoided. When that happens, allow the client to have a quiet area to retreat to.



4. Identify and minimize physical discomfort. Physical discomfort can also play a part in sundowning. Hunger; being wet or soiled, feeling cold/hot and other sources of discomfort can increase agitation, especially in the late afternoon and early evening. Light snacking during the day can be helpful. Apples and other fruits can help replace lost energy ￿ even if your client is pacing back and forth, that does not mean they have an endless supply of energy. Make sure the client￿s personal needs are attended to and that the climate is at a comfortable level.



5. Identify and treat medical ailments. Many ailments can contribute to sundowning and agitation. Arthritis can be one of the most common causes. An over-the-counter painkiller as recommended by the client￿s physician before the time of sundowning might be of great benefit. Urinary Tract Infections (UTI), flus/colds, asthma, allergies and other conditions are all medical ailments that can contribute to sundowning. It is always a good idea that when a client first begins to exhibit sundowning, or when sundowning becomes common, to recommend a visit to the doctor to make sure that there is nothing ailing him/her.



6. Be observant to possible causes. Many times there are triggers to agitation leading to sundowning. An example could be a children￿s video game. Noises from a video game could trigger agitation. Place the video game in a room that is out of the way and it could help decrease sundowning. Mirrors can also be trigger as well as a pictures. Watching to see what is going on, what events are happening and who is present prior to sundowning can help reveal some causes (and possible solutions). Sometimes no matter what we do sundowning will happen. If we cannot prevent it we can help lessen its effects or at least make it less unpleasant for our clients and those around them.



7. Provide a private "time out" space for the client. Ensure that the client has a private off-limits areas of his/her own. The client can retreat to his/her room if things became too much so it became their natural private area. The room should be off-limits to children and general traffic. The caregiver, too, should respect the clients need for occasional privacy while balancing that with safety concerns



8. Clear the living space. There may be times when nothing we do can ease a client during one of their sundowning episodes. You may try turning off unneeded lights, turning off the TV/radios and sitting in a quiet corner for a moment or two. Always make sure the living space is safe for the client. Never leave and always stay close by.



9. Have family check with the doctors. If sundowning is particularly troublesome the client may need some extra help from prescription medications. Talk with the Care Director/family to let them know of the behaviors, time of day and how the client is behaving before sundowning. The doctors may want to prescribe a medication to help ease the symptoms. Medication regimens can be evolving and it may take several attempts with different drugs/dosages to find the best combination for the client. Your notes and observances will be particularly important when medications are introduced or altered. If the medication does not seem to help, do not become discouraged; relay the information to the Care Director/family so that the information can, in turn, be presented to the doctor(s). Medications are only meant to take the "edge" off the behavior and are not meant to make your client dopey or groggy. Should this occur please make sure to inform Care Director/family. Remember that you do *not* provide the client medications but can only provide reminders when it is time to take their prescribed medication.



10. Keep things simple. Keep the surroundings as simple as possible. Be sure the client￿s walking paths are clear from clutter and obstacles. Low furniture such as coffee tables and footstools can make it difficult for the client and a become a source of frustration. Keep knick-knacks to a minimum and the tops of tables, television shelves and other surfaces as clear as possible ￿ working with the client to store-away any unnecessary items. Mirrors and pictures can often become unfriendly visitors that the individual with Alzheimer￿s disease cannot understand. Complicated, noisy appliances can also be frustrating to them. Avoid changing things once you have things simplified. Changes of any kind can be extremely frustrating.

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