Sundowning

My sister’s annual visits from Canada, always timed around the year-end holidays, are usually joyful ones, marked by reunions and celebrations.

But over the last few years the visits have also been times when we face up to the challenges of caring for the elderly, not just our own but of family and friends. As an occupational therapist and speech pathologist, she catches the smallest changes in the way they speak, the way they walk, even facial expressions.

This last visit she pulled me aside one evening when my father was becoming quite distressed, clearly disoriented and agitated, asking to go home, though he was home.  I had noticed this pattern of behavior even before she arrived.

Because I’m still raising young children, I’m all too familiar with the way they can become irritable and difficult to manage toward the end of the day.  I would mutter to myself, or to the child, “Ay, pagod” (Oh, fatigued) and, when they were younger, I would swoop them up and prepare to tuck them in. Sometimes that would get them even more irritated and they would fight back tearfully (the mild part) or holler in protest, at least for a few minutes, and then surrender.

Back to my father, my sister told me, “He’s sundowning.”

I vaguely remembered reading about sundowning among the elderly, but I have never heard the term used locally, even by our geriatricians. But my sister said it’s an easy and common diagnosis in the United States and Canada.

“Don’t worry about it,” she said, “just find ways to get him to call it a day and get him to bed.”

I laughed, “Easier said than done.  At least with children you can just carry them and lull them to sleep, sometimes with a little struggle, but not too much.”

Mental demons

I thought, too, about how we younger adults also go through something similar toward the end of the day.  I’m always telling my work colleagues to be careful about making decisions toward the day’s end because by then we’re tired, and often have feelings that are not quite rational. Anxieties, even panic attacks, tend to occur more frequently at the end of the day.

I couldn’t help but think about the dili ingon nato, the Cebuano term for the “not like us” or evil spirits.  All throughout the Philippines, and in many other places, people fear sunset because this is when the dili ingon nato come out.  Children especially are advised to stay home because of these malevolent, supernatural spirits causing harm.

There is empirical basis to the dili ingon nato beliefs in the sense that as we approach sunset, it becomes darker and we are more prone to accidents or, in urban jungles, getting mugged by ingon nato (i.e., fellow human beings).

With sundown syndrome, I’m beginning to reinterpret the dili ingon nato as little mental demons that assault us toward the end of the day, distorting our perceptions.

After my sister left, I began to read up on sundowning syndrome, which turns out to be one possible—note, possible—symptom of dementia, including Alzheimer’s.  I’m emphasizing “possible” because, as I’ve just described, people of all ages do have some form of sundowning.  The more worrisome sundowning is one marked by severe agitation.

Medical scientists haven’t quite figured out the cause of this sundowning but, curiously, they do suspect it has something to do with light. So here come again the dili ingon nato of our sunsets.  I can imagine sundowning to be much more severe in places with winter, when sunset can happen as early as three or four o’clock in the afternoon and darkness remains until eight o’clock the next morning.

Our bodies have internal Circadian mechanisms that respond to light and the mechanisms have a rhythm, which is why we get jet lag when we travel across several time zones. The body still operates on the rhythm back home so we end up awake when we should be sleeping, and doze off when we have to be alert.

With sundowning syndrome, sunset and the dark seem to disrupt a person’s mental processes even if he or she has not been traveling. Being in a hospital, or even at home with rearranged furniture, can trigger the sundowning.

I suspect there’s culture operating here, most people conditioned to looking at the darkness negatively, maybe more so as we age because it reminds us of our own lives.  Throw in the fear of malignant supernatural spirits and you can imagine the sundown syndrome becoming quite severe, complete with visual and auditory hallucinations.  Note, too, that an elderly person with poor vision, or poor hearing, is also more prone to these hallucinations or distorted perceptions.

Psychosocial support

There are no medicines for the sundowning syndrome; instead, the treatment is psychosocial.  It means making sure that the elderly have people around them toward the end of the day, being alert for these behavioral changes and possible harmful consequences. This is a time when they need to be assured and comforted.

I came across an advice to shift the elderly toward an earlier dinner and bedtime. Food is so important because lowered blood glucose can also aggravate sundowning syndrome.

Then there’s the light factor. Many senior citizens try to cut down on electric bills and are willing to sit in the dark. Encourage them to keep the lights on, then slowly reduce the exposure as bedtime approaches. I would suggest minimizing television or computer tablets as you prepare them for bed because these devices keep the mind too alert (and, with the news, distressed).  Even the light emitted by tablets has been known to cause insomnia.

As our life spans increase, we’ll find more health challenges such as this sundowning syndrome. We “young old,” aged 60 plus, are fortunate because geriatric psychology is developing rapidly and by the time we become “old old,” we should be able to handle these problems more effectively. Meanwhile, we should start conditioning our mind to welcome sunsets at the end of a busy day, a time to rest and find peace. Learn not to be too attached to places, and to habits, so our minds are comfortable with whatever places we’re in.

One of my Zen teachers gave a very good advice for these little demons: Think of them as a bunch of boisterous children rushing into the room—meaning our minds—and let them play awhile; then imagine opening a door and gently shouting at them.  “Out, out, out!” and visualize them rushing out laughing, as do your worries and frustrations.

That doesn’t mean escaping responsibilities. Just know that you will have to deal with the challenges but that you can prioritize rather than try to solve all the problems immediately. I like the biblical injunction: “Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.”  (Matthew 6:34)

Help ourselves so we can better help our older relatives—whose sundowning can become a real burden for caregivers—with more understanding and compassion.

mtan@inquirer.com.ph