What is Sundowning?

Sundowning is a lay term used to describe a set of symptoms that some people living with dementia experience late in the day. It generally describes a state of increased confusion and anxiety that presents in the afternoon; for some, it extends into nighttime. Common symptoms include aggression, pacing, confusion, wandering, and repetitive behaviors. Some people experience hallucinations, delusions, and paranoia.

According to the Alzheimer’s Association, sundowning occurs in as many as 20 percent of those living with Alzheimer’s Disease. Other dementia-related illnesses such as Lewy Body Disease, Fronto-Temporal Dementia, and Vascular Dementia also commonly present sundowning. It is common in middle and late stages of dementias and usually occurs each day, not periodically.

What causes sundowning?

The exact cause of sundowning is not known, but some experts believe it is related to disturbances of the circadian rhythm resulting from dementia-related brain changes. Additionally, the Alzheimer’s Society reports possible stimuli are inadequate interior lighting, too much noise, effects of medications, and disrupted daytime routines.

It is important to note that a person may exhibit behaviors identical to symptoms of sundowning, but they may actually be trying to communicate an unmet need. Verbal communication skills wane as the disease progresses, so the person will begin to rely on behaviors to get the caregiver’s attention.

For example, a person with dementia may display agitation due to their need to use the toilet or from pain. Identifying the need may stop the behavior. But with actual sundowning, turn your focus on acceptance that these challenges are part of the patient’s dementia journey and explore ways to cope.

How to Cope with Sundowning

Family care partners and professional caregivers alike get frustrated with dementia-related behaviors that are barriers to providing care and improving quality of life for the person in their care. Behaviors associated with sundowning are particularly difficult.

Keep a care journal to help identify your loved one’s major triggers. When you have a challenging day, think through what environmental stressors may have been at play. When it comes to caring for someone living with dementia, remember that structure and routine are your friends!

• Was the daily routine off?
• Was there a new visitor (perhaps a rowdy child)?
• Was there a new noise in the mix, such as nearby construction?
• Was there a change in medication or a missed dose?
• Did the person eat differently?
• Was there a change in bowel elimination or urination that may indicate a problem?

Helping the person in your care cope with the effects of sundowning requires great effort. Finding the right combination of environmental adjustments is specific to the individual. Try these practices:

• Before the sun sets, close the blinds and turn on the interior house lights. For some, this needs to be as early as 3 p.m.
• Assess the environment to be sure it is well lit. Shadows can confuse some patients, even to the point of experiencing hallucinations.
• Minimize noise. Turn off the television, as it tends to contribute unnecessary noise that increases confusion. Playing the person’s preferred music softly can help.
• Agitation can also be caused by a lack of stimulation—put simply, boredom. Provide activities that are soothing or enjoyable for the person during this time of day. Playing music, flipping through a large photo-heavy coffee table book, and painting are low-stress activities.
• Ideally, one-on-one interactions are best. Limit visitors to two or three at most.
• At times, your loved one may be insistent about illogical or incorrect subjects. Don’t waste energy on trying to convince the person they are wrong. It just makes the situation worse. Put yourselves in their world and go with flow. For example, if the person is hallucinating, instead of arguing that the images are not really there, you can say things like “How scary! How can I help? Should we close this closet door?”
• Take note of certain activities, such as bathing, that seem to be most difficult in the afternoon. Try to tackle those earlier in the day when the person is less agitated.
• Make sure basic needs are always met. For example, your loved one may not be aware or able to express the need to use the toilet or that they are hungry or thirsty. Providing a snack before dinner can lessen hunger and help provide a distraction while you prepare the full meal.
• Being overly tired can influence the person’s mood. A mid-afternoon nap may help reduce severity of symptoms. Know, too, that the opposite effect is possible. Too much daytime sleeping can sometimes contribute to agitation in the evenings and the inability to settle. As long as the person is still able to get to sleep at night, a nap may be a good practice to add to the daily schedule.

Family Caregiver Resources

Starr Hospice offers complimentary support and resources to individuals who are caring for a loved one living with dementia.  If you live in the San Francisco East Bay, you’re invited to join one of our educational classes, several of which are focused on dementia-care topics. There’s no requirement to be on our hospice service, and there’s no cost to you. Click here to learn more.

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