What is Sundowning | Dementia Care | Elder

Quick overview

Sundowning is a term for “sundowner’s syndrome”, which is a set of symptoms experienced by some people with dementia. These usually include increased confusion, sleep problems, anxiety, agitation and hallucinations. Doctors don’t fully understand why sundowning happens, but certain factors have been identified that can make it worse such as changes to routine, the clocks changing, and prescribed medication wearing off.

It doesn’t affect everyone. It’s estimated that up to 20% of those with dementia or Alzheimer’s will experience sundowning symptoms at some point.

Doctors don’t fully understand why sundowning happens, but certain factors have been identified that can make it worse. These include changes to routine, poor sleep, and prescribed medication wearing off.

There are lots of things you can do to support someone through sundowning. This is especially important around Daylight Savings Time, which can intensify feelings of confusion or exhaustion.

What is sundowning?

Sundowning is the name for behaviours, feelings and thoughts people with mid to late-stage Alzheimer’s and other forms of dementia experience as the sun sets, and is often known as late-day confusion. As dementia progresses sundowning symptoms tend to worsen.

Sundowning behaviours can potentially occur at any time, not just at sunset. Those with dementia can become hyperactive, agitated and confused, and these symptoms can extend into the night, causing sleep disruption.

Sundowning is experienced by approximately 20% of individuals diagnosed with Alzheimer’s disease.

What are the symptoms of sundowning?

Sundowning affects people in lots of different ways, and some symptoms are specific to the time of day. Symptoms associated with sundowning include: rocking in chairs, pacing, violence, wandering, yelling, crying or following their caregiver very closely. People who experience sundowning can feel many emotions and therefore suffer from anxiety, fear, restlessness, sadness, confusion and paranoia.

It’s important to remember that as dementia symptoms progress, a loved one’s behaviour and the way they communicate with you will naturally change.

When these changes happen towards the end of the day, it can be difficult to distinguish them from sundowning behaviours. Take a moment to talk to family members and carers about these changes to understand if there may be other reasons for them aside from sundowning.

What makes sundowning worse?

Sleep deprivation and sleep issues are common causes of episodes of sundowning. However, there are other possible triggers that can make sundowning worse, including infections, dehydration, side effects of medications, physical illnesses, overstimulation and low lighting.

Can Sundowning be treated?

Addressing the root cause is the primary method for managing sundowning. However, there are additional approaches available for addressing its symptoms.

There are non-medication treatment options known to ease sundowning symptoms, such as light therapy, music therapy.

Environmental changes can make sundowning worse. Therefore, keeping a person with dementia in a familiar place, or if this isn’t possible, ensuring they’re surrounded by familiar objects such as family photos, gifts, jewellery, furniture, etc. nearby. It’s important to provide bright natural lighting during the day and a dark environment at bedtime for your loved one. If they wear glasses or hearing aids, ensure they’re easily accessible.

Having a familiar and calming bedtime routine can also ease the symptoms of sundowning. You can do this by –

Creating a peaceful sleeping environment. This may include turning off electronics such as the television.
Playing music with with a calming tempo at a low volume.
Reading a book to them.
Engaging in a straightforward activity such as sharing a snack, completing a basic puzzle, or watching a preferred television program.
Creating consistent sleep habits by ensuring your loved one goes to bed at a regular time each night.

Are there potential medications to treat sundowning?

Medications can be prescribed to treat the behavioural, emotional, and cognitive symptoms experienced by individuals who go through sundowning. Some examples are:

Medications used to treat depression.
Medications for anxiety.
Antipsychotics (should be used with caution due to their long-term risk of stroke.)

How to deal with sundowning

Watching a loved one becoming irritated, upset, hyperactive – or demonstrating other behavioural problems – can be distressing, but it’s important to remember that they are not in control of their actions. There are also lots of approaches for sundowning reduction that you can take.

Every person with dementia is unique, and finding out what works best for your loved one may take a while. Keeping a detailed diary of your loved one’s behaviour can be a helpful way of identifying triggers and managing symptoms.

Maintain a positive routine

The most important thing to do is to ensure that your loved one has a routine tailored around sundowning behaviour to eliminate it as far as possible.

To this end, drawing up a timetable or schedule with target meal times and activities may be helpful – ensuring that busy activities and outings are arranged for the morning when your loved one is feeling at their best. Once you have a routine in place, it’s essential to stick to it.

During the late afternoon, try to engage your loved one in calming activities that don’t require too much thought. The aim is to undertake simple and engaging activities at this time that aren’t too stimulating. Ensure any clutter is tidied away, as this can cause aggravation later in the day.

Stay calm

An emotional outburst in reaction to theirs will only worsen the situation. Try to remain calm, no matter what the provocation. Speak in clear sentences, don’t try to rationalise with them and keep reassuring them that everything is ok.

Encourage good sleep habits.

Try not to let your loved one have an afternoon nap if possible as this may contribute to confusion later – if they have to take a nap, ensure that it doesn’t last too long so they’re still able to rest at night.

Try to minimise their caffeine intake too, or keep caffeinated drinks for the morning.

Provide a peaceful environment.

Making the home a suitable environment for those with dementia is another positive step. In the evening, close the windows to reduce any unexpected or confusing noises from outside. Ensure rooms are at a comfortable temperature and are well-lit so that there are no shadows which could cause upset.

Consider using light therapy, which uses bright daylight tones to help stimulate the brain. Some families find light therapy helpful in the mornings. In contrast, others favour its use around twilight to reset the body’s biological clock and restore the circadian rhythm. Some dementia-friendly products can help make that happen.

Does sundowning get worse when the clocks change?

Many of us will naturally experience tiredness when the clocks change. However, for those with sundowning symptoms, Daylight Savings can be an intensely confusing and anxious time. Sundowning symptoms will often be more pronounced in the days and weeks following the clocks going back, so here are a few additional steps you can take to help them through seasonal changes.

Try not to introduce anything new to their routine the week leading up to and after the time change. Sticking to the same scheduled activities and tasks will provide stability and safety. If you do need to shift their routine forward by an hour, do so in small increments over 7 to 10 days.
During the day, take your loved one outside for a walk or to spend some time in the garden. Natural sunlight helps to regulate their body clock.
Turn on lights and close curtains and blinds before it starts to get dark. Seeing the sky change from day to night when they’re not expecting it can be triggering. Likewise, if light is coming into the bedroom too early and waking your loved one, invest in some blackout curtains.

Worried about wandering?

Our Head of Clinical Alexis Cable has shared some practical steps you can take to manage this symptom of dementia.

This article is for informational purposes only and not to be taken as medical advice. For medical advice, always consult your GP.

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