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Dementia care – what is sundowning?

Sundowning – sometimes referred to as ‘late-day confusion’ – is a symptom that causes those living with dementia to become more agitated or confused in the late afternoon and early evening. In this guide, we run through the essentials you need to know.

Quick Summary:

  • 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 are the symptoms of sundowning?

Sundowning is a distressing symptom that affects people in mid to late-stage Alzheimer’s and other forms of dementia, and as the condition progresses, the symptoms tend to worsen. Those with dementia can become hyperactive, agitated and confused, and these symptoms can extend into the night, causing sleep disruption.

Sundowning effects people in lots of different ways, but common symptoms include:

  • Confusion – for example, asking to go home when they are home
  • Anger – shouting or becoming argumentative 
  • Extreme agitation – becoming upset or anxious 
  • Emotional outbursts – sudden mood swings
  • Hallucinations – hearing/seeing things that aren’t there 
  • Restlessness – rocking, pacing or wandering
  • Paranoia – Becoming suspicious and hiding objects
  • InsomniaTrouble sleeping

It’s important to remember that as dementia progresses, 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 difficult to distinguish them from sundowning symptoms. 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 causes sundowning?

The exact causes of sundowning are not known, but it is thought that dementia damages the body’s circadian clock, which dictates the body’s daily rhythm.

Moreover, the strain of dealing with dementia on a daily basis means that those living with the condition have low energy reserves by the end of the day, and as such can become tired and irritable.

People heading towards the later stages of dementia may be depressed by the condition, but unable to express their feelings appropriately. They could be bored, tired, hungry, thirsty or in pain, but with no way of making their feelings properly felt, they become agitated.

Other factors that can trigger sundowning symptoms include:  

  • A change to their routine, or an increase in downtime over activities
  • A lack of consistent, quality sleep 
  • Too much or too little light. Shadows in particular can increase confusion and fear 
  • Prescribed medication wearing off
  • Lots of noise or an increase in unexpected noise, such as nearby traffic or construction work. 
  • The progression of other conditions, such as loss of sight or hearing. 

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How to deal with sundowning

Watching a loved one becoming irritated, upset, hyperactive – or demonstrate 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 things you can try to minimise sundowning symptoms.

Every person with dementia is unique, and it may take a while to find out what works best for your loved one. Keeping a detailed diary of your loved one’s behaviour can be a useful 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, it is helpful to draw up a timetable or schedule, 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 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, ones that aren’t too stimulating. Make sure that any clutter is tidied away, as this can cause aggravation later in the day.

Stay calm

Raising your voice or becoming angry will only worsen the situation, so 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.

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 point. In the evening close the windows to reduce any unexpected or confusing noises from outside. Ensure rooms a comfortable temperate, and are well lit so that there are no shadows which could cause upset.

Consider the use of light therapy, which makes use of bright daylight-tones to help stimulate the brain. Some families find that light therapy is helpful in the mornings, while 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.

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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.

Sundowning and care at home

Alzheimer’s and dementia can be difficult conditions to live with, not just for your loved one but also for the extended family. That’s why more and more people are turning to live-in carers to help with loved ones who are in the late stages of dementia.

Employing a highly experienced and compassionate caregiver can be a relief to families who are struggling to cope with the demands of the disease, and the peace and calm that a skilled carer can bring to a household are beneficial for everyone.

Live-in carers can provide a range of dementia care services, from simple companion care to the specific demands of dementia. They remain calm under pressure and can cope with emergency situations, making them a great option for families who are concerned about residential care for their loved ones.

They can provide genuine support throughout the day and night, which can make a significant difference for families who are finding things challenging. The cost of live-in care in the UK with Elder starts at £1095 per week.

Even if you think that you are coping well with your loved one, a period of live-in respite care can be helpful for anyone dealing with the particular demands of sundowning, allowing you to return from a short break or holiday refreshed and ready to face the challenges ahead.

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