Dementia and sundowning – advice for caregivers
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Dementia Care
Sundowning is a term for “sundowner’s syndrome”, which is a set of symptoms experienced by some individuals with dementia. These usually include increased confusion, anxiety, agitation and hallucinations. Symptoms often happen towards the end of the day and continue into the night, which can lead to irregular sleep patterns.
Doctors don’t fully understand why sundowning happens, but certain factors have been identified that can make it worse such as changes to daily routine, the clocks changing, or the effects of medication wearing off.
Quick overview
It doesn’t affect everyone. It’s estimated that up to 20% of people with dementia or Alzheimer’s will experience sundowning symptoms at some point.
It can happen at any stage of dementia, but is most common during the middle and late stages.
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 issues.
Why do dementia patients get worse at night?
There are a number of factors that experts believe may cause people with dementia to become more active or distressed at night. These include too much or too little sleep, low light levels and increased shadows or feeling hungry thirsty or in pain.
Side effects of medications or medications wearing off may also make sundowning worse too. If you think a prescribed drug is contributing to sundowning symptoms, it’s important to discuss these worries with your loved one’s GP.
How do you know if someone is sundowning?
Sundowning symptoms can vary person to person, and some symptoms are specific to the time of day.
Common symptoms associated with sundowning include: rocking in chairs, pacing, violent outbursts, 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 dementia-related behaviors 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, or to identify any patterns.
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. Some therapeutic approaches are believed to ease sundowning symptoms, such as light therapy, music therapy. These may help create a sense of calm.
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 may help. It’s important to provide natural light 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.
Keeping things calm at bedtime
Having a familiar and calming routine for bedtime 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 during the evening hours.
- 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 symptoms of sundowning can be managed
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 consistent 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. This will also help them to get some good exposure to sunlight and physical activity which may help them feel sleepier towards the end of the day. 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 in the afternoon hours that aren’t too stimulating. Ensure any clutter is tidied away, as this can cause aggravation later in the day.
Consider meal size
Offering a larger meal at lunch and keeping their evening meal lighter may help sleep, as the body won’t be using large amounts of energy digesting food when your loved one is trying to sleep.
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 loud noises from outside. Ensure rooms are at a comfortable temperature and are well-lit so that there are no shadows which could cause upset.
If there are other people sharing the home see if they can adjust their own routines to limit background noise and activity. A busy environment can cause unnecessary confusion or upset.
Consider using light therapy, which uses bright light 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 with this.
Does sundowning get worse when the clocks change?
Many of us will naturally experience tiredness when the clocks change. However people with dementia become confused and anxious as the change in time can be at odds with their internal clock and expected routine.
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.
Sources:
- https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/sundowning
- https://www.alz.org/help-support/caregiving/stages-behaviors/sleep-issues-sundowning
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