Sundowning and dementia

Sundowning is a symptom of various forms of dementia, including Alzheimer’s disease. The term is used to describe changes in behaviour that typically occur around late afternoon or early evening and last until night time, where a person living with dementia may become confused, agitated, anxious or aggressive.

If you, or a loved one, are living with dementia, understanding what sundowning is and the associated challenging behaviour can help you to better manage the symptoms, and may give you peace of mind, knowing that there is a reason behind these changes.

Below you will find information about what sundowning is and why it happens, symptoms and advice on how to deal with sundowning and what you can do to prevent and manage it.

What is sundowning behaviour?

Sundowning can cause a range of behaviours, and symptoms include confusion, anxiety, aggression, shouting, pacing or wandering. It can also result in problems with getting to sleep.

Around dusk, a person living with dementia may suddenly feel like they are in the wrong place, forget who people are or be confused about what is happening around them.

For example, they may express the need to go home even if they are at home, or they may be adamant they have to go pick up their children from somewhere, such as school.

Why does sundowning happen and what are the causes?

Behaviour associated with sundowning, also known as ‘late-day confusion’, can often be linked to man-made changes to people’s circadian rhythm, the 24-hour cycles naturally occurring in humans to help them anticipate events within the day-night cycle, according to Adam Smith, consultant Admiral nurse at Colten Care.

“Lots of people are at work at that time, they are picking children up, they are getting home from work, cooking dinner, and there’s something innate in all of us at that time of the day, when the sun’s going down as well, this time of day causes this innate sense of stress in us, this kind of nature-versus-nurture,” Mr Smith explains.

“At one of our Colten Care homes in Winchester, on the ground floor where we’ve got our residents who have dementia, but who are still quite able, there’s a school down the road, so at about 3 or 4 o’clock you get all the school children walking past.

“Often we’ll see residents becoming quite unsettled at this point because they are going back to a time where they had to collect their children or be at home for their children.”

Although, the exact cause and triggers of sundowning are unknown, there are several identified factors that may cause behavioural changes in the evening.

As a person living with dementia becomes tired, their symptoms sometimes worsen. In many cases this happens naturally when the day progresses and it becomes darker.

Possible reasons why sundowning occurs can also include:

• A disturbance to the person’s internal clock that tells them when to sleep, resulting in confusion about night and day
• Mental and physical fatigue
• Not enough, or disturbed sleep through an inability to separate dreams from reality
• Less need for sleep
• Low lighting or too much lighting and increased shadows which can cause the person to misinterpret what they see
• Medication that increases confusion or agitation, or medication that wears off
• Conditions such as sight and hearing loss or infections such as urinary tract infection
• Lack of structured activities

These patterns could potentially continue for several months and generally occur from the middle stages of dementia and onwards.

Sometimes the person living with dementia may express these behaviours even if it is not sundowning and the reason could instead be that they are trying to communicate a need. For example, a change in behaviour could indicate the person is hungry, thirsty or that they are in some kind of pain.

How can you reduce sundowning?

Caring for a person living with dementia can be very difficult and takes both an emotional and physical toll. Learning ways to reduce changes in behaviour can relieve some of the stress and help you cope with the situation.

If someone living with dementia is showing signs of sundowning, try asking them what is wrong. This may seem too simple, but in doing this you might be able to identify the source of their distress, including hunger, thirst or the need to go to the toilet, for example.

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Where possible, it’s a good idea to take preventative steps to help alleviate the symptoms of sundowning as much as you can.

Ways to prevent sundowning include:

• Setting up a routine to follow during the day that includes activities the person enjoys. Try to maintain a schedule of meals, trips, bathing, exercise and other activities. Engaging in activities during the day makes it more likely that the person will be ready for bed in the evening.
• Limiting daytime naps to encourage better sleep during the night.
• Exposing the person to natural daylight, such as going outside when the weather allows and leaving the curtains open during the day.
• Reducing the person’s intake of coffee, alcohol, nicotine and other stimulant products that affect the ability to sleep.
• Closing the curtains and turning the lights on before it starts to get dark to ease the transition into nighttime. This helps because the person may struggle to see things which can cause agitation.
• When it is time to unwind for the evening, try to be relaxed and talk slowly and give simple instructions. To soothe the person’s mind, playing familiar music or relaxing sounds of nature can help.
• Creating an evening routine that includes activities the person enjoys. This could include anything from watching their favourite programme on TV, listening to their favourite music or cuddling with their pet.
• Ensuring the person’s sleeping area is safe and comfortable. This includes setting the right temperature, turning on nightlights and decorating the room with personal items to create a familiar setting.
• Talking to a doctor who can help you identify what may cause sundowning and possible solutions to help you deal with the situation.

Ways to manage and cope with sundowning

The behaviours associated with sundowning can be really difficult for both the person and their loved ones to deal with, especially if they become upset or distressed.

Although likely not to eliminate the symptoms altogether, there are a few things you can do to manage the behaviour and make it easier for everybody involved.

These include:

• Trying to remain calm and avoiding arguing when approaching or speaking to the person with dementia. Try to talk slowly and in a comforting way and listen carefully to their response to see if you can identify the cause of distress.
• Using distracting techniques such as going into a different room, putting on some music or taking the person for a short walk.
• Offering reassurance that everything is fine by being close to them and holding their hand.

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Although there are ways to prevent and manage sundowning, it is important to remember to take care of yourself too during dementia care. If you are feeling stressed, your loved one may notice this and become agitated. To combat this, try to get plenty of sleep at night and keep in touch with friends and family for support.

Caring for someone with dementia is hard, so if you feel that you need a break, consider respite care to give yourself a break to recharge your batteries. Respite care can give you much-needed relief while your loved one is being cared for by a professional.