Caregiver Corner
By Jennifer Beach
A term that is widely used with individuals with dementia is “sundowning.” Oftentimes, families, care providers and doctors think this is a typical part of dementia and there is not a whole lot that can be done about it. Sundowning refers to a group of symptoms where individuals with dementia experience increased confusion, agitation, anxiety and other behavioral changes during the late afternoon, evening, and night. Sundowning is not a disease itself but rather a common pattern of behavior linked to the progression of dementia, particularly in the middle to later stages.
Sundowning is thought to affect around 20% of people with dementia, and around 80% of people with dementia in residential settings like assisted living, memory care or nursing homes.
This is particularly evident if they have recently moved out of their home to a new environment, including changing rooms within a community or if the environment is busy in the evenings, lots of hustle and bustle with shift changes, trying to quickly get things done and too often, not enough properly trained support available.
Not everyone with dementia will experience sundowning. It depends on the person, their type of dementia and how far along the progression of the dementia is. A person who is affected by sundowning will not necessarily experience it every night. This is very important to keep in mind.
Why does sundowning happen?
- Unmet needs that individuals cannot express, e.g. hunger, thirst, discomfort, constipation or pain are some of the possibilities.
- Over tiredness
- Lack of activity
- Lack of exposure to natural light during the day
- Overstimulation during the day, such as being in a noisy, busy environment. Be aware of the TV; is it on all day? What is on the TV and what is the volume level? Loud, flashing lights, fast rotation of images, negative images, loud volume all may increase symptoms.
- Medication side effects
- Changes in the person’s body clock that can occur in some types of dementia, such as Lewy Body Dementia
- Environmental changes like streetlights coming on, people leaving at end of shift or people settling in for the evening, which can trigger a sense of being in the wrong place
- The individual’s family members or care providers being tired and less able to meet their needs
- Alcohol or caffeine in late afternoon or evening
- Change in light, low light and increased shadows can trigger fear and anxiety
- Vision or hearing loss can compound behaviors
Tips for managing sundowning
- Observe the individual with dementia and keep a log to see if a pattern can be established. What time do you notice things changing? Where is the individual when these changes start to take place and what specific triggers may be contributing to it?
- Distraction: Try to distract the person when you notice they are becoming restless, agitated or worried. Change things: Go into a different room, make them a drink or snack, play some calming or favorite music.
- Try using a clock that shows the day, date and time of day (e.g. morning, afternoon, evening, night)
- Hold the person’s hand or sit close to them and stroke their arm. There is a tremendous amount of research on gentle touch and its benefits. So often, individuals in long term care settings have very little gentle touch.
- If there are children in the person’s home, explain the need for keeping evenings quiet and calm.
Best ways to communicate with a person who is experiencing sundowning
- Talk in a slow, soothing way
- Speak in short sentences; give simple, one-step instructions to avoid confusing the person
- Ask the person what the matter is; listen carefully to their response and if possible, see if you can resolve the reason for their distress
- Gently remind them what day and time it is
- If the person struggles to communicate, look for clues in their behavior (touching or rubbing a body part may indicate pain)
- Avoid contradicting or arguing with the person, as this may increase their distress
- Let them know they are safe, and you have taken care of things they may be concerned about
Exercise and physical activity
Regular exercise and physical activity can help improve sleep at night and in turn reduce daytime fatigue and evening restlessness.
- Work to create a consistent routine. Get up at the same time and work to make them rise early in the morning. Even if it takes a long time to get moving, have breakfast and get dressed (which should be done daily; it helps the brain know the natural cycles and rhythms of the day). Staying in nightclothes all day may contribute even more to these symptoms.
- Follow a daytime routine that contains activities that the person enjoys. Staying active during the day, whether through simple exercises, multiple small walks, chair exercises, breathing exercises, hobbies, helping do household chores including folding the laundry, vacuuming, visiting or engaging with others. These routines and daytime activities can help to regulate the body clock.
- Try to get outside, even for a few minutes. Take the time to help the individual bundle up and get fresh air. Spending time out in natural light can help to regulate the body clock. If that is not possible, you could position the person’s favorite chair by a window, so they spend time in daylight.
In most cases, medication is not prescribed for sundowning itself, as it is best managed with many of the strategies outlined in this article. However, in some cases, a person with dementia might be prescribed medication for specific symptoms such as anxiety, agitation or restlessness, which might also help with sundowning. Be sure to talk with your care provider about the changes your loved one is experiencing and keep good track of details to help find best ways to manage.
