For many people with dementia, the transition from day to night can be difficult due to a syndrome known as sundowning. It's marked by a regular change of behavior, often involving confusion, agitation, and anxiety. Experts are unclear on the cause.
“Sundowning is difficult and poorly understood behavior,” says Dr. Erinn E. Beagin, MD, Chief of Division of Geriatrics at Saint Peter’s University Hospital in New Brunswick, New Jersey. "We don’t really understand why it happens."
In addition to being aware of the syndrome, the best thing a caregiver can do is to anticipate the change in behavior and have a plan to address it.
Why sundowning happens
Though causes are difficult to pinpoint, one main theory is that dementia may affect the circadian rhythm of the brain, meaning those living with the disease may have trouble telling the difference between night and day. This problem can be exacerbated during changes in the clocks, when daylight is either suddenly extended or lost.
Another potential cause could be that the needs of a person with dementia are not being met. They may be bored, hungry, dehydrated, or overtired, but unable to understand and express it.
“All of those things that we have trouble adjusting to sometimes are exacerbated when someone has dementia,” says Beagin. "And then, unfortunately, that older person can’t express their needs or thoughts to us, so it comes out as a behavior."
People with dementia may also be very attuned to their environment, and could become easily stressed out when changes occur, leading to sundowning. For example, if they live in a nursing facility, shift changes tend to bring about agitation. When they are at home with family, they may easily sense bad moods, which can cause a reaction.
Overstimulation is another possible trigger—for example, from television, noisy children, or even a caregiver doing chores.
Signs of sundowning
Some typical behaviors associated with sundowning are:
- Agitation and irritability
- Yelling or arguing
- A tendency to wander
- Decreased awareness of where they are
- Fidgeting and restlessness
- Rummaging through drawers or rooms
Although sundowning is usually marked with increased activity, some people can become quiet and withdrawn.
If your loved one starts sundowning abruptly, it may be cause for concern. “Say your loved one has never had sundowning and it suddenly comes on out of the blue,” says Beagin. "You should be looking at [whether] there's something else going on, such as infection or constipation."
Sundowning is also a repeated, predictable pattern of behavior. Any rapid changes in a person’s temperament should not be ignored and should be addressed by a healthcare provider (HCP).
Preventing and treating sundown episodes
The most important thing caregivers and family members can do to prevent a sundowning episode is to know the behaviors and learn ways to manage them calmly. Listen to concerns and answer your loved one's questions, but then redirect attention to something else.
“One thing I have discovered with Alzheimer’s patients is that if you tell them to do something or ask them to do something for themselves, they may say no,” says Beagin. “But if you ask them to help you do something, they are more apt to say yes.”
Since many who experience sundowning are often bored and want to feel needed, caregivers should think of ways to include them in evening activities. Give them simple tasks, such as setting the table or folding laundry. The chore may not always be done correctly, but don’t point it out or get upset.
Caregivers should also help people with dementia stick to a routine, with only short naps during the day and adequate overnight rest. If you need to share important news or plan an outing, try to do so earlier in the day. Keep caffeine and alcohol to a minimum, especially in the evening.
Treating sundowning episodes requires caregivers to create a relaxed environment in the evenings and to stay calm themselves. “Arguing with a patient with dementia never gets you anywhere. It only gets everyone more upset,” reminds Beagin.
If an episode is escalating, do something calming, like going for a walk or watching television. Since musicality is still strong in many with dementia, playing a patient's favorite songs can ease their mood.
Dementia is as difficult on family and caregivers as it is on those with the condition. Local support groups are a great place to talk about struggles with sundowning and learn new techniques for caregiving. Most of all, being aware of the symptoms of sundowning and staying educated about dementia will keep both patients and family calmer and happier.
