Sundowning describes a specific group of symptoms and behaviours that can be experienced by people with dementia and Alzheimer’s in the late afternoon or early evening. If you care for a loved one with dementia, you may have noticed changes in their behaviour around sunset. Symptoms may be expressed as increased agitation, confusion, paranoia, or hallucinations.
This phenomenon is called sundowning or sundown syndrome.
Sundowning dementia symptoms
Sundowning gets its name from the time of day when people usually experience worsening dementia symptoms. Sundowning can happen at any stage of dementia but it is more common during the middle stage and later stages of the disease. It is reported that approximately 20% of people with Alzheimer’s disease experience sundowning at some point.
Sundowning symptoms can include:
- Anger and shouting
- Agitation and upset
- Emotional outbursts
- Insomnia – inability to sleep
- Paranoia – hiding objects, becoming suspicious
- Hallucinations – both visual and auditory
- Rocking back and forth in a chair
- Shadowing – following their caregiver wherever they go
- Attention span is more limited than usual
What time of the day does sundowning occur?
Sundowning, as the name suggests, can occur in the late afternoon and early evening. When symptoms present they usually last the rest of the day and into the night, affecting the person’s ability to sleep well. Sundowning symptoms usually dissipate during the night with a relief of symptoms the following day.
In the late stages of dementia and Alzheimer’s, as symptoms become more severe, it can be difficult to distinguish between sundowning and the general symptoms of dementia. In the mid to late stages of dementia, the symptoms listed above can occur at any time throughout the day or night.
If you care for someone with advanced dementia or Alzheimer’s who is displaying increased symptoms, such as those listed above, talk with your family and other caregivers to see if you can identify when symptoms occur and if any factors trigger them. Keeping a diary of when symptoms are worse may make it easier to identify patterns and help you to discuss them with doctors or caregivers.
While there are no treatments currently available for sundowning, there are several things that you can do it minimise, and sometimes avoid, distressing side effects.
What causes sundowning?
There are two main theories as to why sundowning occurs. Some scientists believe that the circadian rhythm, our body’s “internal clock” that helps our body know what time of day or night it is, is affected because of dementia. Our circadian rhythm controls when we want to sleep, wake, eat, and do other activities. It is thought that changes to the brain as a result of dementia and Alzheimer’s can exacerbate symptoms of confusion and cause sundowning.
Another common theory is that sundowning is a result of an excessive burden on the person’s physical and mental capacities. Even in a healthy elderly person, the afternoon usually signals a decline in energy. It is thought by some experts that this normal phenomenon is intensified in people living with dementia, increasing their tiredness and irritability. Coupled with the person’s diminishing ability to communicate their needs and feelings, frustration and agitation increase causing sundowning symptoms to present late in the day.
Factors known to aggravate sundowning
While the exact causes of sundowning are currently unknown, it seems that particular environments and situations can exacerbate symptoms.
The factors known to aggravate sundowning are:
- Fatigue and tiredness due to lack of quality sleep
- Low lighting and shadows – conversely, excessive lighting can also cause disturbances and so can not get enough exposure to sunlight during the daytime. This can be made worse if the person has any sensory impairment, such as hearing or sight loss
- Background noise or excessive noise
- Overstimulation from a busy day, spending time in an unfamiliar place, or changes to a daily routine
- Disrupted circadian rhythm (sleep-wake cycles) which will have an accumulative effect on fatigue
- Difficulty separating dreams from reality causes confusion
- Being hungry, thirsty, in pain, or having another physical need that has not been met
- A physical illness, such as an infection
- Mood disorders such as anxiety and depression
Tips for improving sundowning symptoms
It can be distressing to see a loved one with dementia experience the confusion and agitation of sundowning. While sundowning cannot be eliminated completely there are some things you can do to reduce the frequency and severity of symptoms:
Maintain a simple daily routine
- Keeping a predictable routine for bedtime, waking, meals and activities is essential. The person should be well aware of when is the time for eating, walking, and going to bed. Keep gently reminding them but not in a way that irritates them
- Conduct busy activities and outings in the morning, when your loved one is most active and feeling their best
Limit or avoid things that impact sleep
- Limit daytime napping as much as possible so the person is tired in the evening and ready for bed
- Limit the amount of caffeine and sugary foods and drinks. These are excessively stimulating and should be limited to the mornings only or avoided completely
- Make sure their bedroom feels comfortable and safe by closing windows to keep out unwanted noise and controlling the temperature and lighting. Thick curtains or black-out blinds can help to keep out the unwanted early morning light
- Avoid large meals in the evening as this can disrupt sleep patterns. It is best to eat a large lunch and a smaller evening meal to assist digestion
Keep a calm evening routine
- In the evening, try to reduce background noise and stimulating activities, including TV viewing, which can sometimes cause distress
- Play familiar, gentle music or relaxing sounds of nature, such as the sound of waves. You can find free audio recordings of the sounds of nature on internet websites such as YouTube
Appropriate lighting for the time of day
- Plan for activities and exposure to light during the day to encourage nighttime sleepiness. For example, morning walks or time in the garden before the late afternoon twilight hours
- During the daytime ensure the person has sunlight exposure, without excessive use of very bright indoor lighting
- Close the curtains and turn the lights on before dusk to ease the transition into nighttime and avoid shadows which can be disturbing for people experiencing sundowning
- In the bedroom, turn on a night light to reduce nighttime agitation that occurs when the surroundings are dark or unfamiliar
Manage the environment in an unfamiliar setting
- If your loved one has to be in a strange or unfamiliar setting, bring familiar items — such as photographs — to create a more relaxed, familiar environment, – ensure the familiar items are near the person so they can see and engage with them
- Maintaining the normal routine in an unfamiliar environment is particularly important
- Reduce unnecessary noises around them -try to turn off the TV and other noise-making gadgets such as ringing telephones, electronic games, or loud music – these can produce sounds that are disturbing to people with dementia
Talk with them
- Make them feel they are not alone – try to be patient and ensure that they feel heard when they are communicating with you
- Check that the person is not in pain, uncomfortable, hungry or thirsty, or needs the toilet, unmet needs or not being able to communicate these needs can exacerbate sundowning symptoms
Be aware of daylight saving
Symptoms can be more pronounced immediately after the clocks go back in autumn. Here are some extra steps that can help:
- Exposure to daylight can help to regulate the body’s circadian rhythm. During the day, take your loved one outside for a walk
- 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 causes confusion
- Don’t introduce anything new to the daily routine the week leading up to and after the clocks going back – if you do need to shift their routine forward by an hour due to daylight saving, do so in small increments over a week-long period
Avoiding the triggering factors detailed above is the most effective way to treat sundowning. However, if these steps do not improve your loved one’s sundowning symptoms there are treatments and therapies available which may help or other potential triggering factors that you can look into as potential causes. These include;
Melatonin – some research suggests that a low dose of melatonin — a naturally occurring hormone in our bodies that induces sleepiness — given in combination with exposure to sunlight during the day may help ease sundowning by regulating the body’s circadian rhythm.
An undiagnosed illness – if sundowning develops quickly or is more pronounced than usual, talk with your loved one’s GP or primary health care provider. An undiagnosed medical condition may be to blame, such as a urinary tract infection or sleep apnea, which might be worsening sundowning behaviour.
Adjusting existing medications – a medication side effect may be exacerbating sundowning symptoms. Medications should be discussed with your loved one’s doctor. Sometimes symptoms can be relieved by changing the dose or time a medication is given.
Light and music therapy – both music therapy and light therapy have been shown to have positive effects on people with dementia. While more research and evidence are needed as to why these therapies have such positive effects, there can be no harm in trying out these therapies with your loved one to see how they respond.
What to do if you need help
If you care for someone with dementia or Alzheimer’s, it’s important to know that you are not alone. There are several ways that you can get support, help, and advice:
Home care support
Caring for a loved one with complex needs can be overwhelming, both physically and emotionally. That’s why many families turn to dementia home care agencies, such as Country Cousins. Our professional and compassionate dementia live-in carers support people with dementia, and their families, to live well in the comfort of their own homes. Home care support can be a welcome alternative to a residential care home.
Dementia UK, a leading dementia charity in the UK, has a wealth of online resources and information for people who care for loved ones with dementia.
Alzheimer’s UK, the leading Alzheimer’s charity in the UK, has a dementia support helpline open 7 days a week for help and advice.
If you would like to find out more about dementia home care services and how Country Cousins can help you and your loved one, get in touch with us today. We offer a free enquiry service through our friendly and experienced care team who are on hand to take your call 5 days a week.