What Is Sundowning?
Sundowning, also known as sundown syndrome, is a cluster of symptoms that occur and intensify as daylight fades. While not a disease itself, it is a common and distressing behavioral pattern in people with Alzheimer's disease and other forms of dementia. Symptoms can begin in the late afternoon and persist throughout the night, often subsiding by morning.
The behaviors associated with sundowning are wide-ranging and can differ significantly from one person to another. They often include increased confusion, anxiety, agitation, restlessness, and disorientation. A person may pace, wander, or exhibit aggressive or emotional outbursts. This profound shift in behavior can be incredibly challenging for caregivers, who may feel exhausted and overwhelmed by the change in their loved one.
Why Do Dementia Symptoms Worsen at Night?
While the exact cause of sundowning is not fully understood, a combination of physical and environmental factors is believed to contribute to the problem.
Disruption of the Internal Body Clock
Dementia affects the suprachiasmatic nucleus in the brain's hypothalamus, which regulates our circadian rhythms—the body's internal 24-hour clock. This disruption can cause the individual to become confused about the time of day, leading to daytime sleepiness and nighttime wakefulness. This can result in a cycle of fragmented sleep and increased confusion, as the person's brain struggles to differentiate between day and night.
Fatigue and Overstimulation
Mental and physical fatigue from the day's activities can overwhelm a person with dementia. A caregiver might notice that their loved one can cope with daily routines, but as the day progresses, their ability to process information and manage stress diminishes. Overstimulation from a busy environment, too many visitors, or chaotic noise can also contribute to this exhaustion, triggering sundowning behaviors as evening nears.
Changes in Lighting and Environment
As natural light decreases, the fading light can create long, confusing shadows in a room, which a person with dementia might perceive as threatening or frightening. The change from a bright, active day to a dim, quiet evening can be disorienting. If the individual has vision problems, their ability to navigate their surroundings safely is further impaired, adding to their anxiety and fear.
Medication Side Effects
Some medications, particularly those that affect mood or sleep, can impact an individual's energy levels and contribute to sundowning. The timing of certain medications, such as some antidepressants or cholinesterase inhibitors, might also affect sleep patterns. It is crucial to monitor a loved one's behavior after a medication change and discuss any concerns with a healthcare provider.
Caregiving Strategies for Managing Sundowning
Managing sundowning involves a proactive and patient approach, focusing on routine, environment, and comfort.
Maintain a Consistent Routine
Establishing a predictable daily schedule can significantly reduce anxiety and confusion. Keep mealtimes, wake-up times, and bedtimes consistent. A structured day provides a sense of security and stability, which can help regulate the internal clock.
Optimize the Environment
Creating a calm and safe environment can help minimize nighttime agitation. At dusk, turn on lights to eliminate shadows and ensure rooms are brightly lit. Consider using nightlights in hallways, bedrooms, and bathrooms to help with navigation. Minimize noise and clutter, and create a peaceful atmosphere in the evenings with soft music or other calming activities.
Encourage Daytime Activity
Promote physical activity and sunlight exposure during the day to help encourage sleepiness at night. Short walks or engaging activities can help expend energy and reinforce the body's natural sleep-wake cycle. However, avoid strenuous activity close to bedtime, as this could have an overstimulating effect.
Reduce Stimulants and Sugars
Limit or avoid caffeine, alcohol, and excessive sugar intake, especially in the late afternoon and evening. These substances can interfere with sleep and increase agitation. Instead, offer a light, healthy snack or a warm, non-caffeinated beverage before bedtime.
Comparison of Daytime vs. Sundowning Symptoms
| Symptom Category | Typical Daytime Symptoms | Sundowning Symptoms (Evening) |
|---|---|---|
| Confusion | May experience occasional memory lapses, forget recent events. | Heightened disorientation, inability to recognize familiar people or places. |
| Emotional State | Generally calm, may have occasional mood swings related to specific triggers. | Increased anxiety, restlessness, fear, or paranoia. |
| Behavior | Follows routine, may require gentle reminders for tasks. | Pacing, wandering, resisting help, sudden outbursts of anger. |
| Sleep | May take naps but typically stays awake and alert. | Disrupted sleep-wake cycle, frequent nighttime awakenings, inability to fall or stay asleep. |
| Perception | Relatively clear, though memory and judgment are impaired. | May experience hallucinations or delusions, misinterpreting shadows. |
When to Contact a Healthcare Professional
While sundowning is a common and often manageable aspect of dementia, it is essential to involve a healthcare provider in the management plan. You should consult a doctor if:
- The behaviors pose a safety risk to the person with dementia or the caregiver.
- The symptoms are new or have recently worsened dramatically.
- You suspect a urinary tract infection (UTI), pain, or another underlying medical issue is contributing to the change in behavior. An informative resource from Harvard Health explains how medical issues can sometimes worsen sundowning behavior.
- Current management strategies are not effective, and you need additional support or alternative treatment options.
Conclusion
Understanding that sundowning is a symptom of the disease, not a personal choice, is crucial for maintaining a positive caregiving relationship. By implementing environmental adjustments, maintaining a routine, and using calming techniques, caregivers can better manage the challenges of sundowning. While it can be an emotionally taxing experience, recognizing the triggers and adopting effective strategies can lead to more peaceful evenings for both the person with dementia and their caregiver.
