Can sundowners occur without dementia? What you need to know

While most people associate sundowning with dementia, it is possible for sundowners to occur without dementia. Sundowning is a set of behavioral and psychological symptoms that worsen in the late afternoon and evening, and research shows that a variety of other factors, including medical conditions, anxiety, and changes in routine, can trigger these episodes in older adults who do not have a dementia diagnosis.

Quick Summary

Sundowning episodes, characterized by confusion, agitation, and anxiety in the late afternoon and evening, are not exclusive to dementia. Other factors, such as disrupted circadian rhythms, anxiety, pain, medication side effects, and hospitalization, can also cause these symptoms. Recognizing and managing these triggers is key to alleviating symptoms in individuals without dementia.

Key Points

• Sundowning without dementia is possible: Episodes of increased anxiety and confusion in the late afternoon can occur in individuals without a dementia diagnosis.

• Circadian rhythm disruption is a key factor: Changes to the body's internal clock, caused by factors like age, lack of natural light, and changes in routine, can trigger sundowning behaviors.

• Medications can be a cause: Certain medications, or their side effects, can induce or worsen confusion and agitation, especially in the evening as the dose wears off.

• Environmental changes play a role: Unfamiliar settings like hospitals, poor lighting, and overwhelming noise or activity can disorient a person and trigger symptoms.

• Physical health impacts behavior: Issues such as infections (like UTIs), chronic pain, low blood sugar, and fatigue are known triggers for sundowning behaviors.

• Management focuses on routine and environment: Behavioral and environmental strategies, such as maintaining a consistent schedule and adjusting lighting, are effective first-line interventions.

• Medical evaluation is crucial: If new symptoms appear, a doctor should be consulted to rule out underlying medical issues unrelated to dementia.

Understanding sundowning beyond dementia

Sundowning, or sundown syndrome, is characterized by increased confusion, anxiety, agitation, and sometimes aggression that begins in the late afternoon or early evening. Though strongly associated with dementia, it's not a medical diagnosis itself but rather a collection of symptoms. A key takeaway from recent research is that people without cognitive impairment can and do experience these behaviors, which is a critical distinction for both patients and caregivers. For older adults, especially, understanding the non-dementia-related causes can lead to more accurate treatment and management strategies.

Potential non-dementia causes of sundowning

The causes of sundowning without dementia are often multifactorial, involving a mix of physiological, psychological, and environmental factors. Some of the most common include:

• Circadian Rhythm Disruption: The body's internal clock can become desynchronized due to various factors, leading to sleep-wake cycle disturbances. This can be caused by changes in routine, lack of natural light exposure, and the natural decrease of melatonin production with age.
• Medication Side Effects: Certain medications, especially those for depression, Parkinson's disease, and bladder leakage, can cause confusion or agitation as they wear off later in the day. Interactions between multiple medications can also worsen symptoms.
• Acute Medical Conditions: Infections, such as a urinary tract infection (UTI), can cause delirium and lead to sundowning-like behaviors. Uncontrolled chronic pain, low blood sugar (hypoglycemia), or blood pressure fluctuations can also trigger agitation and confusion.
• Environmental Factors: Unfamiliar settings, such as a hospital or care facility, can cause disorientation and anxiety. Likewise, decreased natural light and increased shadows in the evening can be frightening or confusing. Boredom or overstimulation can also be a contributing factor.
• Psychological Triggers: Mood disorders like anxiety and depression can trigger sundowning behaviors, especially if a person is feeling stressed or lonely at the end of the day. The psychological distress of a major life change, such as recovery from surgery, can also play a role.

Managing sundowning without a dementia diagnosis

For those experiencing sundowning without dementia, management often relies on behavioral and environmental modifications. These are often the first line of intervention before considering medication.

Environmental strategies:

• Maintain a consistent routine: Predictable schedules for meals, sleep, and activities can help stabilize the body's internal clock.
• Adjust lighting: Maximize exposure to natural light during the day. In the evening, increase indoor lighting to minimize confusing shadows. Nightlights can also prevent nighttime agitation.
• Create a calm space: Reduce noise and clutter in the evenings. Play soothing music or use aromatherapy to promote relaxation.
• Introduce familiar objects: In an unfamiliar setting, surrounding the individual with personal items like photos or blankets can provide comfort.

Behavioral approaches:

• Stay active: Encourage physical activity and engagement during the day to promote better sleep at night. Avoid long naps, especially in the late afternoon.
• Manage diet: Limit caffeine and sugar, particularly in the afternoon. Serve a lighter dinner to avoid indigestion.
• Identify triggers: Keep a log of behaviors to help pinpoint specific triggers, such as certain noises or activities.
• Offer reassurance: When symptoms occur, respond calmly and avoid confrontation. Offer gentle reassurance that they are safe. Distraction with a favorite activity or snack can also be effective.

Comparison of sundowning with and without dementia

While the symptoms can appear similar, the underlying causes and treatment approaches often differ. The following table outlines key distinctions:

Feature	Sundowning with Dementia	Sundowning without Dementia
Primary Cause	Neurobiological changes affecting the brain's internal clock and cognitive function.	A variety of factors including circadian rhythm disruption, medication side effects, pain, infection, and anxiety.
Root of Confusion	Difficulty processing information and separating reality from dreams due to cognitive decline.	Can stem from temporary delirium (e.g., from infection), pain, sleep disturbances, or medication.
Persistence	Tends to worsen over time as the dementia progresses.	May be temporary, resolving once the underlying issue (e.g., hospital stay, infection) is addressed.
Treatment Focus	Managing behavioral symptoms through environmental adjustments and, sometimes, medication like acetylcholinesterase inhibitors.	Focusing on the specific underlying cause, such as treating an infection, adjusting medication, or managing anxiety.
Medication Caution	Certain medications, particularly antipsychotics, must be used with great caution in older adults due to heightened risk.	Medication is often a last resort after addressing behavioral and environmental factors.

How to talk to a doctor

If you or a loved one are experiencing these symptoms without a known dementia diagnosis, it's crucial to consult a healthcare professional. Provide as much detail as possible, including a log of when the symptoms occur, potential triggers, and any recent changes in health or medication. The doctor can investigate potential non-dementia causes, such as infections, medication side effects, or other health conditions, to ensure the right treatment plan is pursued. Don't assume the issue is related to dementia; advocate for a full and thorough evaluation.

Conclusion

Sundowning is not an exclusive symptom of dementia. A multitude of other factors, such as circadian rhythm disturbances, medication side effects, environmental changes, acute illnesses, and psychological stress, can cause episodes in individuals without dementia. For caregivers and family members, recognizing the possibility of non-dementia-related causes is the first step toward effective management. By maintaining a structured routine, controlling environmental stimuli, and seeking a comprehensive medical evaluation, many of these behaviors can be alleviated. The best approach involves identifying and addressing the specific triggers unique to each person, ensuring comfort and stability during the challenging late afternoon and evening hours.

Additional resources

• Cleveland Clinic: Information on sundown syndrome: https://my.clevelandclinic.org/health/articles/22840-sundown-syndrome

Frequently Asked Questions

What is the primary cause of sundowning in people without dementia?

There is no single primary cause. It is often a combination of factors, including disruption of the body's circadian rhythm, medication side effects, pain, infection, or anxiety. Environmental factors like unfamiliar settings and changing light levels can also play a major role.

Can a hospital stay trigger sundowning in a non-dementia patient?

Yes, a hospital stay can absolutely trigger sundowning. The unfamiliar environment, constant noise, disrupted sleep, and medication changes can disorient a person, affecting their internal clock and leading to episodes of confusion and agitation.

How can caregivers distinguish between sundowning and general confusion?

The key distinction is the timing. Sundowning symptoms occur specifically in the late afternoon and evening, worsening as the day ends. General confusion or delirium can happen at any time, but if the pattern is consistent with the sun setting, it points toward sundowning.

Are there specific medications that can cause sundowning without dementia?

Yes. Medications for depression, Parkinson's disease, and bladder leakage have been noted as potential culprits. Side effects or interactions between multiple medications can also trigger or exacerbate symptoms.

Does anxiety contribute to sundowning in people without dementia?

Yes, episodes of anxiety or depression can trigger sundowning symptoms. Emotional distress, loneliness, and psychological stress can disrupt a person's mood and contribute to late-day confusion and agitation.

How can I manage sundowning without medication for someone without dementia?

Focus on behavioral and environmental strategies. Maintain a consistent daily routine, ensure plenty of natural light exposure during the day, minimize evening stimulation, and address physical needs like hunger, thirst, and pain. Distraction with a calming activity can also be helpful.

Could a urinary tract infection (UTI) cause sundowning-like symptoms?

Yes. Infections, particularly UTIs in older adults, can cause sudden confusion or delirium that can present as sundowning. If symptoms appear suddenly, a medical check for an underlying infection is essential.