Sundowning Explained: Do Dementia Patients Get More Agitated at Night?

Studies show that up to 66% of people with dementia experience sundowning. The question, 'Do dementia patients get more agitated at night?' points to this common syndrome of late-day confusion, anxiety, and restlessness, which can be distressing for patients and caregivers alike.

Quick Summary

Yes, it is common for dementia patients to become more agitated, confused, and anxious in the late afternoon and evening. This set of symptoms is known as sundowning and can be managed with specific strategies.

Key Points

• What It Is: Sundowning is a state of increased confusion, anxiety, and agitation in people with dementia that occurs in the late afternoon and evening.

• Primary Cause: It's largely linked to the dementia-related disruption of the body's internal clock, or circadian rhythm, which confuses day and night.

• Common Triggers: Triggers include fatigue, low lighting, overstimulation, unmet physical needs like hunger or pain, and even caregiver stress.

• Management is Key: Management focuses on non-pharmacological strategies like maintaining a consistent daily routine and managing the environment.

• Proactive Strategies: Maximize daytime light exposure, encourage gentle daily exercise, and create a calm, well-lit environment in the evening to prevent episodes.

• Reactive Techniques: When agitation occurs, respond with a calm voice, validate feelings, and use distraction with a simple, pleasant activity.

• Medical Consultation: Always consult a doctor to rule out underlying causes like pain or infection and to discuss any potential medication-based interventions.

Understanding Sundowning: Why Nighttime Can Be Difficult

Sundowning, or sundown syndrome, refers to a collection of neuropsychiatric symptoms like heightened confusion, anxiety, agitation, and aggression that begin or worsen as daylight fades. While the exact cause isn't definitively known, it is believed to be linked to the impact of dementia on the brain's circadian rhythm, or internal clock, which regulates sleep-wake cycles. Prevalence rates vary, but some studies suggest it affects as many as 66% of individuals with dementia, particularly those in the middle to late stages.

This phenomenon isn't a disease itself but a pattern of symptoms that can make evenings a particularly challenging time for both the person with dementia and their caregivers. Common behaviors include restlessness, pacing, yelling, paranoia, and resistance to help.

Key Causes and Triggers of Sundowning

Several factors can trigger or exacerbate sundowning episodes. Understanding these can be the first step toward effective management:

• Disrupted Circadian Rhythm: Dementia can damage the suprachiasmatic nucleus of the hypothalamus, the part of the brain that acts as the body's internal clock, confusing day and night.
• Fatigue: The mental and physical exhaustion from a full day of trying to navigate a confusing world can overwhelm a person with dementia, reducing their ability to cope with stress in the evening.
• Low Light and Shadows: As natural light fades, increasing shadows can lead to misinterpretation of the environment, causing fear and confusion.
• Unmet Needs: Basic needs like hunger, thirst, a full bladder, or unmanaged pain can be difficult for a person with dementia to communicate, often manifesting as agitation.
• Overstimulation or Under-stimulation: A noisy, cluttered environment or, conversely, a lack of engaging activity (boredom) can both lead to restlessness.
• Caregiver Stress: People with dementia can be sensitive to the nonverbal cues of others. A stressed or frustrated caregiver can inadvertently increase the person's anxiety.

Proactive and Reactive Strategies for Managing Sundowning

Managing sundowning involves a combination of proactive environmental adjustments and compassionate in-the-moment responses. The goal is to reduce stressors and create a sense of calm and security.

Proactive Environmental and Routine-Based Strategies

1. Maximize Daytime Light: Ensure the person gets plenty of exposure to bright, natural light during the morning and early afternoon to help regulate their internal clock. Open blinds and consider going for a walk or sitting by a window.
2. Establish a Consistent Routine: Predictable schedules for waking, meals, and activities provide a sense of security and can reduce anxiety. Try to schedule appointments and more demanding activities for the morning.
3. Encourage Physical Activity: Regular, gentle exercise during the day, like walking, can promote better sleep at night and reduce restlessness. Avoid intense activity too close to bedtime.
4. Limit Late-Day Stimulants and Naps: Avoid caffeine and sugar in the afternoon and evening. If a nap is necessary, keep it short and earlier in the day.
5. Prepare the Evening Environment: Before dusk, close the curtains and turn on lights to minimize shadows and create a well-lit space. Reduce background noise from TVs or appliances and consider playing soft, calming music.

Comparison of Coping Strategies

Strategy Type	Proactive (Preventative)	Reactive (In-the-Moment)
Goal	To reduce the likelihood and severity of sundowning episodes.	To de-escalate agitation and provide comfort once it begins.
Examples	- Sticking to a daily schedule

• Morning light exposure
• Limiting caffeine
• Planning calm evening activities | - Speaking in a calm, reassuring voice
• Using gentle touch or a hug
• Redirecting to a favorite activity or snack
• Validating their feelings instead of arguing | | When to Use | Throughout the day, every day. | When you notice the first signs of agitation or confusion. |

In-the-Moment Calming Techniques

When a person is actively sundowning, your response can make a significant difference.

• Stay Calm and Reassuring: Approach the person calmly. Listen to their concerns, even if they don't make sense, and validate their feelings. Reassure them that they are safe.
• Avoid Arguing or Correcting: Trying to reason with someone who is confused will likely increase their agitation. Reality orientation is often counterproductive.
• Redirect and Distract: Gently shift their focus to a simple, enjoyable activity. This could be folding laundry, looking at a photo album, listening to music, or having a favorite snack.
• Check for Physical Needs: Quietly assess if they might be in pain, hungry, thirsty, or need to use the restroom. Offering a drink or a light snack can sometimes resolve the issue.

When to Seek Medical Advice

While non-pharmacological strategies are the first line of defense, it's crucial to involve a healthcare professional. Unmanaged pain, urinary tract infections (UTIs), sleep apnea, or medication side effects can all cause or worsen sundowning symptoms. A doctor can rule out underlying medical issues and discuss potential treatments.

Pharmacological options are sometimes considered but must be weighed carefully due to side effects. These interventions should always be supervised by a physician. For more information, the National Institute on Aging provides comprehensive resources for caregivers.

Conclusion

To answer the question, 'do dementia patients get more agitated at night?'—yes, this is a very common experience known as sundowning. It stems from a combination of brain changes, environmental triggers, and unmet needs. While there is no cure, a combination of creating a predictable and calm environment, managing daytime activities, and responding with empathy and patience can significantly reduce the frequency and intensity of these challenging episodes, improving the quality of life for everyone involved.

Frequently Asked Questions

What are the first signs of sundowning?

Early signs often include subtle increases in restlessness, irritability, confusion, or disorientation as the afternoon progresses. The person may become more demanding or suspicious than usual.

At what stage of dementia does sundowning usually start?

Sundowning can occur at any stage of dementia, but it most commonly appears and peaks during the middle stages of the disease and may lessen in the very late stages.

Can sundowning happen to people without dementia?

Yes, while most commonly associated with dementia, older adults without dementia can experience similar symptoms of late-day confusion, especially if they are ill, sleep-deprived, or in an unfamiliar environment like a hospital.

How long do sundowning episodes typically last?

An episode of sundowning usually lasts for a few hours, typically beginning between late afternoon (around 4:30 PM) and evening, and it often subsides by the next morning.

Does sundowning get worse in the winter?

Some studies suggest sundowning can increase in the fall and winter months. This may be due to the decreased duration and intensity of natural sunlight, which can further disrupt the body's internal clock.

Are there medications that help with sundowning?

Non-drug approaches are recommended first. However, a doctor may suggest medications to aid sleep, or in some cases, antidepressants or antipsychotics for severe symptoms. These must be carefully managed by a professional.

How can I prevent myself from getting frustrated as a caregiver?

It's important to take care of yourself. Take breaks, find support from others, and remember that the behaviors are caused by the disease, not the person. Speaking calmly and not taking things personally can help de-escalate the situation for both of you.