What are the early signs of sundowning?

According to research, sundowning affects up to 20% of people with Alzheimer's disease and other forms of dementia. Knowing what are the early signs of sundowning is crucial for caregivers to anticipate and manage these behavioral changes effectively.

Quick Summary

Early signs of sundowning often include increased restlessness, agitation, confusion, and anxiety that appears or worsens in the late afternoon and evening. These subtle behavioral changes can be inconsistent at first, but with a keen eye, caregivers can identify them and take proactive steps to improve comfort and reduce distress for their loved one.

Key Points

• Identify Restlessness and Pacing: Watch for increased fidgeting and an inability to sit still, especially as daylight fades, as this is a key early sign of agitation.

• Notice Mood Swings: Pay attention to uncharacteristic irritability, anxiety, or tearfulness in the late afternoon and evening, indicating a change in emotional state.

• Spot Heightened Confusion: An increased sense of disorientation, such as asking to "go home" when already there, is a crucial indicator of developing sundowning.

• Create a Calm Environment: Reduce evening noise, adjust lighting to minimize shadows, and maintain a familiar, clutter-free space to help soothe and reassure.

• Establish a Predictable Routine: A consistent daily schedule for meals, activities, and sleep can help regulate the body's internal clock and reduce evening confusion.

• Use Gentle Reassurance: During an episode, use a calm, reassuring tone and avoid confrontation to prevent escalating the person's anxiety and fear.

Understanding Sundowning

Sundowning is a state of confusion and agitation that commonly affects individuals with dementia, typically emerging in the late afternoon or early evening. It is not a disease itself, but rather a group of symptoms that occur at a predictable time of day. While the exact cause is not fully understood, experts believe it may be linked to a disruption in the person's internal body clock, or circadian rhythm, which helps regulate sleep-wake cycles. Other contributing factors can include fatigue, a loss of routine, and changes in lighting. Recognizing the initial manifestations is key to managing this challenging aspect of caregiving.

Behavioral Signs: Spotting the Subtle Shifts

In the beginning stages, the signs of sundowning can be easily mistaken for simple crankiness or tiredness at the end of the day. However, a closer look reveals patterns that are distinct from typical late-day fatigue. Paying attention to these early, subtle shifts can allow caregivers to intervene sooner and create a more peaceful evening for their loved one. It's helpful to keep a journal of a person's behavior to notice the timing and consistency of these changes.

Increased Restlessness and Pacing

One of the most common early indicators is an escalation in physical and motor activity. The person may become fidgety and unable to sit still, often pacing back and forth. This restlessness can feel purposeless and is often accompanied by an underlying sense of unease or anxiety. A person might also engage in repetitive movements, like rocking back and forth. This behavior isn't just about boredom; it stems from a feeling of disorientation and a need to be moving.

Heightened Agitation and Irritability

As the day progresses, a person may seem more on edge than usual. This irritability can lead to a shorter fuse and quick-to-anger outbursts over minor issues. The person may also become easily frustrated and more difficult to console. This emotional volatility can be confusing for caregivers who are used to a different demeanor earlier in the day. This agitation is a direct result of their increasing confusion and anxiety.

Worsening Confusion and Disorientation

The hallmark of sundowning is the increase in confusion during the late afternoon and evening. A person might lose track of where they are or what time it is, even in a familiar environment. They might express a strong desire to "go home," even if they are already there. Disorientation can also manifest as asking the same questions repeatedly or suddenly having difficulty with once-familiar tasks.

Changes in Mood and Anxiety

The emotional state of a person experiencing early sundowning often shifts noticeably. Anxiety, sadness, and fear may become more prominent. A calm and happy person in the morning might become tearful and withdrawn by late afternoon. This change can be emotionally taxing for both the individual and their caregivers, who are witnessing a profound shift in personality. The person might express feelings of paranoia, such as believing someone is trying to harm or steal from them.

Managing Early Sundowning Symptoms

Catching the signs early is only the first step. Effective management involves a combination of environmental adjustments and behavioral strategies. Focusing on a structured routine can help to minimize the impact of sundowning.

Creating a Soothing Environment

• Light control: As natural light fades, bright, consistent indoor lighting can help reduce confusion and diminish frightening shadows that can lead to paranoia. Using blackout curtains to block out the stimulating evening view can also be beneficial.
• Noise reduction: Keeping evening noise to a minimum can prevent overstimulation. This may mean turning off the television, listening to calming music, or simply creating a quiet space for relaxation.
• Familiar surroundings: Surrounding the person with familiar objects like family photos or a favorite blanket can provide comfort and a sense of security during a disorienting time of day.

Adapting Routines and Activities

• Maintain a consistent schedule: Establishing a predictable daily routine for meals, activities, and bedtime can help regulate the body's internal clock. Scheduling stimulating activities earlier in the day can help tire the person out naturally.
• Evening activities: Plan calming evening activities, such as listening to soft music, looking through a photo album, or engaging in a simple, quiet hobby. Avoid stressful tasks like bathing or complex conversations late in the day.
• Manage naps: Discourage long, late-afternoon naps that can disrupt nighttime sleep. Instead, a short, early-afternoon nap may be helpful.

Environmental Triggers vs. Early Behavioral Indicators

Aspect	Environmental Triggers	Early Behavioral Indicators
Source	External factors that contribute to or worsen symptoms.	Internal changes in mood and behavior that signal onset.
Examples	Dim lighting, overstimulation, fatigue, disruption in routine, low melatonin levels.	Increased restlessness, irritability, anxiety, mood swings, heightened confusion.
Observation	Can be observed by a caregiver adjusting conditions.	Requires attentive observation of the person's disposition and actions.
Management	Involves modifying the physical environment and routine.	Involves redirection, reassurance, and providing a calm presence.
Timing	Happens consistently in the late afternoon/evening.	The initial appearance of symptoms, often subtle and inconsistent.

For more in-depth information on managing sundowning, the Alzheimer's Association provides valuable resources on caregiver strategies: https://www.alz.org/help-support/caregiving/stages-behaviors/sundowning.

Conclusion

Early detection of sundowning signs, such as increased restlessness, agitation, and confusion in the late afternoon, is critical for effective management. By implementing proactive strategies like maintaining a consistent routine, controlling the environment, and providing gentle reassurance, caregivers can significantly reduce the severity of sundowning episodes. Recognizing these subtle shifts and understanding the triggers allows for a more compassionate and successful caregiving approach, improving the quality of life for everyone involved. Ultimately, early intervention can make a world of difference in navigating the challenges of sundowning and fostering a calmer, more predictable environment for your loved one.

Frequently Asked Questions

What is the very first sign of sundowning?

The very first signs are often subtle and inconsistent, including increased restlessness, a sense of unease, or mild agitation that appears in the late afternoon.

Can sundowning start suddenly?

While it can appear to start suddenly, sundowning is typically linked to the gradual progression of dementia. A noticeable, abrupt onset may warrant checking for other medical issues, such as a urinary tract infection or other illness.

How long does sundowning usually last?

Sundowning episodes can last a few hours, typically starting in the late afternoon and fading later in the night. The duration and severity can vary greatly from person to person.

Are there any non-medication ways to manage early sundowning?

Yes. Non-medication strategies include maintaining a consistent daily routine, managing environmental factors like lighting and noise, and planning calming evening activities to provide distraction and comfort.

Does sundowning happen every day?

Not necessarily. In the early stages, episodes may be inconsistent or infrequent. As dementia progresses, however, sundowning can become a more regular occurrence, with symptoms becoming more pronounced.

How can I tell if it's sundowning or delirium?

The key difference is the timing of onset and duration. Sundowning follows a predictable late-day schedule and is tied to dementia, while delirium often sets in quickly over days or weeks and can fluctuate throughout the day.

Is sundowning the same for everyone with dementia?

No. While the overall pattern is similar, the specific symptoms and triggers can vary significantly among individuals. Some may become restless, while others experience heightened paranoia or anxiety.

Can a bad night's sleep trigger sundowning?

Yes, fatigue is a known trigger for sundowning. Poor sleep patterns can disrupt the circadian rhythm, exacerbating confusion and restlessness in the late afternoon.