How can you tell if someone is sundowning?

According to the Alzheimer's Association, sundowning affects up to 20% of people with Alzheimer's. Learning how can you tell if someone is sundowning is the first critical step toward providing better care and understanding these behavioral changes.

Quick Summary

Sundowning is characterized by increased confusion, anxiety, and agitation in the late afternoon or evening in individuals with dementia. Recognizing patterns of worsening restlessness, mood swings, and wandering as daylight fades is key to identifying this phenomenon and distinguishing it from other issues.

Key Points

• Timing is key: Sundowning is most notable for its predictable timing, with symptoms of confusion, anxiety, and agitation consistently appearing or worsening in the late afternoon or evening.

• Look for behavioral changes: Common signs include increased restlessness, wandering, pacing, and following a caregiver closely (shadowing).

• Notice emotional shifts: Watch for unexplained mood swings, irritability, paranoia, or emotional outbursts that emerge as the day ends.

• Distinguish from normal tiredness: Unlike typical fatigue, sundowning symptoms do not improve with rest and often involve significant disorientation and judgment impairment.

• Identify potential triggers: Pay attention to environmental factors like dim lighting or overstimulation, and physical triggers such as pain, hunger, or fatigue, which can worsen episodes.

• Focus on routine and environment: Proactive management involves maintaining a consistent daily schedule and creating a calming, well-lit evening environment to minimize triggers.

• Stay calm and redirect: During an episode, the best response is to stay calm, offer reassurance, and gently redirect the person's attention with a simple, pleasant activity.

What is Sundowning?

Sundowning, also known as sundown syndrome or late-day confusion, is not a disease itself but a collection of symptoms that occur in the late afternoon and evening, affecting individuals with Alzheimer's and other forms of dementia. This phenomenon manifests as behavioral disturbances that can range from mild agitation and confusion to more severe symptoms like aggression and hallucinations. While the exact cause is not fully understood, it is believed to be linked to disruptions in the person's internal body clock (circadian rhythm) caused by brain changes from dementia.

Identifying the Core Signs of Sundowning

The key to identifying sundowning is observing a predictable pattern of behavioral and emotional changes that consistently worsen as daylight fades. While every individual's experience is unique, several common signs point toward sundowning. Caregivers and family members should pay close attention to any combination of the following indicators, especially as evening approaches.

Behavioral Indicators

• Wandering or pacing: An individual may become restless and start pacing the floors or wandering aimlessly. This can be a significant safety concern if they attempt to leave the home.
• Shadowing: The person may follow their caregiver closely, mimicking their movements. This behavior is often rooted in anxiety and a need for reassurance.
• Hiding objects: A person may begin hiding or hoarding items, convinced that their possessions are being stolen.
• Resistance to routine: As bedtime approaches, the person may resist going to bed, bathing, or changing clothes, exhibiting increased stubbornness or non-cooperation.
• Aggression or violence: In more severe cases, heightened agitation can lead to verbal or physical aggression toward caregivers or family members.

Emotional and Psychological Indicators

• Increased confusion and disorientation: The person may become increasingly confused about time and place, forgetting recent conversations or events that happened earlier in the day.
• Anxiety and fear: Feelings of anxiety, fear, and paranoia often escalate. A person might feel threatened for no apparent reason, leading to defensiveness.
• Mood swings and irritability: Noticeable shifts in mood, from being pleasant and cooperative to irritable and angry, are common hallmarks of sundowning.
• Crying or emotional outbursts: Unexplained crying or sudden emotional outbursts can occur as the individual struggles to process overwhelming feelings and sensory input.
• Paranoia and delusions: A person might develop unfounded suspicions that someone is trying to harm them or steal from them, leading to distressing delusions.

Factors that Trigger or Worsen Sundowning

Beyond the daily cycle of light and dark, several other factors can exacerbate sundowning symptoms. Being aware of these triggers can help caregivers better manage and mitigate episodes.

Environmental Triggers:

• Low lighting: Diminishing natural light can cast shadows that a person with dementia might perceive as threatening or confusing.
• Overstimulation: A noisy or chaotic environment, too much activity, or large gatherings of people can be overwhelming.
• Unfamiliar surroundings: Being in a new or unfamiliar place can heighten anxiety and confusion.

Physical Triggers:

• Fatigue: Exhaustion from a busy day can cause confusion and lower the person's tolerance for stimulation.
• Lack of sleep: A disrupted sleep-wake cycle can worsen cognitive function and increase agitation.
• Underlying health issues: Undiagnosed pain, dehydration, hunger, or infections (like a UTI) can trigger or intensify symptoms.
• Medication side effects: Some medications, especially those that affect sleep, can contribute to sundowning.

Normal Evening Tiredness vs. Sundowning: A Comparison

To effectively identify and manage the issue, it’s helpful to distinguish true sundowning from the general tiredness or moodiness that can affect anyone toward the end of the day.

Feature	Normal Evening Tiredness	Sundowning (Dementia-Related)
Timing & Pattern	Occurs inconsistently; may be related to a busy day.	Predictable pattern, occurring consistently in the late afternoon/evening.
Behavior	May feel cranky, sleepy, or less sociable.	Increased confusion, agitation, wandering, and aggression.
Cognition	Mind feels tired, but orientation remains intact.	Significant disorientation, impaired judgment, and memory lapses.
Rest	A short rest or quiet time can alleviate symptoms.	Symptoms persist or worsen even with rest.
Emotional State	Generally proportional to the day's stress.	Can involve extreme, seemingly unprovoked anxiety, fear, or paranoia.

How to Manage and Respond to Sundowning

Managing sundowning is a multi-faceted effort that focuses on establishing routine, controlling the environment, and responding with patience and calm. These strategies can help minimize triggers and soothe the person during episodes.

Proactive Management Strategies

1. Maintain a routine: Keep a consistent daily schedule for meals, waking, and bedtime to help regulate the body's internal clock.
2. Increase daytime activity: Encourage morning walks, light exercise, and engaging activities to promote alertness during the day and better sleep at night.
3. Optimize lighting: Maximize exposure to natural light during the day. In the evening, turn on lights to eliminate dark corners and shadows that might cause fear.
4. Limit stimulating activities: Avoid stressful or overwhelming events in the late afternoon and evening. This includes large gatherings, loud TV programs, or complex conversations.
5. Address underlying causes: Work with a doctor to rule out medical issues like pain, infection, or medication side effects that could be contributing to the behavior.

Responding During an Episode

1. Stay calm and reassuring: Your calm demeanor can help de-escalate the situation. Use a soft, gentle tone of voice.
2. Redirect and distract: Gently shift the person's attention to a favorite activity, a simple task, or a calming sensory input like soft music. Try not to argue or confront their reality.
3. Offer a gentle touch: A comforting hand on the arm or a gentle hug can provide reassurance, but be mindful of the person's reaction, as some may not want to be touched.
4. Ensure safety: If wandering is a concern, make sure the home is secure. Lock doors and windows and consider using a door alarm or a monitoring system.

Understanding and recognizing sundowning is crucial for providing compassionate and effective care. By identifying the signs and implementing proactive management and calming techniques, caregivers can improve the quality of life for both themselves and their loved ones.

For more detailed strategies and resources on dementia care, consider consulting an organization like the Alzheimer's Association. Their resources can provide invaluable guidance for managing the challenges associated with sundowning and other dementia-related behaviors.

Frequently Asked Questions

What is the primary sign that distinguishes sundowning from general confusion?

The primary distinguishing factor is the consistent, time-based pattern. Sundowning symptoms reliably intensify as daylight fades, typically in the late afternoon and evening, whereas general confusion can happen at any time of day.

Can sundowning occur in people without dementia?

While sundowning is most commonly associated with dementia and Alzheimer's, some older adults without a dementia diagnosis may exhibit similar symptoms when they are ill, in an unfamiliar environment, or experiencing delirium.

What should I do if my loved one becomes agitated during sundowning?

During an episode, remain calm and reassuring. Try to redirect their attention with a quiet activity they enjoy, such as listening to soft music or looking at a photo album. Avoid arguing or confronting their confused reality, which can escalate the agitation.

Are there specific triggers I should look out for?

Yes, common triggers include fatigue, changes in routine, low lighting, hunger, pain, and overstimulation. It is helpful to keep a log of what happens before episodes to identify and manage these triggers.

How can I make the evening hours more peaceful for someone with sundowning?

Establish a consistent, predictable routine for evenings. Ensure the environment is well-lit to reduce shadows, and minimize noise and stimulating activities like loud television. A calm atmosphere can help ease anxiety.

Is wandering a symptom of sundowning?

Yes, increased restlessness and wandering are common behavioral symptoms of sundowning. This behavior is often driven by anxiety and confusion and can be a significant safety concern. Ensuring doors are locked and creating a safe, clutter-free space is important.

Does sundowning always involve aggression?

No, aggression is not present in all cases of sundowning. Symptoms can vary widely, from mild confusion and sadness to more severe anxiety, paranoia, and agitation. The specific signs depend on the individual.

When should I contact a doctor about sundowning?

You should contact a doctor if the sundowning behaviors worsen significantly, if new or unusual symptoms appear, or if you suspect an underlying medical issue like an infection or pain is contributing to the problem. Your doctor can help evaluate and adjust the care plan.