What is Sundowning?
Sundowning, or sundown syndrome, is not a disease but a term used to describe a pattern of behavioral changes that occur in people with dementia. The key characteristic is that these symptoms emerge or intensify as the day fades into evening. What may appear as calm, normal behavior in the morning can transform into agitation and confusion by dusk. While the exact cause is not fully understood, research suggests it is linked to changes in the brain's internal 'body clock' (circadian rhythm) caused by dementia.
The Hallmark: Late-Day Behavioral and Emotional Shifts
Recognizing sundowning starts with paying close attention to the timing and nature of behavioral changes. The pattern of late-day worsening is the primary identifier.
Behavioral Symptoms
- Restlessness and Pacing: A person may become unable to sit still, fidgeting, pacing, or walking with purpose as if they need to go somewhere. This can sometimes escalate to wandering.
- Agitation and Aggression: Increased irritability and agitation are common. This can lead to verbal or physical outbursts, resisting help from caregivers, or lashing out for seemingly no reason.
- Shadowing: Some individuals may follow a caregiver closely, mimicking their movements, and refusing to be left alone. This often stems from anxiety and a need for reassurance.
- Hiding Objects: As confusion increases, a person may hide familiar objects in unusual places, then become suspicious or paranoid that someone has stolen them.
Emotional Symptoms
- Anxiety and Fear: Feelings of worry or fear can intensify as daylight fades. The dimming light can create long shadows and alter familiar surroundings, triggering anxiety.
- Confusion and Disorientation: While confusion is a hallmark of dementia, it can become more pronounced during sundowning episodes. A person may not recognize their surroundings, familiar faces, or even what time of day it is.
- Crying or Sadness: Some individuals may experience unexplained sadness or crying as evening approaches.
- Paranoia and Delusions: These can include false beliefs, such as thinking a family member is stealing from them, or unwarranted suspicion of others.
Cognitive and Physical Changes
- Communication Difficulties: The ability to communicate and follow a conversation may decline. A person might repeat questions endlessly or use incorrect words.
- Hallucinations: In some cases, sundowning can involve hallucinations—seeing or hearing things that are not there—which can be frightening and disorienting.
- Disrupted Sleep Patterns: Trouble falling asleep, staying asleep, and frequent waking during the night are significant components of sundowning, often exacerbating daytime fatigue and evening confusion.
Sundowning vs. Delirium: A Comparison
It's important to distinguish sundowning from delirium, as they share some similar symptoms but have different causes and treatment approaches. The timing and speed of onset are key differentiators.
| Feature | Sundowning | Delirium |
|---|---|---|
| Onset | Gradual onset and predictable timing in the late afternoon/evening. | Sudden onset, often over hours or days. |
| Pattern | Symptoms follow a consistent late-day pattern. | Symptoms fluctuate throughout the day. |
| Cause | Primarily linked to dementia and disrupted circadian rhythm. | Often caused by an underlying medical condition, like an infection, new medication, or pain. |
| Duration | Lasts for a few hours, easing by morning. | Can last days or weeks if the underlying cause is not treated. |
If symptoms appear suddenly and are more severe than typical, it's crucial to consult a doctor to rule out delirium or another medical issue.
Common Triggers for Sundowning
Several factors can trigger or worsen a sundowning episode. Identifying and minimizing these can help manage symptoms.
- Fatigue: Overstimulation and physical or mental exhaustion from the day.
- Environmental Factors: Low light, increased shadows, or an unfamiliar environment.
- Disrupted Routine: Unpredictable changes to the daily schedule.
- Hunger or Thirst: Unmet physical needs can be hard for someone with dementia to express.
- Boredom: Lack of mental stimulation can lead to restlessness.
- Pain: Undiagnosed or untreated pain can cause agitation.
- Medication Side Effects: Some medications can cause or worsen confusion as they wear off in the evening.
- Caregiver Stress: A caregiver's own fatigue or frustration can be sensed by the person with dementia, adding to their anxiety.
How to Manage and Track Sundowning
Observing and documenting behavior is a practical step for caregivers. By keeping a simple journal, you can pinpoint patterns and share information with a doctor.
- Log Behavior: Write down the time of day when a behavior starts, what it is (e.g., pacing, yelling, anxiety), and how long it lasts.
- Note Triggers: Record any events, people, or changes that occurred before the behavior. Was there a loud noise? Did they skip a meal? Was the lighting low?
- Track Solutions: Make a note of what, if anything, helped calm the person. Did a quiet activity, soft music, or a familiar voice make a difference?
- Discuss with a Doctor: This documentation will be invaluable for a healthcare provider to develop an effective management strategy. Medications, light therapy, or behavioral approaches may be suggested.
Conclusion: Taking Steps Towards Better Care
Understanding how do you know if you are sundowning is the first step toward better management and improved quality of life for both the individual and their caregivers. By recognizing the late-day pattern of increased confusion, anxiety, and agitation, and identifying the common triggers, caregivers can develop proactive strategies. While sundowning is a challenging aspect of dementia, professional medical guidance, combined with careful observation and consistent routines, can help mitigate its effects. For more resources and information on dementia, visit the National Institute on Aging website www.nia.nih.gov.
