How do you know when someone has sundowners? Signs and Management

According to the Alzheimer's Association, studies suggest sundowning affects up to 20% of individuals with Alzheimer's disease. Knowing how do you know when someone has sundowners is crucial for caregivers to understand and effectively manage these challenging evening behavioral changes.

Quick Summary

Sundowning is typically identified by a predictable pattern of heightened agitation, anxiety, and confusion that begins in the late afternoon and worsens into the evening. These behavioral changes may also include wandering, restlessness, and emotional outbursts, distinguishing it from other types of confusion.

Key Points

• Pattern Recognition: The key to identifying sundowning is observing a predictable pattern of worsening confusion and agitation in the late afternoon and evening.

• Behavioral Changes: Symptoms include increased confusion, anxiety, restlessness, wandering, and emotional outbursts that subside by morning.

• Environmental Management: Creating a calm, well-lit, and predictable evening environment helps minimize distress and disorientation.

• Routine is Key: Maintaining a consistent daily schedule, including meals, activities, and bedtime, helps regulate the body's internal clock.

• Distinguish from Delirium: The predictable timing of symptoms differentiates sundowning from delirium, which has a rapid, non-specific onset.

• Seek Support: If sundowning symptoms become unmanageable or unsafe, it is essential to consult a healthcare professional for guidance and support.

Understanding Sundowning

Sundowning, or sundown syndrome, is not a disease itself but a collection of behavioral and psychological symptoms associated with dementia, particularly Alzheimer's disease. These symptoms predictably emerge in the late afternoon or early evening and can persist into the night. For caregivers and family members, recognizing this pattern is the first critical step toward providing effective support and maintaining a calm environment. The underlying cause is still not fully understood, but it is believed to be linked to disruptions in the body's internal clock (circadian rhythm) caused by the disease's progression.

Key Behavioral Signs of Sundowning

The symptoms of sundowning can vary widely among individuals but tend to follow a recognizable pattern. Observing these signs can help you confirm that your loved one is experiencing this specific phenomenon.

• Increased Confusion: As daylight fades, the individual may seem more disoriented, struggle with familiar tasks, and have trouble recognizing people or places they know.
• Agitation and Restlessness: A person might become more anxious, irritable, or start pacing. This can sometimes escalate to yelling or more aggressive behavior.
• Emotional Outbursts: Unpredictable mood swings, crying, or unprovoked anger are common during sundowning episodes. These emotional displays can be distressing for everyone involved.
• Wandering: A strong urge to walk or pace aimlessly can occur as evening approaches. The person may try to leave the house, convinced they need to go somewhere or see someone.
• Shadowing: The individual may follow a caregiver closely, mimicking their movements and displaying increased dependence, known as shadowing.
• Paranoia and Delusions: Heightened suspicion, fear, and paranoia can manifest, with the individual sometimes believing they are in danger or that people are stealing from them.
• Repetitive Actions: The person may repeat the same questions or tasks over and over, unable to be easily redirected.

Distinguishing Sundowning from Other Conditions

When evaluating a loved one's behavior, it is essential to consider the timing and pattern to differentiate sundowning from other potential health issues. For example, a urinary tract infection (UTI) or other illness can cause sudden, rapid-onset delirium, which is distinct from the predictable evening pattern of sundowning. If the confusion is not tied to the late-day routine, a medical evaluation is warranted.

Sundowning vs. Delirium

Feature	Sundowning	Delirium
Onset	Gradual, predictable worsening in late afternoon/evening.	Rapid, often sudden onset (hours to days).
Fluctuation	Worsens predictably with the setting sun and improves by morning.	Fluctuates throughout the day, not tied to a specific time.
Underlying Cause	Primarily linked to disruption of the body's circadian rhythm due to dementia.	Caused by an underlying medical condition (e.g., UTI, infection, medication side effects).
Duration	Occurs in predictable, often daily, episodes.	May last for days or weeks until the underlying cause is treated.
Symptoms	Worsening of existing dementia symptoms (e.g., confusion, agitation).	More severe and acute changes in mental state, attention, and awareness.

Common Triggers for Sundowning Episodes

Identifying and managing potential triggers is a cornerstone of managing sundowning. Caregivers can make significant improvements by adjusting the environment and daily routine.

1. Light Changes: Diminishing daylight and increasing shadows can be confusing and frightening, causing disorientation.
2. Fatigue: Physical and mental exhaustion from a long day can heighten confusion and irritability.
3. Overstimulation or Understimulation: Too much activity, noise, or crowds late in the day can be overwhelming. Conversely, boredom and lack of engaging activity can also trigger agitation.
4. Disrupted Routine: Changes in daily schedule, meals, or sleep patterns can disrupt the internal body clock, leading to distress.
5. Unmet Needs: Basic needs like hunger, thirst, or pain may be difficult for the individual to express, resulting in agitated behavior.

Strategies for Managing and Coping with Sundowning

Effective management involves a multi-pronged approach focused on routine, environment, and communication. Here are some strategies that can help.

• Establish a Predictable Routine: A consistent daily schedule for waking, meals, and bedtime provides a sense of security and structure. Limit daytime naps or schedule them early in the day.
• Maximize Daytime Light: Ensure plenty of natural light exposure during the day. Consider using a light therapy box in the morning to help regulate circadian rhythms.
• Control the Evening Environment: As evening approaches, turn on lights to eliminate confusing shadows. Reduce noise and clutter to create a calm, peaceful atmosphere.
• Incorporate Calming Activities: Engage in low-stress, quiet activities in the evening. This could include listening to soothing music, looking at photo albums, or a simple hand massage.
• Adjust Diet and Hydration: Avoid caffeine, alcohol, and large meals late in the day, which can disrupt sleep. Offer a light, healthy snack and ensure adequate hydration throughout the day.
• Redirect and Reassure: When an episode occurs, use a calm, gentle tone. Redirect their attention to something familiar or comforting. Avoid arguing or correcting their perceptions, as this can increase their distress.

Seeking Professional Help

While many caregivers can manage sundowning with behavioral strategies, there are times when professional intervention is necessary. If the symptoms are becoming more frequent or severe, posing a risk of harm to the individual or others, or if your own well-being as a caregiver is suffering, it is time to consult with a healthcare provider. A doctor can rule out other medical issues, review medications, and offer additional support or resources. Organizations like the BrightFocus Foundation offer valuable resources and tips for managing sundowning. BrightFocus Foundation on Sundowning

Conclusion

Recognizing the predictable late-day pattern of confusion, anxiety, and agitation is how you know when someone has sundowners. By understanding the potential triggers and implementing consistent routines, a supportive environment, and calming evening activities, caregivers can significantly reduce the impact of sundowning. Knowing when to seek professional help is also a vital part of effective, long-term care.

Frequently Asked Questions

What is sundowning?

Sundowning is a term used to describe a state of increased confusion, anxiety, and agitation that affects some people with dementia, particularly in the late afternoon and evening hours.

How do you know when someone has sundowners?

You can identify sundowning by observing a consistent pattern of behavioral changes, such as increased confusion, restlessness, and emotional outbursts, that occur specifically as daylight fades and into the evening.

Does sundowning happen every day?

No, sundowning does not necessarily happen every day. While some individuals experience a daily pattern, the frequency and intensity can vary. It may be triggered or exacerbated by specific factors like fatigue or changes in routine.

Can sundowning occur without dementia?

While sundowning is most commonly associated with dementia and Alzheimer's disease, similar symptoms of late-day confusion and agitation can occur in other elderly individuals, sometimes due to hospitalization or medication side effects.

What are common triggers for sundowners?

Common triggers for sundowning include late-day fatigue, changes in lighting (like shadows), overstimulation or boredom, a disrupted daily routine, and unmet needs such as hunger or pain.

How can caregivers manage sundowning behaviors?

Caregivers can manage sundowning by establishing a consistent daily routine, maximizing natural light exposure during the day, creating a calm evening environment, and using distraction and redirection during episodes.

When should you seek professional help for sundowning?

It is advisable to seek professional help if sundowning symptoms are severe, pose a risk of harm, become unmanageable for caregivers, or if standard management strategies are proving ineffective.

What is the difference between sundowning and delirium?

The main difference is the timing and onset. Sundowning follows a predictable late-day pattern associated with dementia, while delirium has a sudden, non-specific onset caused by an underlying medical condition.