A Caregiver's Guide: How to tell if someone is sundowning?

It's estimated that up to 66% of people with Alzheimer's disease experience sundowning. This common phenomenon of increased confusion and agitation in the late afternoon and evening makes it crucial for caregivers to understand how to tell if someone is sundowning to provide effective care and support.

Quick Summary

Learning the signs of sundowning involves recognizing a predictable pattern of late-afternoon behavioral changes, including increased confusion, anxiety, agitation, restlessness, and wandering as daylight fades. Observing these symptoms can help you provide more effective and compassionate care.

Key Points

• Timing is everything: Sundowning is characterized by a predictable pattern of worsening confusion, anxiety, and agitation in the late afternoon and evening hours.

• Watch for agitation and restlessness: Key behavioral signs include pacing, wandering, fidgeting, and an inability to settle down.

• Environmental triggers matter: Changes in lighting, increased shadows, and overstimulation can all exacerbate sundowning symptoms.

• Emotional outbursts are common: A loved one may exhibit sudden irritability, anger, suspicion, or emotional distress as the day ends.

• Check for unmet needs: Before concluding it's sundowning, consider if there are unmet physical needs like hunger, thirst, pain, or fatigue.

• Maintain a consistent routine: Establishing a predictable daily schedule can be one of the most effective management tools for minimizing evening agitation.

• Use gentle reassurance: Avoid correcting a person's reality during a sundowning episode. Instead, speak calmly and reassure them that they are safe to prevent escalation.

Understanding the Pattern of Sundowning

Sundowning, also known as 'sundown syndrome' or 'late-day confusion', is not a disease itself but a collection of behaviors that occur in the late afternoon and evening. This phenomenon is most common in individuals with dementia, including Alzheimer's disease. As daylight fades, those affected may experience increased confusion, anxiety, agitation, and other behavioral changes. The key to identifying sundowning is recognizing this consistent daily pattern and observing the specific behavioral and emotional symptoms that arise.

The tell-tale signs to look for

Observing the specific behaviors and emotional shifts can help confirm if a loved one is experiencing sundowning. These signs can be subtle at first and become more pronounced as the condition progresses. A single symptom might not be conclusive, but a combination of several, occurring predictably around dusk, is a strong indicator.

Here are some common symptoms to watch for:

• Increased Agitation and Restlessness: Look for behaviors like pacing, fidgeting, an inability to sit still, or engaging in repetitive motions like rocking back and forth.
• Wandering: An urge to walk aimlessly, sometimes with the intent of leaving the house or 'going home', even if they are already in their own home.
• Emotional Outbursts: Sudden, unprovoked crying spells, yelling, or disproportionate anger or irritability are common. This can be distressing for both the individual and the caregiver.
• Suspicion and Paranoia: The individual may become unusually suspicious of family members or caregivers, accusing them of theft or other harmful intentions.
• Shadowing: Following a caregiver closely from room to room, seeking constant reassurance or feeling abandoned.
• Confusion and Disorientation: A worsening sense of confusion, difficulty recognizing familiar people or places, and an increase in repetitive questions.
• Hallucinations and Delusions: In some cases, sundowning can trigger vivid hallucinations (seeing or hearing things that aren't there) or delusions (false beliefs).

Potential environmental triggers

While the exact cause of sundowning is not fully understood, many factors can contribute to or worsen its symptoms. Often, environmental changes and overstimulation are significant triggers.

• Fading Light and Shadows: As natural light decreases, it can create confusing shadows, making familiar surroundings seem strange or frightening.
• Overstimulation: Too much noise, crowded rooms, or excessive activity in the afternoon can overwhelm a tired, sensitive brain.
• Changes in Routine: A sudden change in schedule or unexpected visitors can disrupt the predictability that is comforting to someone with dementia.
• Fatigue: Mental and physical exhaustion from the day can lower a person's coping mechanisms, making them more vulnerable to agitation in the evening.

Non-behavioral signs to consider

It's also important to consider underlying physical issues that might be contributing to the behavior. An individual with dementia may not be able to articulate their discomfort effectively, leading to behavioral outbursts.

• Unmet Physical Needs: Hunger, thirst, pain, or the need to use the restroom can all trigger agitation.
• Sleep Problems: Disruptions to the natural sleep-wake cycle (circadian rhythm) are common in dementia and are a major factor in sundowning.

Sundowning vs. Typical Day-to-Day Confusion: A Comparison

To help distinguish sundowning from typical, sporadic dementia-related confusion, consider the following points:

Aspect	Sundowning Behavior	Typical Dementia-Related Confusion
Timing	Worsens predictably in the late afternoon or evening as daylight fades.	Can occur at any time of day and is less consistent.
Intensity	Symptoms often intensify and can include extreme agitation or paranoia.	Symptoms are generally milder and may not escalate to emotional or physical outbursts.
Nature of Symptoms	Characterized by restlessness, wandering, and emotional volatility.	Typically involves memory lapses, confusion about tasks, or difficulty finding words.
Triggers	Strongly associated with environmental shifts, like fading light and fatigue.	Triggers are less consistent and can be sporadic or context-dependent.

Practical steps for managing sundowning

Once you recognize the signs, several strategies can help manage and reduce the severity of sundowning episodes. These interventions focus on creating a calming, predictable environment and addressing underlying needs.

• Establish a Predictable Routine: Create a structured daily schedule for meals, activities, and bedtime. This can provide a sense of security and familiarity that helps prevent late-day confusion.
• Promote Daytime Activity: Encourage physical activity and engagement during the day, such as walks or simple chores. This can help burn off excess energy and promote better nighttime sleep.
• Modify the Environment: As dusk approaches, close curtains and increase interior lighting to eliminate confusing shadows. Reduce background noise and clutter to create a more peaceful setting.
• Use Gentle Distraction: If agitation begins, try redirecting their attention with a calming activity like listening to soft music, looking at a photo album, or offering a favorite snack.
• Stay Calm and Reassuring: Your tone and body language are critical. Approach with a calm, patient voice and reassure the individual that they are safe. Do not argue or try to correct their reality.

For more extensive resources on Alzheimer's and dementia care, the Alzheimer's Association offers a wealth of information and support.

When to seek professional help

Managing sundowning is often a long-term process, and there may be times when it feels overwhelming. It is important to consult a healthcare professional, especially if:

• Symptoms become increasingly severe or unmanageable.
• The behavior poses a risk to the individual or others.
• You suspect an underlying medical issue, such as a urinary tract infection (UTI), is exacerbating the symptoms.

Conclusion

Identifying and understanding sundowning is the first step toward providing compassionate and effective care for a loved one with dementia. By recognizing the tell-tale patterns of evening confusion, implementing a structured routine, and creating a supportive environment, caregivers can significantly reduce the distress caused by this syndrome. Patience, reassurance, and strategic adjustments can make a profound difference in improving quality of life for both the person experiencing sundowning and those who care for them.

Frequently Asked Questions

What is sundowning, and who does it affect?

Sundowning is a collection of behavioral symptoms, such as increased confusion, agitation, and anxiety, that occur in the late afternoon and evening. It most commonly affects individuals with dementia, including Alzheimer's disease.

When is the best time to schedule appointments for someone who is sundowning?

Schedule appointments and other stimulating activities for the morning or early afternoon. This is when individuals with dementia tend to be more alert and less prone to agitation.

Can you prevent sundowning from happening?

While it may not be entirely preventable, managing sundowning is possible by maintaining a consistent routine, controlling the environment, and promoting daytime activity. Avoiding known triggers can also help.

Should I correct someone who becomes confused while sundowning?

No, correcting or arguing with them can increase their frustration and agitation. Instead, it's best to reassure them calmly and try to distract them with a comforting activity or object.

Are there medical reasons someone might be sundowning?

Yes. Sometimes, an underlying medical issue, such as a urinary tract infection (UTI), pain, or side effects from medication, can trigger or worsen sundowning behaviors. A doctor can help rule out these causes.

How can I adjust the lighting to help with sundowning?

As dusk approaches, close curtains and turn on lights to minimize confusing shadows. Keeping the environment brightly lit can help reset the body's internal clock and provide a sense of security.

Is wandering a sign of sundowning?

Yes, increased restlessness, pacing, and wandering are common behaviors associated with sundowning. These actions are often a response to underlying feelings of anxiety and confusion.

How long does a sundowning episode typically last?

The duration of a sundowning episode can vary widely, from a few hours to lasting throughout the night. It usually subsides by the next morning, but the sleep disturbance can affect the following day.