What strategy is most useful to reduce sundowning? A guide for caregivers

Research indicates that up to 20% of dementia patients experience sundowning, a pattern of increased confusion, anxiety, and agitation during late afternoon and evening hours.

Determining what strategy is most useful to reduce sundowning is crucial for improving the quality of life for both the individual and their caregivers.

Quick Summary

Creating and maintaining a consistent, predictable daily routine—with an emphasis on balanced daytime activity, regulated light exposure, and a calm, low-stimulation environment during transitional periods—is the most effective strategy for managing and reducing sundowning symptoms.

Key Points

• Consistent Routine: A predictable daily schedule provides security and reduces anxiety, which often triggers sundowning.

• Daylight Exposure: Maximizing exposure to natural light during the day helps regulate the body's internal sleep-wake cycle.

• Calm Evenings: Reducing noise, minimizing stimulation, and eliminating confusing shadows as evening approaches can prevent agitation.

• Balanced Activity: Engaging in low-stress, purposeful activities during the day helps prevent restlessness without causing overexertion.

• Gentle Redirection: During an episode, validate feelings and distract with familiar, comforting activities rather than attempting to reason.

Understanding the Phenomenon of Sundowning

Sundowning, also known as sundown syndrome, is a cluster of symptoms that often occur in people with dementia or Alzheimer's. While not a disease in itself, it refers to a state of increased confusion, anxiety, agitation, and restlessness that begins in the late afternoon and continues into the evening. Understanding the potential causes of this behavior is the first step toward finding a successful management strategy.

Contributing factors often include:

• Circadian rhythm disruption: The body's internal clock is often disrupted by dementia, affecting sleep-wake cycles.
• End-of-day fatigue: As the day wears on, mental and physical exhaustion can increase confusion and trigger challenging behaviors.
• Environmental changes: The transition from light to dark, combined with shadows and reduced visibility, can be disorienting and frightening.
• Stimulation overload: Too much noise, activity, or chaos in the evening can overwhelm the person's coping abilities.
• unmet needs: The person may be hungry, thirsty, in pain, or need to use the restroom but is unable to communicate their needs effectively.

By addressing these underlying issues, caregivers can lay the groundwork for a more peaceful and predictable evening.

The Most Useful Strategy: Establishing a Consistent Daily Routine

Caregiving experts widely agree that implementing and sticking to a structured daily routine is the single most useful strategy to reduce sundowning. A predictable schedule provides a sense of security and familiarity, reducing the anxiety that often triggers agitation. This routine should include consistent times for waking up, meals, activities, and bedtime.

Practical Steps for Routine-Based Sundowning Management

1. Maximize Daylight Exposure: Help the individual get plenty of natural sunlight during the day. This helps regulate the body's internal clock. Consider a morning walk, sitting by a sunny window, or using light therapy boxes during darker months.
2. Encourage Daytime Activity: Incorporate purposeful, low-stress activities during the day to prevent boredom and restlessness. This could include folding laundry, sorting objects, listening to music, or gentle exercise like walking.
3. Limit Late-Day Napping: While a short, early afternoon nap is acceptable if needed, long or late naps can interfere with nighttime sleep and worsen evening confusion. Try redirecting the person with a light snack or activity if they appear drowsy later in the day.
4. Reduce Evening Stimulation: As the late afternoon approaches, transition the environment to a calmer state. Lower the volume of the television or radio, close blinds to eliminate confusing shadows, and minimize the number of visitors or loud noises.
5. Serve an Early, Light Dinner: A heavy, late meal can cause discomfort and disrupt sleep. Opt for a lighter dinner earlier in the evening and limit caffeine and sugar intake, especially after lunchtime.

Environmental Adjustments for a Calmer Evening

Beyond routine, the physical environment plays a significant role in mitigating sundowning symptoms. Creating a safe, calm, and familiar space can dramatically reduce anxiety and disorientation.

• Ensure Adequate Lighting: A well-lit home, especially during the transition from dusk to dark, can prevent shadows and reduce confusion. Use nightlights in hallways, bathrooms, and bedrooms.
• Use Soothing Sensory Cues: Familiar, gentle music can be a powerful tool for relaxation. You might also try aromatherapy with calming scents like lavender, if the person responds well to it.
• Minimize Clutter: A cluttered or visually busy environment can be overwhelming. Keep common areas tidy and remove unnecessary items that could cause distraction or anxiety.
• Address Basic Needs: Ensure the individual isn’t hungry, thirsty, cold, or in pain. Sometimes, a seemingly random outburst is simply a cry for help that they can't verbalize.

Comparison of Sundowning Strategies

To highlight the most effective approaches, here is a comparison of different strategies and their primary focus.

Strategy	Primary Focus	Key Benefit	Potential Limitation
Consistent Daily Routine	Behavior & Internal Clock	Provides security, reduces anxiety, regulates sleep.	Requires discipline and consistency from caregivers.
Environmental Modification	Sensory & Safety	Reduces confusion and fear caused by light changes and shadows.	May not address underlying fatigue or biological factors.
Increased Daytime Activity	Physical & Mental Stimulation	Combats restlessness, promotes better sleep quality at night.	Must be balanced; overexertion can worsen symptoms.
Pharmacological Treatment	Symptom Management	Can quickly relieve severe agitation or insomnia.	Often has side effects and is not a first-line solution.
Validation Therapy	Emotional & Psychological	Eases emotional distress during an episode by acknowledging feelings.	Doesn't address the root cause of the behavioral pattern.

Responding to Sundowning Episodes in the Moment

Even with the best preventative measures, sundowning episodes can still occur. When they do, the key is to remain calm and reassuring. Trying to reason with a confused person is often ineffective. Instead, focus on redirection and validation.

1. Validate their Feelings: Acknowledge their distress without challenging their reality. Phrases like, "I can see you're upset," or "It sounds like you want to go home," can be comforting.
2. Provide a Safe Distraction: Redirect their attention to a pleasant, low-key activity. Look at an old photo album, listen to a familiar song, or offer a favorite snack. The Mayo Clinic provides expert answers on sundowning and other Alzheimer's-related questions.
3. Offer Reassurance: A gentle touch on the arm, a hug, or holding their hand can provide comfort and a sense of security. Speak in a calm, soothing voice.

Conclusion

While multiple approaches can help manage sundowning, the most useful strategy combines proactive routine management with environmental modifications. By establishing a consistent daily schedule, ensuring proper light exposure, and creating a peaceful evening setting, caregivers can significantly reduce the frequency and intensity of sundowning episodes. Consistency and a calm, reassuring approach are the caregiver's most valuable tools in navigating this challenging aspect of dementia care.

Frequently Asked Questions

Why does sundowning happen?

Sundowning is believed to be caused by a combination of factors, including the disruption of the body's internal clock (circadian rhythm), end-of-day fatigue, changes in environmental light, and difficulty distinguishing reality.

Can medication help with sundowning?

In some cases, medication can be prescribed to manage severe sundowning symptoms, but it is typically not the first course of action. Lifestyle and environmental strategies are often more effective and have fewer side effects.

What should I do if a sundowning episode occurs?

Remain calm and reassuring. Instead of arguing or reasoning, validate their feelings and try to redirect their attention to a soothing activity, like listening to music or looking at familiar objects.

How can I adjust the lighting to help with sundowning?

Ensure ample natural light during the day. In the evening, increase indoor lighting to prevent shadows and dark corners. Use nightlights in critical areas like bedrooms and hallways.

Is lack of sleep a factor in sundowning?

Yes, fatigue and disrupted sleep patterns are major contributors to sundowning. Promoting better sleep through a consistent routine and limited daytime naps can help reduce evening symptoms.

Does sundowning only affect people with Alzheimer's?

While it is most commonly associated with Alzheimer's disease, sundowning can also occur in individuals with other forms of dementia and cognitive impairment.

What are some good evening activities to prevent sundowning?

Good evening activities should be calming and low-stress. Examples include listening to soft music, doing a simple craft, looking at old photos, or having a light snack.