Two Common Behaviors That Cognitively Impaired Residents Have

According to the Alzheimer's Association, over 60% of people with dementia will wander at some point, and sundowning affects up to two-thirds of individuals with Alzheimer's. These statistics highlight the prevalence of two common behaviors that cognitively impaired residents have: wandering and sundowning, which can be challenging for caregivers but can be managed with the right approach.

Quick Summary

This article explores two frequent behaviors seen in cognitively impaired residents: wandering and sundowning. It provides an overview of the causes and offers effective, non-pharmacological management techniques for caregivers to improve safety and quality of life for residents.

Key Points

• Wandering is a common behavior driven by confusion, anxiety, or unmet needs, and it presents a significant safety risk.

• Sundowning involves increased confusion and agitation in the late afternoon and evening, linked to a disrupted body clock and environmental triggers.

• Maintain a consistent daily routine with engaging activities to provide a sense of security and reduce restlessness.

• Create a safe and calming environment by controlling light, noise, and clutter, and by securing potential exit points.

• Respond with patience and reassurance, rather than confrontation or arguments, focusing on the feelings behind the behavior.

• Distraction and redirection are effective strategies to shift a resident's focus away from a triggering situation.

• Rule out underlying medical issues or pain that might be causing or worsening behavioral symptoms.

Understanding Common Behaviors in Cognitively Impaired Residents

Caring for a cognitively impaired resident presents unique challenges, with behavioral and psychological symptoms of dementia (BPSD) being common occurrences. These behaviors, often stemming from confusion, anxiety, and an inability to communicate needs, are not intentional acts but rather manifestations of the underlying cognitive decline. Understanding the root causes of these behaviors is the first step toward effective management and ensuring the safety and well-being of both the resident and the caregiver.

The Problem of Wandering

Wandering is one of the most frequently reported behavioral problems in cognitively impaired individuals. It is often triggered by disorientation, confusion, or a desire to follow a previous routine, such as going to work or going "home," even if they are already in their own residence. Wandering can present serious safety risks, especially if the resident leaves a secure area, but it can be managed effectively with proper strategies.

Causes of Wandering

• Disorientation: A person may not recognize their current location, leading them to believe they need to find their way home.
• Unmet Needs: Wandering can be a way of expressing a need for food, water, a restroom, or to be outside.
• Boredom or Restlessness: A lack of engaging activities can lead to restlessness, causing the person to pace or wander in search of something to do.
• Stress or Anxiety: Feeling overwhelmed by an unfamiliar or chaotic environment can cause a person to feel unsafe and want to leave.
• Past Routines: The person may be trying to follow old habits, such as heading to a former workplace or visiting a friend.

Management Techniques for Wandering

• Assess and Address Needs: Rule out physical discomfort, such as hunger, thirst, or pain, that might be causing the restlessness.
• Maintain Routine and Engagement: Keep the person engaged with meaningful activities, and maintain a consistent daily schedule to provide a sense of security and structure.
• Create a Safe Environment: Secure the home with door and window alarms, and install locks that are difficult to open. Remove tripping hazards and ensure all living spaces are well-lit.
• Use Visual Cues and Barriers: Camouflage exits by painting doors the same color as the walls, or placing posters over them. A large black mat in front of a door can also deter some individuals.
• Enroll in a Tracking Program: Consider using wearable GPS tracking devices or registering with a program like the Alzheimer's Association's Safe Return to help locate the person if they do wander off.

The Challenge of Sundowning

Sundowning, or "sundown syndrome," is another common behavior where a resident experiences increased agitation, confusion, and anxiety as daylight fades. This phenomenon is believed to be linked to disruptions in the person's internal body clock, which regulates the sleep-wake cycle. The resulting fatigue and confusion can lead to heightened emotional reactions and restlessness in the late afternoon and evening.

Causes of Sundowning

• Circadian Rhythm Disruption: Damage to the brain can affect the body's internal clock, making it difficult to distinguish between day and night.
• Fatigue: A long, active day can lead to exhaustion, making it harder for the person to cope with normal stimuli.
• Environmental Triggers: Fading light can cause shadows that appear frightening, while overstimulation from loud noises or too many people can be overwhelming.
• Anxiety and Depression: Existing mood disorders can be exacerbated during the evening hours, contributing to increased agitation.
• Sleep Problems: A lack of quality sleep at night can make a person more fatigued and disoriented during the late afternoon.

Management Techniques for Sundowning

• Establish a Consistent Schedule: Maintain regular mealtimes, waking times, and bedtimes. Schedule physically and mentally stimulating activities during the day, tapering off toward the evening.
• Enhance Light Exposure: Ensure the resident gets plenty of natural light during the day, such as by going for a walk or sitting by a window. Increase indoor lighting in the evening to reduce shadows and confusion.
• Create a Calm Evening Environment: Reduce stimulation by limiting background noise, such as television. Engage the person in quiet, relaxing activities like listening to soft music or looking at family photos.
• Adjust Diet and Medication: Avoid giving caffeine, sugar, and alcohol later in the day, as these can disrupt sleep. A doctor may also review medications to see if side effects are contributing to the symptoms.
• Rule Out Other Issues: Ensure unmet physical needs like hunger, thirst, or pain are not contributing to the behavior. Consider a medical check-up to rule out conditions like a urinary tract infection.

Comparison of Wandering and Sundowning Management

Aspect	Wandering	Sundowning
Primary Cause	Disorientation, unmet needs, restlessness, or past routines	Disrupted circadian rhythm and increased fatigue in the late afternoon/evening
Timing	Can occur at any time, but sometimes linked to past routines	Occurs specifically in the late afternoon and evening
Goal of Intervention	Ensure safety, manage potential triggers, and redirect	Calm agitation, create a soothing environment, and regulate sleep patterns
Environmental Strategy	Secure exits with locks/alarms, reduce clutter, and use visual deterrents	Increase light during the day, reduce stimulation in the evening, use nightlights
Caregiver Response	Remain calm, redirect with distraction, join and walk with them	Remain calm, reassure the person, validate feelings, and redirect
Proactive Strategy	Maintain a consistent routine, provide engaging activities	Schedule activities earlier in the day, ensure daytime light exposure

Conclusion

Wandering and sundowning are two common, and often intertwined, behavioral challenges faced by cognitively impaired residents and their caregivers. While neither behavior is malicious, both require a deep understanding of their triggers and sensitive, patient management. Implementing proactive strategies such as maintaining a consistent routine, ensuring a safe and calm environment, and engaging the resident in meaningful activities can significantly reduce the frequency and intensity of these behaviors. For caregivers, responding with reassurance rather than confrontation is key to de-escalating difficult situations and fostering a sense of security for the resident. By focusing on these non-pharmacological interventions, it is possible to enhance the quality of life for both the cognitively impaired individual and those who care for them.

Additional Management Considerations

Regardless of the specific behavior, consistent, compassionate communication is paramount. Approaching the resident calmly, using simple language, and validating their emotions can help de-escalate situations before they become overwhelming. This person-centered approach acknowledges the resident’s feelings and reduces their anxiety, building trust and strengthening the caregiver-resident relationship. It is also important for caregivers to practice self-care and seek support from others, as managing these behaviors can be emotionally and physically taxing. Ultimately, a flexible, compassionate, and observant care strategy provides the best possible outcome when dealing with challenging behaviors stemming from cognitive impairment.

Managing challenging behaviours in dementia

Frequently Asked Questions

What is the difference between wandering and sundowning?

Wandering is the act of walking aimlessly or attempting to leave a secure area, which can happen at any time due to disorientation or restlessness. Sundowning refers to a specific pattern of increased confusion, anxiety, and agitation that occurs in the late afternoon and evening, often due to changes in light and the body's internal clock.

What should I do if a cognitively impaired resident is wandering?

First, ensure their safety by securing doors and having a tracking system if necessary. Maintain a consistent routine to provide structure. If they start wandering, remain calm, and use distraction and redirection techniques by offering a snack, activity, or going for a safe walk with them.

How can I manage sundowning behaviors in the evening?

To manage sundowning, maintain a regular daily schedule, provide plenty of natural light exposure during the day, and create a calm, low-stimulation environment in the evening. Keep rooms well-lit to prevent confusing shadows and engage the resident in relaxing activities like listening to soft music.

Is it okay to argue with a resident who is confused or agitated?

No, arguing is not effective and can increase a resident's agitation and confusion. It is better to validate their feelings, offer reassurance, and calmly redirect their attention to another topic or activity. The resident is not being intentionally difficult, but is reacting to their cognitive impairment.

Why do cognitively impaired residents repeat the same questions?

Repetitive questioning is often caused by short-term memory loss and anxiety. The resident may forget they have already asked or received an answer. To manage this, provide a brief and reassuring answer, and then try to distract them with a different, engaging activity.

How do environmental factors affect cognitively impaired residents?

Environmental factors like loud noises, overstimulation, and unfamiliar surroundings can increase anxiety and trigger challenging behaviors like wandering or agitation. A calm, familiar, and predictable environment helps reduce stress and confusion for residents.

When should I seek medical help for a resident's behavior?

You should seek a doctor's advice for any sudden changes in a resident's behavior. A medical checkup can rule out underlying issues such as pain, infections (like a UTI), medication side effects, or a worsening of their cognitive condition.