What is one basic need that may not be met in people with sundowning?

An estimated 20% of people with Alzheimer's disease experience sundowning, a state of increased confusion and agitation in the late afternoon and evening. To understand why this happens, it's crucial to identify what is one basic need that may not be met in people with sundowning.

Quick Summary

The failure to meet a fundamental physiological need, such as hunger, thirst, or pain management, often triggers or worsens symptoms of sundowning in individuals with dementia. Because they may be unable to express these needs clearly, a caregiver must be observant and proactive in addressing their discomfort.

Key Points

• Unmet Physiological Needs: The inability to communicate basic needs like hunger, thirst, or pain is a primary trigger for sundowning agitation.

• Communication Breakdown: Dementia impairs the ability to articulate discomfort, causing frustration and confusion that manifests as restless behavior.

• Environmental Triggers: Changes in lighting, such as increasing shadows at dusk, can be disorienting and frightening for someone with dementia.

• Importance of Routine: A consistent daily schedule helps regulate the body's internal clock and provides a sense of security, which minimizes confusion.

• Proactive vs. Reactive Care: Addressing potential unmet needs before they cause distress is more effective than reacting to a full-blown sundowning episode.

• Caregiver's Role: A calm and patient demeanor from the caregiver is essential, as their own stress can inadvertently worsen the individual's anxiety.

The Core Unmet Need: Physiological Discomfort

In the context of sundowning, one basic need that is frequently unmet is the inability to effectively communicate and resolve a physical discomfort, such as hunger, thirst, or pain. Unlike during the day, when a person might be more easily redirected or able to express their needs, the mental fog of sundowning makes it nearly impossible for them to articulate what is bothering them. The resulting frustration and confusion manifest as agitation, restlessness, and anxiety.

Why Communication Breaks Down

Sundowning is characterized by an exacerbation of dementia symptoms, including memory loss and language difficulties. For someone in this state, the simple act of saying, “I’m hungry,” becomes a monumental task. They may feel a deep, gnawing discomfort but be unable to connect that feeling to the concept of food. Instead, their distress is expressed through behavioral symptoms, which can be easily misinterpreted by a caregiver. The individual might pace anxiously, wander aimlessly, or become irritable, all as a cry for help that they can no longer articulate.

Other Common Unmet Needs

Beyond hunger and thirst, several other basic needs can go unmet and exacerbate sundowning symptoms:

• Pain: Chronic pain from conditions like arthritis or even an undiagnosed ailment like a urinary tract infection (UTI) can cause significant discomfort that the individual cannot explain. As fatigue sets in toward the end of the day, their pain tolerance may decrease, leading to increased agitation.
• Fatigue: Physical and mental exhaustion is a major trigger for sundowning. A long, overstimulating day can leave a person with dementia drained. The inability to articulate this fatigue leads to restlessness and a sense of being overwhelmed, rather than simply going to sleep.
• Sensory Issues: Changes in lighting can be particularly confusing. As the sun sets, shadows lengthen and a poorly lit room can seem menacing or full of strange shapes. For someone with visual impairment, this can be particularly terrifying and disorienting, triggering fear and anxiety.
• Disruption of Routine: People with dementia thrive on routine. A sudden change in their schedule, mealtime, or environment can be very unsettling. The evening change in light and daily activity is a significant disruption to their internal clock and sense of predictability.

How to Identify and Address Unmet Needs

Caregivers can learn to recognize the signs of unmet needs by closely observing the individual's behavior and developing a consistent routine. It involves proactive, not reactive, care.

1. Monitor Physical Cues: Look for non-verbal signs of distress. Is the person fidgeting? Is their body language tense? Are they rubbing a particular area of their body? Changes in facial expression or vocalizations can be key indicators.
2. Establish a Predictable Routine: A consistent daily schedule helps to regulate the person's internal clock and reduces anxiety. Regular mealtimes, bedtimes, and activity schedules provide a sense of stability.
3. Proactive Care: Don't wait for the person to express a need. Offer food, water, or a bathroom break at regular intervals throughout the day. Check for signs of pain or discomfort before it escalates into a full-blown sundowning episode.
4. Manage the Environment: As evening approaches, control the lighting. Close curtains to minimize confusing shadows and turn on lights to create a bright, calm, and familiar atmosphere. Reduce noise and other stimuli to prevent overstimulation.
5. Use Distraction and Comfort: When agitation begins, use familiar, soothing activities to redirect their attention. This could be looking at a photo album, listening to calming music, or simply offering a gentle touch and reassurance.

Behavioral Interventions vs. Environmental Modifications

Managing sundowning often requires a dual approach that combines behavioral strategies with environmental adjustments. The following table compares these two types of interventions.

Feature	Behavioral Interventions	Environmental Modifications
Primary Focus	Managing individual actions and moods	Altering the physical surroundings
Examples	Distraction techniques, gentle redirection, therapeutic communication, consistent routines	Adjusting lighting, minimizing noise, reducing clutter, adding familiar objects
Proactive Strategy	Planning structured, low-stress daytime activities	Maximizing daylight exposure, ensuring well-lit rooms in the evening
Reactive Strategy	Providing reassurance, offering a favorite snack or activity, using calming music	Closing curtains to block out confusing shadows, turning on a nightlight
Benefits	Addresses immediate distress, builds trust with caregiver, de-escalates situations	Reduces triggers for confusion, promotes a sense of safety and predictability
Limitations	May require a high level of caregiver patience, may not work for all individuals	May not address the underlying physiological or emotional needs

The Importance of a Calm Caregiver

It is essential to remember that sundowning can be just as stressful for the caregiver as it is for the person experiencing it. An exhausted or frustrated caregiver can inadvertently worsen the situation through their body language and tone of voice. Approaching the situation with a calm, gentle, and patient demeanor is crucial for de-escalation and providing effective support. Seek support from a physician if symptoms worsen or become unmanageable.

Conclusion

While sundowning has no single cause, a critical and often overlooked trigger is the inability to express or resolve a basic physical need. By being a detective and looking beyond the agitated behavior, caregivers can identify and address underlying issues such as hunger, thirst, pain, or fatigue. A consistent routine, a calming environment, and proactive care are powerful tools in managing and mitigating the challenging symptoms of sundowning. Understanding this root cause empowers caregivers to provide more compassionate and effective support, ultimately improving the quality of life for both themselves and their loved one. For more information on supportive care strategies, the National Institute on Aging is an excellent resource.

Frequently Asked Questions

What is one basic need that may not be met in people with sundowning?

One of the most frequently unmet basic needs is the inability to express physical discomforts like hunger, thirst, or pain. The agitation of sundowning is often a signal of this unresolved physical need.

How can a caregiver tell if a person with sundowning is in pain?

A caregiver should look for non-verbal cues, such as changes in body language, facial expressions, or an increase in restlessness. Pacing, moaning, or rubbing a specific body part can all indicate that the individual is in pain.

Why do shadows bother someone with sundowning?

As daylight fades, increasing shadows can be confusing and frightening for a person with dementia, whose perception is already impaired. They may misinterpret shadows as people or objects, leading to increased anxiety and agitation.

Does being tired cause sundowning?

Yes, fatigue is a significant trigger for sundowning. Mental and physical exhaustion from a long day can reduce coping abilities and increase confusion, leading to the behavioral symptoms associated with sundowning.

Is it helpful to keep a routine for someone with sundowning?

Absolutely. A consistent daily routine for meals, activities, and bedtime provides a sense of stability and predictability. This helps regulate the person's internal clock and reduces anxiety and confusion.

How can I calm a person down during a sundowning episode?

Approach calmly and reassuringly. Use distraction techniques with a favorite activity, soothing music, or a simple snack. Avoid arguing or showing frustration. Providing a gentle touch can also be comforting.

Should I give medication to someone experiencing sundowning?

Non-drug approaches are generally the first and safest step. If behavioral interventions and environmental changes are not effective, consult a physician. Never give over-the-counter sleep aids, as these can increase confusion.