What is Sundowning?
Sundowning is not a disease itself but a set of symptoms and behaviors that emerge or intensify as daylight fades, continuing into the night. This phenomenon can affect anyone with dementia, but it is particularly common in those with Alzheimer's disease, especially in the middle to later stages. The behaviors can vary significantly in intensity and type from person to person and from one day to the next. For caregivers, recognizing and understanding this pattern is crucial for managing care and reducing stress.
Common Symptoms of Sundowning
Symptoms of sundowning encompass a range of emotional and behavioral changes, often triggered by the shift from day to night. Some of the most frequently observed symptoms include:
- Increased confusion and disorientation
- Anxiety, restlessness, and agitation
- Irritability and mood swings
- Pacing or wandering
- Hallucinations, paranoia, or delusions
- Aggression or resistance to help
- Shadowing, where the person closely follows their caregiver
- Crying or emotional outbursts
- Difficulty sleeping or disrupted sleep-wake cycles
Why Sundowning Occurs
While the precise cause of sundowning is still under investigation, several contributing factors have been identified. The combination of these elements can overwhelm a brain already compromised by dementia, making it difficult to process information and maintain a sense of calm and routine.
The Role of Circadian Rhythms
Dementia-related changes in the brain can damage the suprachiasmatic nucleus of the hypothalamus, the body's primary internal clock. This disruption leads to an impaired sleep-wake cycle, causing the individual to feel less alert during the day and more awake and agitated at night. The progressive decline of natural melatonin production also contributes to this cycle disruption.
Environmental and Psychological Factors
Several external factors can exacerbate sundowning symptoms:
- Fatigue: Physical and mental exhaustion from a full day's activities can make it harder for the brain to cope with daily stressors.
- Lighting and Shadows: As natural light diminishes, the low lighting and increased shadows can be frightening and confusing, leading to misperceptions or hallucinations.
- Overstimulation or Boredom: A busy, noisy environment can be overwhelming, while a lack of stimulation can lead to boredom and restlessness.
- Unmet Needs: Hunger, thirst, pain, or a need to use the bathroom can cause anxiety and trigger agitation, especially if the person cannot clearly communicate their needs.
- Medication Side Effects: Some medications or drug interactions can increase restlessness or confusion, particularly as doses wear off towards the end of the day.
- Disrupted Routine: Changes to a consistent daily schedule can increase confusion and trigger anxiety in someone with dementia.
Management Strategies for Caregivers
Proactive and compassionate strategies can help minimize and manage sundowning episodes. Consistency and calm are key to providing a supportive environment.
Establishing a Calming Routine
- Maintain a Predictable Schedule: Establish a regular routine for waking, meals, and bedtime to help regulate the body's internal clock.
- Encourage Daytime Activity: Plan for regular physical activity and sunlight exposure during the day. A walk or sitting near a window can be very helpful.
- Reduce Evening Stimulation: Limit loud noises, visitors, and stimulating activities like watching intense TV shows in the evening.
- Manage Diet: Avoid caffeine, alcohol, and large meals in the late afternoon and evening.
Creating an Ideal Environment
- Keep rooms well-lit to reduce confusing shadows during the transition from day to dusk.
- Use nightlights in bedrooms, hallways, and bathrooms for safety and orientation.
- Create a quiet, soothing atmosphere with soft music or familiar objects.
- Minimize clutter to prevent trips and falls, especially during nighttime wandering.
- Ensure familiar items, like photos, are visible to provide comfort and reassurance.
Sundowning vs. Delirium: A Key Difference
It is important for caregivers to distinguish between sundowning and delirium, as the latter can be a sign of a serious medical issue. While both involve confusion, their timing and nature are different.
| Feature | Sundowning (Sundowner's Syndrome) | Delirium |
|---|---|---|
| Timing | Predictable onset in late afternoon/evening | Abrupt onset, can occur at any time |
| Duration | Lasts for a few hours, often resolves by morning | Can last for hours or days, fluctuates throughout the day |
| Underlying Cause | Related to dementia progression, fatigue, and environmental factors | Underlying medical condition (e.g., infection, medication side effect, dehydration) |
| Urgency | Managed with behavioral and environmental strategies | Requires urgent medical evaluation and treatment |
Coping as a Caregiver
Navigating sundowning can be emotionally and physically draining. Remember that the behavior is caused by the disease, not a personal choice. Remaining calm, speaking in a gentle, reassuring tone, and validating the person's feelings can de-escalate anxiety. When a sundowning episode occurs, try redirecting their attention with a simple, calming activity, like folding towels or looking at a photo album. For persistent or worsening issues, consulting a doctor is essential to rule out other medical problems. The National Institute on Aging offers valuable resources for caregivers coping with agitation and sundowning: Coping with Agitation, Aggression, and Sundowning.
Conclusion
While facing what do they call dementia at night can be distressing, understanding it as 'sundowning' provides a framework for management. By focusing on consistent routines, creating a calm and well-lit environment, and employing distraction and reassurance, caregivers can significantly reduce the severity of symptoms. Recognizing the difference between sundowning and delirium is also vital for ensuring proper medical care. With patience, education, and the right strategies, it is possible to navigate the challenges of sundowning and improve the quality of life for both the person with dementia and their care team.
