Understanding the Terms: Sundowning and Wandering
When a dementia patient wanders at night, the behavior is most commonly associated with sundowning, or "sundowner's syndrome". It is not a disease itself but a collection of symptoms that tend to emerge or intensify in the late afternoon or evening. While sundowning is a key cause, the act of aimless or purposeful walking itself is referred to simply as wandering. It is a complex and common behavioral symptom in dementia, with up to 60% of patients experiencing it.
The Relationship Between Sundowning and Night Wandering
Sundowning and nighttime wandering are closely linked. The increased confusion and disorientation caused by sundowning can cause a patient to feel agitated and restless, prompting them to walk or pace. Their disrupted internal body clock, or circadian rhythm, may cause them to become more active at night and less so during the day, further contributing to nocturnal restlessness and wandering.
Key Causes of Sundowning and Wandering
Multiple factors can contribute to sundowning and nighttime wandering. Identifying these triggers is the first step toward effective management:
- Circadian rhythm disruption: Damage to the brain's internal clock can cause people with dementia to confuse day and night.
- Fatigue: Physical and mental exhaustion from a long day can increase confusion and trigger sundowning behaviors.
- Environmental triggers: Low lighting and increased shadows in the evening can be confusing and frightening, leading to anxiety and wandering.
- Pain or discomfort: A person with dementia may wander in an attempt to find comfort or relief from an uncommunicated physical need, such as hunger, thirst, or pain from ill-fitting shoes.
- Fear and confusion: A new or confusing environment, or feeling lost even in familiar surroundings, can cause anxiety that leads to wandering.
- Disrupted routines: A sudden change in daily routines or a recent stressful event can trigger episodes of wandering.
- Need for stimulation: Sometimes, a patient may be wandering out of boredom or a need for physical activity.
- Past memories or obligations: The person may be trying to fulfill a past duty, such as going to work, or may be searching for their "home," even when they are already in their own residence.
Management Strategies for Night Wandering
Managing nighttime wandering requires a proactive and compassionate approach focused on safety, routine, and identifying underlying needs. It involves both preventive measures and in-the-moment responses.
Prevention Techniques
- Establish a strong daily routine: A structured day with consistent wake-up, meal, and bedtimes can help regulate the patient's internal body clock.
- Encourage daytime activity: Incorporate supervised walks or other forms of exercise during the day to help expend energy and promote better sleep at night.
- Increase light exposure: Maximizing sunlight exposure during the day can help reinforce the day-night cycle. In the evening, keep the home well-lit to reduce shadows and confusion.
- Create a calming evening: Reduce stimulation in the hours leading up to bedtime. Avoid loud TV, busy environments, or over-stimulating activities. Instead, try calming music, a warm bath, or looking at family photos.
- Reduce evening liquids: Limiting fluids a couple of hours before bed can help minimize the need for nighttime bathroom trips, which can lead to disorientation.
- Check for discomfort: Rule out other causes of restlessness, such as pain, hunger, or the need to use the toilet, before concluding the behavior is purely due to dementia.
Safety Measures and Technology
Ensuring the patient's physical safety is paramount. Several strategies can help minimize risk during nighttime wandering episodes.
| Strategy | Description | Pros | Cons |
|---|---|---|---|
| Securing the home | Installing locks on external doors and windows, potentially above or below the patient's line of sight. | Prevents elopement; provides a secure environment. | Can be seen as restrictive; may cause increased distress if a patient feels confined. |
| Door/window alarms | Alarms that sound when a door or window is opened. | Alerts caregivers immediately if the patient tries to exit; allows for faster intervention. | Can be startling for the patient and caregiver; false alarms can be disruptive. |
| GPS tracking devices | Wearable devices like watches or shoe inserts with GPS capabilities. | Allows for quick location of a lost patient; can provide peace of mind. | Raises ethical concerns about privacy and dignity; can be expensive. |
| Visual barriers | Placing a black mat in front of a doorway to mimic a hole, discouraging passage. | Non-intrusive and low-cost method; does not physically restrain the patient. | May not work for all individuals; some may still try to cross. |
| Identification program | Enrolling the patient in a national program like MedicAlert + Safe Return. | Provides identification and emergency contact information if the patient is found by others. | Only works if the patient is wearing the identification; relies on public awareness. |
What to Do During a Wandering Episode
If a patient begins to wander at night, the caregiver's response is critical. The key is to remain calm, validate their feelings, and redirect them gently.
- Don't argue or try to reason: A person with dementia is not acting logically and will not be swayed by reason. Arguing can increase their agitation and distress.
- Validate their reality: If they are looking for a past loved one or trying to go to "work," acknowledge their feeling. For example, say, "I know you want to go home, but it's late now. Let's have some tea first," rather than, "You are home".
- Use gentle distraction: Redirect their attention to a comforting activity, such as listening to music, looking at photos, or offering a snack.
- Provide reassurance: Use a calm voice and comforting touch to reduce their anxiety and remind them they are safe.
- Accompany them: If they insist on walking, walk with them safely indoors to provide companionship and prevent falls.
- Adjust the environment: Check if the light is too dim or if a noise is causing distress. Simple adjustments to the environment can sometimes resolve the issue.
Conclusion
Night wandering in dementia patients is most commonly known as sundowning and is a complex behavioral issue rooted in the disease's effects on the brain's internal clock and the patient's ability to cope with confusion and stress. The phenomenon is a significant challenge for caregivers, but with proper understanding and preparation, it can be managed effectively. Focusing on consistent routines, daytime activity, a calm evening environment, and implementing safety measures like alarms and GPS devices are crucial steps. Responding with compassion, validation, and distraction during an episode is key to ensuring the safety and well-being of the patient. While there is no cure for sundowning, proactive and compassionate care can mitigate its risks and provide greater peace of mind for both the person with dementia and their caregivers. For further support, the Alzheimer's Association offers a wealth of resources, including their nationwide identification program.
