What is sundowning in simple terms? A guide for caregivers

According to research, sundowning affects up to 40% of people with Alzheimer’s and other dementias, presenting a significant challenge for caregivers. Understanding what is sundowning in simple terms is the first step toward managing this difficult phenomenon and improving the quality of life for your loved one.

Quick Summary

Sundowning is a behavioral pattern where individuals with dementia experience increased confusion, anxiety, and agitation during the late afternoon or early evening hours as daylight fades. Symptoms like restlessness, wandering, and mood swings can appear or worsen during this period.

Key Points

• Late-Day Confusion: Sundowning is a pattern of increased confusion, anxiety, and agitation that affects people with dementia in the late afternoon and evening, not a disease itself.

• Disrupted Body Clock: One primary cause is believed to be the disruption of the brain's internal circadian rhythm, leading to confusion between day and night.

• Manage with Routine: A consistent daily schedule, including regular meals and bedtimes, can significantly reduce anxiety and help manage sundowning behaviors.

• Environmental Controls: Adjusting lighting to minimize confusing shadows and reducing noise and clutter can create a calmer, more secure environment.

• Distraction and Reassurance: If an episode occurs, offering calm reassurance and gentle redirection to a familiar, comforting activity can help de-escalate the situation.

• Watch for Triggers: Caregivers should keep a log to identify and address personal triggers, which can include fatigue, hunger, pain, or overstimulation.

Unpacking the Symptoms of Sundowning

While sundowning is most commonly associated with dementia, it is not a disease in itself but rather a collection of symptoms that become more pronounced as the day progresses into night. For a caregiver, recognizing these behaviors is crucial for effective management. Symptoms can range from mild disorientation to severe agitation.

Common Behavioral Manifestations

• Increased Confusion and Disorientation: As day turns to night, an individual may lose their sense of time and place, forgetting where they are or what they are doing.
• Anxiety and Fear: The fading light can cause shadows and make familiar rooms appear different, triggering feelings of fear or paranoia.
• Agitation and Restlessness: Many people with sundowning become agitated, pacing, or unable to sit still. This restlessness can be constant and exhausting for both the individual and the caregiver.
• Aggression and Mood Swings: Verbal or physical aggression can occur, as can crying or angry outbursts. Mood can shift rapidly and without a clear trigger.
• Wandering: A person may feel the need to walk or wander, potentially becoming lost or putting themselves in danger.
• Hallucinations and Delusions: Some individuals experience hallucinations or delusions, seeing or hearing things that are not there.
• Sleep Disturbances: Insomnia and a reversed sleep-wake cycle are common, making it difficult for the person and their caregiver to get adequate rest.

Why Does Sundowning Occur? Exploring the Causes

There is no single known cause for what is sundowning in simple terms, but a combination of factors is believed to contribute. Understanding these potential triggers can help caregivers better anticipate and prevent episodes.

Disruption of the Body Clock

The most widely accepted theory points to a disruption in the body's internal clock, or circadian rhythm. Brain changes from dementia can affect the signals that regulate sleep and wakefulness. As a result, the body may become confused about the time of day, leading to restlessness and agitation in the evening.

Environmental and Physical Triggers

• Fatigue: A long, busy day can lead to mental and physical exhaustion, making it harder for a person with dementia to cope with changing stimuli and increasing confusion.
• Changes in Lighting: The transition from bright daylight to dim indoor lighting can increase disorientation and fear. Shadows can be perceived as threats, causing anxiety.
• Overstimulation: A noisy or chaotic environment, especially in the late afternoon, can overwhelm the senses and trigger a sundowning episode. Too many visitors or too much activity can be a factor.
• Hunger, Thirst, or Pain: Unmet basic needs are often a major cause of agitation. A person may not be able to communicate that they are hungry, thirsty, or in pain.
• Depression or Boredom: Loneliness, boredom, or feelings of loss can exacerbate symptoms. It’s important to keep the person engaged in calming activities during the day.

Effective Strategies for Managing Sundowning

Managing sundowning involves a multi-faceted approach focused on routine, environment, and addressing underlying needs. Small adjustments can make a significant difference.

Creating a Calm and Predictable Routine

1. Maintain a Consistent Schedule: Stick to regular times for waking up, meals, and going to bed. Predictability can reduce confusion and anxiety.
2. Encourage Daytime Activity: Incorporate light exercise or engaging activities during the day to prevent boredom and promote better sleep at night. Avoid over-scheduling to prevent fatigue.
3. Minimize Late-Day Stimulation: Scale back on demanding activities and excessive noise in the late afternoon and evening. Create a calm, quiet atmosphere.
4. Avoid Caffeine and Sugar: Limit the intake of stimulants, especially later in the day, as they can disrupt sleep patterns.

Making Environmental Adjustments

Strategy	Explanation	Benefit
Increase Lighting	As daylight fades, turn on lights to minimize shadows that can be frightening or confusing.	Reduces fear and disorientation.
Close Blinds/Curtains	At dusk, close window coverings to block the changing light and confusing external shadows.	Creates a consistent, secure environment.
Reduce Noise and Clutter	Create a peaceful atmosphere by turning off the TV or radio and decluttering the living space.	Prevents overstimulation and promotes calm.
Use Comforting Cues	Play soft, familiar music or use soothing aromas like lavender to create a relaxing mood.	Offers a sense of safety and nostalgia.

Behavioral and Medical Approaches

• Observe for Triggers: Keep a log of episodes to identify personal triggers, such as certain foods, times of day, or activities.
• Offer Reassurance: If agitation begins, remain calm and speak in a soothing voice. Reassure the person that they are safe.
• Redirect and Distract: Gently redirect the person's attention to a favorite object, snack, or simple task, like folding towels.
• Consult a Physician: If symptoms persist, discuss the situation with a doctor to rule out underlying medical issues like UTIs, pain, or medication side effects. The Alzheimer's Association provides excellent resources on navigating these discussions with healthcare professionals Alzheimer's Association.

Living with Sundowning: A Caregiver's Perspective

Caring for someone with sundowning can be emotionally taxing, but remember that the behavior is not intentional. It's a symptom of their condition. Patience and understanding are key. Creating a supportive, predictable environment and knowing how to respond can help reduce the frequency and severity of episodes. Connecting with other caregivers or support groups can also provide valuable insights and emotional support.

Conclusion: Empowering Caregivers with Knowledge

Understanding what is sundowning in simple terms is an essential tool for any caregiver of a senior with dementia. By recognizing the symptoms, exploring potential triggers, and implementing proactive management strategies, you can transform the most challenging part of the day into a period of calm and safety. Your knowledge and compassionate approach are invaluable in navigating this complex aspect of senior care.

Frequently Asked Questions

What is the primary sign of sundowning in simple terms?

The primary sign of sundowning is a noticeable worsening of confusion, agitation, and anxiety that occurs in the late afternoon or early evening.

Does sundowning only affect people with Alzheimer's?

While most often associated with Alzheimer's disease, sundowning can affect individuals with other forms of dementia and some older adults without a dementia diagnosis.

How can I tell if my loved one is sundowning or just tired?

Sundowning is more than just tiredness; it involves specific behavioral changes like pacing, wandering, and increased confusion that consistently occur during the same late-day time frame. Tiredness might be a contributing factor, but it’s not the sole cause.

Is there a cure for sundowning?

There is no cure for sundowning, as it is a symptom of an underlying condition. However, it can be effectively managed with consistent routines, environmental adjustments, and other coping strategies.

Can medication help with sundowning symptoms?

Sometimes, if behavioral and environmental changes aren't enough, a doctor might recommend a low-dose medication. This should be discussed carefully with a healthcare provider, as some drugs can have side effects.

What should I do when a sundowning episode begins?

During an episode, remain calm and reassuring. Speak in a gentle voice and try to redirect their attention to a simple, comforting activity. Avoid arguing or reasoning, as that can worsen their agitation.

How long do sundowning episodes typically last?

The duration of sundowning episodes varies widely among individuals. Symptoms may last from a few minutes to several hours, sometimes continuing into the night and disrupting sleep.

What kind of environmental changes can help with sundowning?

Key environmental changes include ensuring rooms are well-lit to reduce shadows, closing blinds at dusk, and minimizing noise and clutter to create a calm, less overwhelming space.