What to do when someone is sundowning?

According to the Alzheimer's Association, up to 20% of people with Alzheimer's disease experience sundowning, a state of increased confusion and anxiety during the late afternoon and evening. Knowing what to do when someone is sundowning is crucial for both their well-being and a caregiver's peace of mind, as these episodes can be distressing for everyone involved.

Quick Summary

Managing a sundowning episode involves minimizing triggers, maintaining a calm routine, adjusting the environment, and using distraction and redirection techniques to soothe the individual's anxiety and confusion.

Key Points

• Stay Calm: Your calm demeanor is crucial for de-escalating a sundowning episode.

• Validate, Don't Argue: Acknowledge the person's feelings without correcting their reality to reduce agitation.

• Use Distraction: Redirect their attention with a favorite, simple activity, such as listening to music or looking at photos.

• Optimize the Environment: Increase lighting in the evening to eliminate confusing shadows and reduce sensory overload.

• Maintain Routine: Establish and stick to a consistent daily schedule to provide a sense of security and predictability.

• Watch for Triggers: Observe and minimize fatigue, hunger, pain, or overstimulation that can worsen symptoms.

Understanding Sundowning: What's Happening?

Sundowning, or sundown syndrome, is a cluster of symptoms that occur in individuals with dementia or Alzheimer's as daylight fades. While the exact cause isn't fully understood, theories suggest it may be linked to fatigue at the end of the day, disruption of the body's internal clock (circadian rhythm), and increased shadows causing misinterpretation and fear. Recognizing that this behavior is a symptom of their condition, not intentional misbehavior, is the first step toward managing it effectively.

Common Triggers for Sundowning

Identifying specific triggers for your loved one is key to prevention and management. These can vary widely, but often include:

• Fatigue: Physical and mental exhaustion from a long day can lead to irritability and agitation.
• Disrupted Routines: Unfamiliar places or a change in daily schedule can increase confusion.
• Environmental Changes: Low lighting and long, confusing shadows can cause fear and visual misinterpretations.
• Overstimulation: Loud noises, a house full of people, or a busy evening can overwhelm an individual with dementia.
• Physical Discomfort: Hunger, thirst, pain, or a need to use the restroom can intensify agitation.

Immediate Actions During a Sundowning Episode

When a sundowning episode begins, your response is critical. The goal is to de-escalate the situation calmly and prevent further agitation. Here are some steps you can take in the moment:

1. Remain Calm and Reassuring: Your tone of voice and body language are powerful tools. Speak in a gentle, calm voice and maintain a relaxed posture. Reassure the person that they are safe and you are there to help.
2. Validate Their Feelings: Acknowledge their emotions without arguing or correcting them. For example, if they insist they need to go home, you can say, "I hear that you want to go home. Tell me more about why you feel that way."
3. Use Distraction and Redirection: Gently pivot their attention toward a pleasant activity. This could be looking at old family photos, listening to calming music, or sorting laundry.
4. Check for Basic Needs: Ensure they aren't hungry, thirsty, or in pain. A simple snack and a glass of water can sometimes be all that's needed to settle them down.
5. Adjust the Environment: Turn on more lights to eliminate confusing shadows. Close blinds or curtains as it gets dark to signal the end of the day.

Long-Term Strategies to Reduce Sundowning

While managing an episode is important, proactive planning can significantly reduce the frequency and intensity of sundowning. These strategies focus on establishing a predictable rhythm and a comforting environment.

Maintaining a Consistent Daily Routine

A regular schedule provides comfort and security by reducing uncertainty. Try to establish fixed times for meals, waking up, and going to bed. Schedule appointments and more stimulating activities for the morning or early afternoon when the person is likely to be less fatigued.

Optimizing the Home Environment

Create a calming, safe space that minimizes confusion and potential hazards.

• Increase Light Exposure: Ensure your loved one gets plenty of natural light during the day. Consider using a light box, especially during winter months with shorter daylight hours.
• Control the Atmosphere: In the late afternoon, reduce noise and clutter. Play soothing music or nature sounds. Some people find white noise machines helpful.
• Prioritize Safety: If wandering is an issue, install door and window alarms to keep them safe. Minimize tripping hazards and lock up any potentially dangerous items.

Dietary and Lifestyle Adjustments

Subtle changes to diet and daily habits can have a big impact on mood and energy levels.

• Monitor Caffeine and Sugar: Restrict caffeine and sugar intake to the morning hours. This helps prevent overstimulation and sleep disruption later in the day.
• Light Evening Meals: Offer a larger meal at lunchtime and a lighter dinner to avoid discomfort before bed.
• Short Daytime Naps: If naps are necessary, keep them short and limited to the early afternoon to avoid interfering with nighttime sleep.
• Encourage Exercise: A small amount of daily physical activity, like a walk, can help with sleep patterns and overall mood.

Comparison of In-the-Moment vs. Preventative Strategies

Strategy Type	Best For	Focus	Key Actions
In-the-Moment	Active sundowning episodes	De-escalation and soothing	Validate feelings, distract with favorite activities, check basic needs, provide reassurance.
Preventative	Reducing frequency and severity	Routine, environment, lifestyle	Establish consistent daily schedule, optimize lighting, manage diet, encourage daytime activity.

When to Seek Professional Help

If sundowning behaviors are becoming more frequent, severe, or unmanageable, it's essential to consult a healthcare professional. A doctor can rule out other medical issues, such as a urinary tract infection (UTI), that could be exacerbating the symptoms. They can also discuss potential medication options, such as low-dose melatonin, which may help regulate sleep cycles. For caregivers, resources from organizations like the Alzheimer's Association can provide invaluable support and further information.

Conclusion: Patience and Preparation are Key

Dealing with sundowning is challenging, but with patience, empathy, and a proactive approach, caregivers can make a significant difference. By understanding the triggers, implementing calming techniques in the moment, and establishing a supportive environment, you can help manage the symptoms and improve the quality of life for your loved one and yourself. Remember that each individual is unique, so observing their specific patterns and triggers will be your most effective tool.

Frequently Asked Questions

What is sundowning?

Sundowning is a state of increased confusion, anxiety, and agitation that can occur in individuals with dementia or Alzheimer's during the late afternoon and evening hours as daylight begins to fade.

What are the common symptoms of sundowning?

Symptoms can include increased confusion, anxiety, restlessness, pacing, emotional outbursts, and sometimes hallucinations or paranoia. These behaviors worsen as the day progresses toward night.

How can I prevent sundowning from happening?

While you can't always prevent it, you can minimize triggers by maintaining a consistent daily routine, ensuring adequate daytime sunlight, limiting caffeine and sugar, and keeping evening activities calm and predictable.

Is it best to argue with or correct someone who is sundowning?

No, it's generally best to avoid arguing or correcting them. Their sense of reality is different during these episodes, and arguing will only increase their frustration and agitation. Instead, validate their feelings and gently redirect them.

Should I restrain someone who is sundowning?

You should never try to physically restrain someone who is sundowning. This can increase their agitation and could be dangerous for both of you. Instead, ensure they are in a safe environment where they can pace or wander without harm, and supervise them calmly.

Can diet and medication help with sundowning?

Yes, dietary changes like avoiding late-day caffeine and having a lighter dinner can help. A doctor might also suggest medications, such as melatonin, to help regulate sleep cycles, or rule out underlying medical issues like a UTI that can cause confusion.

How long does a sundowning episode typically last?

The duration of an episode can vary. Symptoms typically begin in the late afternoon and can last into the night. Most people with dementia eventually calm down after the peak of the episode.