Why do people with dementia get crazy at night? Understanding sundowning

An estimated 20 to 45% of people with Alzheimer's disease experience sundowning, a condition characterized by increased confusion and agitation in the evening. Addressing the question of why do people with dementia get crazy at night? is crucial for caregivers seeking effective strategies to manage this challenging behavior.

Quick Summary

The phenomenon known as sundowning occurs due to complex changes in the brain that disrupt a person's internal body clock, leading to increased confusion and agitation as daylight fades. Factors like fatigue, sensory changes, and environmental triggers can also exacerbate these challenging nighttime behaviors in individuals with dementia.

Key Points

• Disrupted Circadian Rhythms: A primary cause of sundowning is the damage to the brain's internal clock, leading to confusion between day and night and a reversed sleep-wake cycle.

• Environmental Changes Act as Triggers: Decreased light and increased shadows in the evening can cause fear and disorientation, triggering agitation and erratic behavior.

• Underlying Issues Worsen Symptoms: Unmet physical needs like pain, hunger, or infection, as well as emotional distress such as anxiety and boredom, can significantly aggravate sundowning.

• Structured Routine is a Key Strategy: A predictable daily schedule for meals, activities, and sleep helps provide comfort and stability, minimizing confusion and agitation.

• Non-pharmacological Interventions are Recommended First: Strategies like maximizing daytime light, reducing evening stimulation, and using calming techniques can be highly effective in managing symptoms.

• Professional Guidance is Important for Severe Cases: If sundowning symptoms become unmanageable or include severe aggression, a doctor can help rule out other causes and suggest appropriate medical treatments.

What is Sundowning?

Sundowning, or Sundowner's Syndrome, refers to a state of increased confusion, anxiety, restlessness, and other agitated behaviors that start in the late afternoon or early evening and continue into the night. It is not a disease in itself but rather a set of symptoms affecting individuals with memory-related illnesses like Alzheimer's disease. The erratic behavior associated with sundowning can be particularly distressing for both the person with dementia and their caregivers. Symptoms can vary but often include pacing, wandering, emotional outbursts, and difficulty sleeping. The severity and duration of these episodes can differ from person to person and may change as the disease progresses.

The Role of Circadian Rhythms

One of the most significant factors contributing to sundowning is the disruption of the body's internal biological clock, or circadian rhythm. This internal clock regulates the sleep-wake cycle, among other physiological functions. Dementia, particularly Alzheimer's, can damage the region of the brain responsible for regulating this clock, leading to confusion between day and night. As a result, the person may feel tired during the day and be awake and agitated at night. This reversal of the sleep-wake cycle is a major cause of nighttime restlessness and confusion.

Environmental Triggers and Sensory Changes

The transition from daylight to darkness can be a major trigger for sundowning behaviors. As natural light fades, the reduced lighting can create increased shadows and cause misinterpretations or fears. A person with dementia may see a shadow and perceive it as a threat, leading to heightened anxiety and agitation. Other environmental factors can also contribute, such as:

• Overstimulation: Too much noise, a busy environment, or a house full of visitors in the late afternoon can overwhelm a person with dementia, triggering confusion.
• Understimulation: Conversely, a lack of stimulating activity during the day can leave a person bored and prone to restlessness in the evening.
• Disruptions in Routine: Changes in daily schedules, caregivers, or surroundings can cause stress and disorientation.
• Sensory Impairments: Difficulty with vision and hearing can worsen confusion, especially in low-light conditions.

Psychological and Physical Factors

Beyond the brain's internal clock and external environment, several psychological and physical issues can trigger or worsen sundowning. A comprehensive approach to managing these behaviors requires addressing these underlying needs.

Emotional and Mental Distress

Anxiety and depression are common in individuals with dementia and can significantly increase the risk of nighttime agitation. As the day winds down, emotional stress can build up, leading to emotional meltdowns or mood swings. The inability to communicate feelings effectively can also manifest as agitated behavior. For example, a person may become restless because they feel lonely or anxious but cannot express it verbally.

Physical Discomfort and Fatigue

Physical discomfort can be a major driver of agitation, especially in individuals who cannot articulate their pain or needs. A person with dementia may get crazy at night due to an underlying issue they can't communicate. This could include:

• Exhaustion: Both mental and physical fatigue from a full day of activities can overwhelm a person with dementia, making it harder for their brain to cope.
• Infections: Urinary tract infections (UTIs) are a common cause of delirium and behavioral changes in older adults and can be a trigger for sundowning.
• Hunger or Thirst: Unmet basic needs can heighten agitation.
• Medication Side Effects: Certain medications can affect sleep cycles, mood, and energy levels, contributing to nighttime restlessness. It is crucial to discuss any behavioral changes with a doctor, as medications may need adjustment.

Management Strategies for Caregivers

Effective management of sundowning requires a multi-faceted approach, focusing on routine, environment, and addressing unmet needs. Here is a comparison of preventive and in-the-moment strategies.

Strategy Type	Focus	Specific Actions
Preventive Measures	Regulating routines and environment to minimize triggers.	Maintain a predictable daily routine: Consistent times for waking, meals, and bedtime provide structure and comfort. Maximize daytime light exposure: Encourage time outside or use a light therapy box to help regulate the sleep-wake cycle. Encourage daytime activity: Engage in physical exercise and stimulating activities during the day to help ensure restful sleep at night. Limit daytime naps: Keep naps short and earlier in the day to prevent sleeplessness at night. Avoid caffeine/sugar late in the day: These can disrupt sleep patterns and worsen agitation.
In-the-Moment Response	Calming the individual during an episode.	Remain calm and reassure: Speak in a soothing voice and offer gentle touches, like a hand rub, to provide comfort and security. Redirect attention: Distract the person with a favorite snack, activity, or familiar music. Address unmet needs: Check for signs of pain, hunger, thirst, or bathroom needs. Create a quiet, dimly lit space: Minimize noise and clutter to create a peaceful environment.

Creating a Soothing Evening Environment

As dusk approaches, intentionally creating a calm and reassuring atmosphere is key. Dimming lights gradually can help with the transition, but it's important to avoid creating shadowy corners that might be frightening. Playing soft, familiar music or a nature sounds recording can have a calming effect. Monitoring television is also important, as startling or violent images can be particularly distressing. Consider a nightlight in hallways and bathrooms to help with orientation if they wake up during the night.

When to Seek Professional Help

While non-pharmacological strategies can be very effective, caregivers should know when to consult a doctor. Persistent or severe aggression, hallucinations, or behaviors that are unsafe for the individual or others require medical attention. A physician can rule out underlying medical conditions like UTIs or sleep apnea and review current medications for potential side effects. In some cases, medication such as a low-dose melatonin supplement or an FDA-approved medication for agitation associated with Alzheimer's dementia may be considered.

Conclusion: Managing the Challenges of Sundowning

Understanding why people with dementia get crazy at night? is the first step toward managing this difficult symptom. Sundowning is a complex issue stemming from a mix of biological, environmental, and emotional factors. While it can be emotionally and physically taxing for caregivers, implementing proactive strategies like a structured daily routine, managing environmental factors, and addressing underlying needs can make a significant difference. Staying calm, patient, and redirecting your loved one's attention can help de-escalate difficult moments. For severe cases, or when non-medical interventions are insufficient, a healthcare professional can offer additional support and medical treatment options. The right approach can greatly improve the quality of life for both the individual with dementia and their caregiver. For more in-depth information, the Alzheimer's Association offers a wealth of resources for support and caregiving guidance on its website.

Visit the Alzheimer's Association website for caregiving resources

Frequently Asked Questions

What is the primary cause of sundowning?

The primary cause is believed to be the disruption of the brain's internal clock (circadian rhythm) due to the progression of dementia, which can affect the sleep-wake cycle and lead to confusion and agitation in the evening.

Does sundowning happen to everyone with dementia?

No, sundowning does not affect everyone with dementia, though it is very common. The severity and occurrence of symptoms can vary widely depending on the individual, the stage of dementia, and environmental factors.

How can I tell if my loved one is sundowning?

Key signs include increased confusion, anxiety, agitation, wandering, and restlessness that typically begin in the late afternoon and extend into the night. Symptoms may also include mood swings, emotional outbursts, and paranoia.

What are some immediate things I can do when a loved one is sundowning?

When an episode begins, remain calm, speak in a gentle and reassuring voice, and try to redirect their attention with a soothing activity like listening to music or looking at old photo albums. Check for any immediate needs like hunger or thirst.

Can diet affect sundowning behavior?

Yes. It is recommended to avoid caffeine and sugar, especially in the afternoon and evening, as they can disrupt sleep patterns. Offering a light meal in the evening and ensuring proper hydration throughout the day can also be helpful.

Is there medication available to treat sundowning?

While non-pharmacological interventions are often recommended first, a doctor may consider medication for severe or persistent symptoms. A low dose of melatonin or other prescribed medications may be suggested, but should always be discussed with a healthcare professional first.

Does low light make sundowning worse?

Yes, low or faded light and the increased shadows it creates can cause confusion and trigger fear, worsening symptoms. Keeping the home well-lit in the evening can help reduce this anxiety.