Sundowning in Dementia

Sundowning is not exclusive to specific stages of dementia, and there can be significant variations in its presentation among individuals but below is a general overview of how sundowning may manifest in different stages of dementia:

Early-Stage Dementia:

●      Some may experience mild agitation, restlessness, or confusion which is more pronounced in the evening.

●      Caregivers may notice subtle changes in behavior or mood such as wandering and requiring more direction and reassurance and which worsens later in their day.

Moderate to Later Stages of Dementia:

●      Sundowning can become more noticeable and frequent.  

●      Individuals may experience increased agitation, confusion, restlessness, and anxiety.

●      Delusions, hallucinations, and mood swings may become more pronounced during later stages.

●      Symptoms may be severe, with individuals exhibiting heightened confusion, anxiety, aggression, and disorientation during the late afternoon and evening.

Sundowning symptoms can vary from person to person but here are some of the most common symptoms:

●      Agitation and Anxiety: Individuals may become anxious, restless, or easily agitated about things that don’t bother them at other times during the day.  This heightened state of agitation can lead to various challenging behaviors, making it difficult for both the affected individuals and their caregivers.

 ●      Confusion: There may be increased confusion and disorientation, with individuals not recognizing familiar people, objects, routines, or places, such as the location of their bedroom or how to brush their teeth.   This can be distressing for the affected person and lead to fear and anxiety.

 ●      Hallucinations: Some people may experience hallucinations, seeing or hearing things that are not there. These disturbances can present as benign or bothersome, depending on the individual and can intensify feelings of fear and anxiety.  This can also be pretty frightening for caregivers too. 

 ●      Delusional thoughts and paranoia: False beliefs or misconceptions may arise, leading to irrational thoughts and behaviors. These could present as an incorrect narrative or a sudden fear for their own safety.

●      Wandering: Restlessness and confusion may lead to wandering, which can be dangerous if the person becomes lost or enters an unsafe space.   Perhaps one of the most commonly reported symptoms of sundowning is the frequently expressed desire to ‘go home’.   They may be acting out childhood memories and seem confused about where they are now, believing that their parents are still alive and that they need to go home to them for example. 

●      Mood Swings: Sudden, sometimes severe mood swings, from anger to sadness and even crying, are common during sundowning episodes and can be a sign of stress and anxiety caused by other symptoms or just a complete inability for the individual to self-regulate their emotions.

●      Disrupted sleep:  Sleep patterns are often disrupted in someone with dementia but especially so when sundowning.  The person may have difficulty falling asleep but also may experience nightmares and/or wakefulness with accompanying confusion or delusions which add to the inability to settle and rest.

Disruption in circadian rhythms: One theory is that the body's internal clock, known as the circadian rhythm, is disrupted in people with dementia. Changes in light, temperature, and other environmental cues during evening hours may confuse the internal clock, leading to behavioral changes and symptoms of sundowning.

Fatigue and end-of-day stress: As the day progresses, mental and physical fatigue can set in for individuals with dementia. This exhaustion can increase their normal dementia symptoms leading to decreased orientation and emotional control.

Sensory overload:  Changes in lighting, noise levels and activity can be overwhelming particularly to someone who’s senses have already been reduced by dementia.

Physical health issues: Pain, discomfort, and other physical health problems may become more pronounced in the evening, exacerbating sundowning symptoms. These can be acute, such as itchiness, or chronic, such as an arthritis flare-up.

Medication effects: Some medications may have side effects that worsen during the late afternoon and early evening, contributing to symptoms of sundowning.

1. Maintain a Routine: Consistent daily routines can help regulate the circadian rhythm and reduce confusion. This includes regular mealtimes, activity schedules and bedtime routines. 

• Sundowning symptoms can escalate when a person with dementia does not get adequate sleep and so routine and sleep hygiene are very important. 

• The person may need a different routine to what they used to have before their dementia onset. 

• Review the comfort and suitability of their room and bed to ensure that it is quiet and that they feel safe and comfortable enough to rest.  

2. Calming Activities: Reducing stimulating activities before bed and engaging them in calming activities such as listening to soothing music, reading, or playing a digital therapeutic like Memory Lane Games can be helpful in helping them to wind down ready for sleep.  

• Select a game on Memory Lane Games that enables them to remember happy times, maybe about their pets or the place they lived when they were small to leave them calm and happy.

• Minimize unnecessary noise and visitors later in the day too. 

3. Adequate Light: Ensure that people are exposed to daylight during the day and that the indoor environment is well-lit in the afternoon and evening to reduce confusion related to changes in light levels. 

• Any changes to lighting, later in the day should be made gradually. 

• It can also be helpful to use night lights to avoid confusion during the night which might be caused by darkness. 

• People with dementia can experience sensory loss and difficulties with spatial awareness so set up their environment to meet their needs.

4. Limit Stimulants: If possible, limit caffeine and sugar in the late afternoon and evening as they can exacerbate symptoms of agitation.

• Avoid alcohol completely instead offering zero or low alcohol alternatives if necessary.

5. Hydrate: Dehydration can exacerbate dementia and sundowning symptoms however it can be challenging to get someone with dementia to drink enough fluid of their own accord. 

• Try incorporating hydrating foods such as soups, jelly, melon or cucumber

• Do not rush someone whilst drinking and use cups that are easy to pick up and not heavy.  

• When trying to get someone to eat or drink it can also be useful to incorporate this with an engaging and fun activity such as playing Memory Lane Games.  An approach of ‘one sip/bite, one question’ can distract and reduce anxiety and pressure around the need to eat and drink.

• Try playing games on favorite foods to raise an appetite!

6. Create a Safe Environment: Ensure that the living space is secure and safe to prevent accidents. 

• Think about getting additional help during sundowning hours to anticipate the needs of the individual. 

• Keep external doors locked and minimize clutter. 

• There are various technologies, such as motion sensors and pressure mats that can be used to anticipate or alert wandering and minimize associated dangers.

1. Being safe and feeling safe: A living environment free from trip hazards and clutter seems obvious, however it is important to consider this from the point of view of someone who may have reduced senses or spatial awareness and potential difficulty remembering where they are.  Aim to provide an area where they can freely move around without concern. An important element of calming sundowning is also providing them with a feeling of safety too.  It may be challenging to overcome their seemingly irrational fears or confusion however it may be possible to establish triggers which could be avoided in future.  Be curious, question and talk to them about how you can make them feel happy and safe and be prepared to go along with them into their memories.  

2. Ask Questions: It is also helpful to determine if the person is wandering aimlessly (boredom, looking for direction) or wandering with purpose (attempting to locate something or go somewhere) in order to assign the best tool to the behavior.  Providing that their purpose is not potentially dangerous, caregivers often find it is more helpful to go along with someone on their ‘journey’ and this can result in a calmer, happier person who feels they have fulfilled what they set out to do.  

3. Validating Communication: Maintain clear and simple communication with the person experiencing sundowning. Use reassuring language and validate their feelings. Try not to correct or disagree with someone with dementia as it is not possible to reason with someone in a state of sundowning and this can increase anxiety and distress for you both.  Repeated and monotonous questioning can be eased with distraction or by providing the answer in written form so that they can see it.  

4. Redirection: Attempt to change the subject from their worry or fear to something they enjoy. Distractions, like playing a game, listening to music, going for a short walk or enjoying their favorite treat, can help de-escalate sundowning behaviors and occupy their mind for a short while. 

5. Medication Review: Consult a healthcare provider to review the individual's medication regimen, as some drugs may worsen sundowning symptoms.           

6. Caregiver Support: Caring for someone with sundowning can be emotionally and physically demanding. Seek help from family members and friends, or find a dementia support group. Hiring extra help or using respite care, even a few hours a week can help to avoid caregiver burnout. See the Carer Support section within the Memory Lane Games app for further guidance.