Sundowning a term used widely to describe a range of behaviours that occurs in people with or without dementia that worsen in the late afternoon and evening, or as the sunsets.
The behaviours you may observe during this time of the day could be agitation, confusion, anxiety, aggression, increased physical activity that includes wandering, pacing, constant redirection, as well as verbal activity such as yelling. Whilst people with dementia may exhibit some of these symptoms already, the presence of sundowning distinguishes itself as these behaviours are characteristically worse in the evening hours.
The cause for sundowners is mostly unknown however it is thought to result from changes occurring in the brain.
We have put together some strategies to consider for people with dementia. Whilst not all strategies work for everyone, it is important to find out what works for the person you care for.
Video by dignityfirstdoctors Dr Goethe (Neuropsychologist) and Dr Leatherman (Geriatric Specialist in Psychiatry)
Changes in the body’s sleep-wake cycle or circadian rhythm, is thought to be one of the main causes for sundowning. Research published in the Clinical Geriatrics suggests being exposed to light helps your body recognise the differences between day and night. Keeping you home brightly lit in the afternoon to the evening may help to improve the symptoms of sundowning and sleeping in the evening.
Continue to schedule in some form of light to moderate exercise in the routine of the person with dementia. Depending on the individual’s capabilities or limitations will determine the extent to what form of activity you can do. In more advanced stages of dementia this can be more challenging however there are often some activities that they will be capable of, such as walking around the house or bed exercises. It is advised to seek advice from your doctor or a physiotherapist about the individual’s ability. It’s not uncommon for people with dementia to rest a lot during the day, however napping during the day often can contribute to poor sleep at night.
Depending on when the person with dementia rises, it may be best to plan
activities and outings in the mornings so they can rest more in in the afternoon. Calming activities that are less stimulating in the evening are advisable. Such as playing relaxing music or a hand massage.
Try to ensure the person with dementia’s daily routine is consistent. Too much variance can be unsettling for people with dementia often unable to make sense or adapt to new situations or tasks which can cause increased agitation or anger as a result of stress encountering an unfamiliar environment or activity.
Fear, stress and frustration are significant factors often adding to confusion and irritability in people who are affected by sundowning. Whilst you may need to make some changes at times to fit in with yours or your family’s schedule, start small rather than changing too many things at once as this can be frightening for people with dementia.
The world and their surroundings for people with dementia can at times be a scary place when they are unable to recognise or make sense of they what they see, hear and experience. Providing reassurance and validation that everything will be ok, remain positive, smile and help guide them through the unfamiliar or confusion they may be feeling.
Sometimes people with dementia can only express their needs and wants through agitation or restlessness. Therefore ensuring that they are not hungry, thirsty, in pain, too hot or cold or needing the toilet can often help settle the person down and help them restore their sense of familiarity or security.
If the person with dementia needs to go to hospital or is moving into a new nursing home provide comforting strategies such as bringing in familiar objects of their everyday life, this can include: photos, picture books, familiar music, blankets or other comforting or familiar items to help transition into their new environment.
Especially in the beginning when you are first starting to notice the signs of sundowning it’s a good idea to keep a diary of what symptoms you are observing and at what time. You can then discuss what you are observing with you doctor or a dementia care nurse.
You may start to notice a pattern at a particular time of the day, certain interactions with people, activities or simply at that time of the day can start to make the person with dementia more unsettled. This can help you either prepare for that time of day or avoid those particular interactions.
If you are concerned about the worsening behaviours of someone you care then always seek guidance from your doctor to eliminate an acute infection or provide guidance around other possible non-pharmacological and pharmacological strategies (this means using medication or without medication strategies).
Likewise, watch for sundowning in early-stage dementia or rapidly worsening symptoms, both of which may suggest delirium.
If you are at home or working in a nursing home and are concerned about the behaviours of people with dementia then you can phone The Dementia Behaviour Management Advisory Service (DBMAS)
which is a government funded national service. They can provide confidential advice, assessment, intervention and education over the phone for caregivers and aged care workers 24 hours a day, 7 days a week, simply phone 1800 699 799.