If you are living with someone with dementia, you may notice changes in their behaviour as the day wears on. These changes in behaviour are often referred to as ‘sundowning’, or ‘sundowning syndrome’.
Caring for a loved one with sundowning dementia can be very difficult, as you are having to respond to increasing levels of agitation and distress which tends to peak as the sun starts to set. It can be heartbreaking to see that person’s behaviour change so considerably and you can feel completely at a loss as to how to help.
We spoke to an Dementia UK Admiral Nurse —Mutsai Hove Bird — about how professional dementia nurses manage sundowning. We hope that this will help you understand how you can make things better for you and your loved one.
What is sundowning?
Sundowning is a term referring to changes in behaviour of a person with dementia in the late afternoon and evening; normally around dusk. People with sundowning dementia experience a heightened level of anxiety, distress or agitation at this time. It can occur in people with different types of dementia, including Alzheimer’s.
Admiral Nurse, Mutsai Hove Bird adds that “other symptoms might include shouting or arguing, pacing, or becoming confused about who people are and have a compelling sense that they are in the wrong place. The person with dementia might say they need to go home, even if they are home.”
What causes sundowning?
Despite its name, sundowning is not caused predominantly by the change in light levels – though it may play a factor. It is likely that sundowning occurs due to a disruption in the circadian rhythm of people with dementia i.e. their body clocks. This can cause people with dementia to have disruptions in their sleep patterns. As the day wears on, the person with dementia becomes more tired and therefore is more likely to feel confused and agitated.
Other factors that may lead to sundowning
There are other factors that can contribute to increased agitation in the late afternoon/early evening for people with dementia. The causes may be different for different people, so it may be worth trying to address different factors one at a time and seeing what makes a difference.
Reduced lighting and increased shadows
If a person is feeling confused due to their dementia, reduced lighting and the inability to see things, can compound this.
Darkness can increase uncertainty about where they are, which can contribute to people with sundowning syndrome thinking that they are "in the wrong place".
Loss of routine at a previously busy time of day
A person may be used to a previously busy routine in the afternoon. For example work or a social activity. The transition can be confusing as their expected routine fails to materialise which can cause confusion and agitation.
Carers can become exhausted
Caring for someone with dementia is incredibly stressful and they might be responding to your tiredness or anxiety. Sadly, this can increase their confusion and agitation.
Being hungry and thirsty
Being hungry and thirsty can cause confusion. People with dementia can forget, or refuse, to eat and drink. This can take its toll over the course of the day, and lead them to feeling uncomfortable without knowing why. You may want to read our tips on getting someone with dementia to eat more.
Prescribed medication wearing off
If your relative takes prescribed medication at a fixed point in the day, it may wear off in the afternoon or evening.
It is important to remember that a person with dementia being distressed is not necessarily sundowning behaviour. They may be trying to communicate a specific need to you, such as pain or constipation.
Tips for managing sundowning
There is not a simple ‘cure’ for sundowning behaviour. The best thing that you can do is find ways of managing your relative’s sundowning when it happens, and taking steps to prevent the agitation that they feel in the afternoon and evening. If your relative is feeling very restless or agitated, there are simple things that you can do to comfort them.
Mutsai Hove Bird recommends the following ways of managing sundowning.
Approach them calmly
Approach the person in a calm reassuring manner and avoid arguing.
Try to identify the cause of distress
Try to talk slowly in a reassuring way and listen carefully to their response to see if you can deal with source of distress which may include hunger, thirst or needing to go to the toilet.
Use distraction techniques
If there is no distinct cause of their distress then try to focus their attention on a simple activity. This could be going into a different room, making a drink, having a snack, turning some music on, or going out for a walk.
Consider the physical environement
Try to maintain a calm physical environment. Minimise noise and lights.
Tips for preventing sundowning
There are a number of steps that you can take to prevent sundowning. Because there are many factors that contribute to sundowning, not all of these tips will work for everyone. It is best to keep a record of what does and does not work for your relative.
Mutsai suggested the following tips for trying to prevent sundowning.
Maintain a routine
Routine is very important for managing and preventing sundowning. Try to keep mealtimes, sleeping times and waking up times consistent. Having a consistent daily routine also reduces worries about being "in the wrong place", which is common for sundowners.
Plan relaxing afternoon activities
A good way of managing sundowning is to plan relaxing afternoon activities. This could be as simple as watching a certain TV show everyday, having a phone call at a fixed time, or doing a puzzle.
Encourage trips outside while it is light
Spending time outdoors in the natural light is a good idea for people prone to sundowning.
If a person's body clock is distorted, they may expect it to be light when it is not. Making sure a person has been in the natural daylight when they can means they are less likely to feel confused about the time of day, or that they have not been outdoors for a while.
Make sure that they have been eating and drinking
Maintaining a generally good standard of care is important. Making sure that the person you're caring for has been eating and drinking, and using the toilet regularly, is also likely to improve mood and health for people with dementia.
Improve lighting in the home
Close curtains and turning on the lights as light changes from day to night to help reduce disorientation between day and night-time.
Stimulants such as caffeine and alcohol can lead to people feeling more distressed and agitated. Caffeine-free and alcohol-free drink alternatives are available, and they may not notice the switch.
Track what helps and what doesn't
Track the behaviour of your relative and try to work out if specific things trigger their sundowning behaviour. Also keep notes of what seems to help them, or keep them relaxed. Take a look at our page on useful apps for keeping track of care at home.
Look after yourself
We know that people with dementia may take stress cues from their carers. Make sure that you are looking after yourself so that you can feel less stressed when with your relative. You may want to read our guide to care for the carer.
Some people find that avoiding naps in the day is a good idea, in order to keep the sundowner close to the body’s natural circadian rhythm. Other people find that a short afternoon nap helps to alleviate agitated behaviour due to tiredness in the evening. Whether or not napping is effective will depend on how well your relative is able to sleep through the night.
Frequently Asked Questions about Sundowning
Does sundowning happen to all people with dementia?
Sundowning is a common issue for many people with dementia. It tends to occur in mid-to-late stages of dementia where it affects up to two in three people (66%) of people who have dementia.
Is sundowning more common with certain types of dementia?
Sundowning can occur with all types of dementia. It is not known if it is more prevalent in certain types.
How long does sundowning last?
Sundowning does not last a fixed amount of time. It can pass in a matter of minutes, or last all afternoon and evening. It will vary person-to-person and day-to-day.
Should I seek medical help to manage sundowning?
The Admiral Nurse that we spoke to says:
"Always seek medical advice if you are concerned about changes in behaviour in someone with dementia. While the behaviour may be attributed to sundowning, it is important that other causes of distress / discomfort such as pain or a urinary tract infection are managed. In some cases where lifestyle changes fail to prevent or reduce impact of anxiety and agitation on the person with dementia, medication may be prescribed."