How to Manage Sundowning

Sundowning, or Sundowner's Syndrome, is a term used to describe the state of confusion or agitation people with Alzheimer's disease and other forms of dementia can experience during the late afternoon and evening hours. 

It is estimated that sundowning affects up to 66% of those living with dementia, though not everyone who experiences this phenomenon will have the same symptoms. Nor will all of the commonly suggested strategies for managing sundowning work for everyone.  

What Causes Sundowning?

The exact causes of sundowning are not fully understood. However, one possibility is that Alzheimer-related brain changes can affect a person's internal clock, leading to confused circadian rhythms, also know as sleep-wake cycles. (NIH.gov) 

Common Symptoms of Sundowning

Sundowning can affect memory, personality, reasoning, mood, and behavior. Behaviors commonly associated with sundowning include:

1. Confusion: A person may become disoriented and have difficulty recognizing familiar people or places.
2. Agitation: Restlessness, pacing, and increased irritability can occur.
3. Anxiety: Heightened levels of anxiety or fear, sometimes without an obvious trigger.
4. Mood swings: Emotional fluctuations, such as sudden mood changes or increased sadness, anger, frustration, or aggression.
5. Shadowing: When the individual closely follows their caregiver everywhere they go. 
6. Hallucinations: Some individuals may experience visual or auditory hallucinations.
7. Sleep disturbances: Difficulty falling asleep or staying asleep throughout the night.

Tips for Reducing Sundowning

Managing sundowning can be challenging, especially for family caregivers. However, the following strategies may be helpful:

1. Establish a Routine: Create a structured daily schedule with regular mealtimes, activities, and sleep patterns. Consistency can help regulate the individual's circadian rhythm.
2. Adequate Lighting: Ensure that the environment is well-lit during the evening hours to reduce shadows which can cause fear and confusion. Consider using nightlights to minimize disorientation.
3. Calming Activities: Engage in calming activities during the evening, such as listening to soft music, practicing relaxation techniques, or engaging in gentle exercise like walking.
4. Monitor Diet: Ensure your loved one is well-nourished and hydrated. Hunger and dehydration can worsen symptoms. Limit caffeine and sugar intake, especially in the afternoon.
5. Limit Daytime Napping: As we age, our bodies require less sleep. Getting too much sleep during daylight hours can make it more difficult to sleep later in the evening.
6. Medication Review: Consult with a healthcare provider to review and adjust medications that may be contributing to sundowning.
7. Limit Sensory Stimuli: Reduce environmental triggers by minimizing noise, avoiding stimulating activities before bedtime, and creating a relaxing, peaceful atmosphere.
8. Physical Activity: Encourage regular exercise during the day, as it can improve sleep patterns and reduce restlessness at night.
9. Support and Education: Seek support from healthcare professionals and dementia care specialists who can provide guidance and strategies for managing sundowning.
10. Respite Care: Consider respite care options to provide temporary relief and allow you to recharge your battery.

How to Communicate With Someone Experiencing Sundowning

Maintaining your composure when dealing with a loved one experiencing confusion or agitation as a result of sundowning can be challenging. A gentle approach, including the following suggestions, can be helpful:

• Be patient. Do not raise your voice, show stress, or demonstrate frustration.
• Avoid arguing, correcting behavior or mistakes, and understand that trying to explain why their thoughts may be irrational will likely agitate them further. 
• Gently offer reassurance that everything is all right. A quick hug can go a long way.
• Use non-verbal communication (i.e., hand gestures, facial expressions, etc.) to help help get your message across.
• Keep your sentences short and to the point, especially as the disease progresses. In the later stages or Alzheimer's disease, for example, you may need to limit your questions to those with a yes/no answer.
• Try not to take their comments personally. Support groups often remind caregivers that it's the disease talking, not necessarily the way your loved one would choose to speak to you prior to effects of dementia.

When to Consult a Professional

You should bring any sundowning related concerns to your healthcare provider as soon as possible.

Not only will they be able to rule out other potential reasons reasons for the symptoms your loved one is experiencing (e.g.,  urinary tract infection, restless leg syndrome, a sleep disorder, depression, medication conflict, etc.) via testing. They can also prescribe medications to manage severe sundowning symptoms when other strategies fall short. Just be sure to ask about potential side effects.

Self-Care Is Essential

It's important to remember that sundowning can be distressing for both the person with dementia and their caregiver.

Caregivers should prioritize their own well-being and seek assistance from support groups and healthcare professionals to cope with the challenges of sundowning and dementia care.