Dementia Care: What is Sundowning?


What is sundowning?

Sundowning and dementia are terms often heard together. Sundowning dementia syndrome, also known as late-day confusion, is characterised by a set of symptoms occurring specifically in the late afternoon or early evening. Simply put, sundowning in dementia patients is unexplained agitation and confusion at a certain time of the day. So, sundowning means dementia worsening at the time of sunset.

Sundowning Dementia: Causes

The exact mechanism behind sundowning in dementia is still unknown. Numerous theories have been presented explaining its causes.

  • According to one, sundowning dementia is related to a disturbance in the circadian rhythm. The circadian clock is the body's natural clock that detects the sunset and sunrise timings and decides the daily activities accordingly. It tells the person when to sleep, wake, eat and do other activities. When this clock is disrupted, sunset affects dementia negatively and makes it worse.
  • According to another theory, dealing with dementia already poses a significant burden on the patient's mental and physical health. At the time of the afternoon, the energy reserves exhaust and the person becomes more irritable, confused, and agitated. Considering the fact that communication skills are poor in dementia patients, they cannot express their feelings. They become bored, tired, thirsty, and fatigued but cannot express these feelings in words, so they adopt aggressive behaviour to communicate. All this manifests as sundowning syndrome in dementia.

The trigger factors for sundowning:

There are certain trigger factors particularly implemented in sundown syndrome dementia:

  • Change in routine activities or too much activity at the time of sunset.
  • Lack of peaceful sleep.
  • Inappropriate lighting and noise pollution compounded with the loss of sight and hearing.

Sundowner’s dementia symptoms

Sundowning in dementia can cause a wide variety of symptoms varying in severity. Generally, it is seen that the symptoms worsen with the advanced stage of the disease. Often, the sundowning symptoms extend up till night affecting the sleep of the patient. The most common symptoms occurring in sundowning dementia are:

  • Confusion
  • Anger
  • Argument
  • Agitation
  • Emotional outburst
  • Insomnia – Inability to sleep
  • Paranoia – hiding objects, becoming suspicious
  • Hallucinations both visual and auditory
  • Restlessness
  • Wandering
  • Eloping
  • Straying

In the late stages of the disease, the dementia symptoms often become so severe that it becomes difficult to distinguish the sundowning effect. If this happens with your loved one, take the time to talk about it with other family members and caregivers so that the care plan can be decided accordingly.

Sundowning dementia prognosis

Sundowning in dementia usually occurs in the mid-stage to the late course of the disease. It occurs in dementia of different types, such as sundowning Alzheimer's disease, sundowning Lewy body dementia, vascular dementia sundowner's syndrome, and frontotemporal dementia sundowning. Sundowning without dementia can also occur especially in elderly people.

Once started, the symptoms usually progress and extend up to the night. They may affect the sleeping pattern of the individual and add to the severity of dementia. The severity of the symptoms can be managed by certain techniques. If managed successfully, for instance, by a professional caregiver, the sundowning symptoms become less pronounced the very next day morning.

Sundowner’s syndrome without dementia

In elderly patients, the brain shrinks in size over time. This is the reason their intellect, memory, and judgment decrease with age. If severe, it results in the symptoms of dementia, which may or may not be compounded by sundowning. However, in the elderly, sundowning often occurs without any prior dementia symptoms. The reason is a comparatively shrunken brain not being able to cope with the stress of daily activities.

Sundowning in people with anxiety in non-dementia patients can occur because of the biological clock being out of sync. Anxiety is associated with many changes in the body system. It badly affects the mood, energy, and whole circadian rhythm of the body. In the late afternoon time, a normal person also exhausts and thus, needs to refresh him/herself to continue the rest of the routine. Anxiety patients already coping with their stress in the late afternoon can become agitated and show the symptoms of sundowning.

Dementia sundowning treatment

Dementia sundown syndrome treatment focuses on a special dementia sundowning care plan and sundowning dementia medication. With good support, these people usually recover. Here are some tips for sundowning dementia:

  • Maintain a predictable and easy routine for a dementia patient. The patient should be well aware of when is the time for eating, walking, and going to bed. Keep reminding them but not in a way that irritates them.
  • Limit daytime naps, sugar, and caffeine in the morning time.
  • Keep them busy in different activities in the sunlight. Encourage them to sleep well at night.
  • The light exposure should be appropriate, not too dark, and not too bright either. Keep a dim light open so that the agitation does not occur in dark or unfamiliar surroundings.
  • Reduce unnecessary noises around them. Try to turn off the TV and other noise-making gadgets. These produce sounds that are disturbing and make dementia symptoms worse.
  • Make the environment in which they reside familiar. If they have to go to some unfamiliar places for some reason help them out by adding photos or other known items at their residing place.
  • Play gentle and soft music in the evening.
  • Talk with them. Make them feel they are not alone. Be patient and considerate of them.

Some medication also helps with sundowning symptoms. These include low-dose melatonin – a naturally occurring hormone produced by the body to make a person asleep, antipsychotics, acetylcholinesterase inhibitors, and some other drugs that aids in behaviour modification.

Frequently Asked Questions (FAQs)

How to deal with sundowning in dementia?

How to help dementia patients with sundowning is what carers think of most. Dealing with sundowning in dementia is essential to reduce the stress of the patient. Some tips can help reduce the symptoms of sundowning dementia:

  • Reduce stressful stimuli such as noise, clutter, and crowded places.
  • Distract the patient by involving him/her in his/her favourite activity, snack, or any other thing.
  • Keep the room dark and quiet at the time of early evening to minimise shadows and unwanted noises.

What is sundowning in dementia?

Sundowning in dementia is the exaggeration of anxiety, aggression, and confusion at the time of late afternoon and evening.

How long does sundowning last in dementia?

Sundowning dementia symptoms once started usually last for the whole day and may worsen at the night. The sundowner dementia then resolves by the next morning. The severity of the symptoms however can be controlled by careful measures and tips.

What stage of dementia is sundowning?

Sundowning in dementia usually occurs at the mid to late stage of the disease.

Can one experience sundowning without dementia?

Sundowning in the elderly without dementia can also occur.

Dr Jamie Wilson
Founder and Chief Medical Officer at Hometouch
Dr Jamie Wilson is hometouch’s founder and Chief Medical Officer. Jamie’s creation of hometouch was inspired by his work as a dementia psychiatrist in the NHS, and he has written about healthcare issues in The Times and the Evening Standard. Jamie has a MBBS from the University of Leeds and has spent a decade in the NHS, working as a Psychiatric Registrar and Memory Specialist at Imperial College Hospital.