For many people with Alzheimer’s disease or other forms of dementia, the late afternoon and early evening can be an especially troubling time of day. That’s when a condition known as sundowning can occur, including agitation, anxiety, and confusion. The changes in personality and behavior can be upsetting for the people experiencing sundowning, as well as those around them.
While sundowning may not be entirely preventable, caregivers and family members can try some coping strategies to avoid, or at least limit, sundowning symptoms. To have a better idea of what might help you and your loved one, it’s best to know more about this common problem.
What Is Sundowner’s Syndrome?
Sundowning is a set of symptoms and dementia-related behaviors. Sundowning, as the name implies, usually comes on in the late afternoon or early evening. Episodes may last a couple of hours or the entire evening, until the person falls asleep. Sometimes, an individual experiencing sundowner’s syndrome may wake up in the middle of the night still feeling anxious or confused.
Agitation in dementia is common, but the causes of sundowning aren’t entirely understood. Estimates of people with dementia who experience sundowning at any one time range from less than 5% to more than 60%, but many patients manifest it at some point in the course of their illness.
The onset of sundowning may indicate disease progression or other changes in the brain.
“I don’t think it’s well understood mechanistically,” says Deborah Blacker, MD, ScD, a geriatric psychiatrist at Massachusetts General Hospital. “I suspect that with age, and especially with brain disease, people become more susceptible to all kinds of perturbations, such as illness, metabolic disturbances, and fatigue. As the day wears on, patients tend to become more upset, agitated, etc.”
Recognizing the Signs and Symptoms
Sundowning symptoms include late-day confusion and other changes in personality and behavior. They can differ from one person to another and can present differently depending on the day or the circumstances the individual is in at the moment.
Typical signs and symptoms include:
- Anxiety and/or agitation
- Difficulty sleeping
- Disorientation
- Increased confusion
- Pacing or wandering
Someone experiencing sundowning may talk about a deceased spouse or family member who is on their way to pick them up or may not seem to recognize their room or the people around them.
What Causes Sundowning in Dementia?
Even though researchers don’t yet know exactly why sundowning occurs, there are some common factors and triggers that often contribute to an episode of sundowning. The mental and physical exhaustion of a busy day may lead to sundowning symptoms. Similarly, if there is too much activity going on in the late afternoon or evening—such as having several visitors around or having a medical appointment or other outing—a person with dementia may feel overwhelmed. A person with sundowner’s dementia may be especially sensitive to the mood and behaviors of others, so someone exhibiting stress or impatience may trigger those feelings in a person susceptible to sundowner’s syndrome.
Sundowning is also associated with sleep issues in dementia. A person’s internal body clock, or circadian rhythms, may also become confused. An individual may therefore be tired during the day but feel more awake at night. Dementia can also cause some people to confuse dreams with real life, so it can be confusing when events from a dream don’t match up with what a person is seeing or experiencing in their waking life.
Dr. Blacker adds that people who experience sundowning may do so because they have become more sensitive to changes that occur late in the day. Things like cumulative fatigue and stress, less structure, fewer environmental cues, and even low lighting that increases shadows can be disorienting or frightening.
Being in a new environment, such as moving into a skilled nursing facility, can lead to confusion and sundowning symptoms.
When Does Sundowning Occur?
Alzheimer’s disease and sundowning often co-occur, with sundowning usually coming on during the middle stages of Alzheimer’s. Sundowning symptoms sometimes manifest in the early stages, with increased anxiety and mild irritability. In the late stages of Alzheimer’s, sundowning may be characterized by longer periods of distress. Confusion and sleep problems also may worsen during these stages.
In the absence of Alzheimer’s disease or other types of dementia, sundowning—or a form of sundowning—may develop. Feelings of anxiety, restlessness, or confusion, however, may be more likely to be signs or symptoms of temporary changes related to sleep disruption, medication side effects, or physical illness. As Dr. Blacker notes, older adults often struggle more with changes in their environment, health, or other circumstances. As a result, emotional or psychological complications can appear in situations that individuals used to weather more easily.
Practical Strategies to Manage Sundowning
If you’re a caregiver, you can employ coping strategies and ways to help mitigate late-day confusion and episodes of agitation in dementia. They don’t always work, but it’s helpful to have some strategies you can try to help manage dementia-related behavior changes.
If you’re trying to help ease the intensity of sundowning symptoms in a loved one, pay close attention to possible triggers of late-day confusion and other changes. Take note of what may be happening before the start of a sundowning episode, and think about ways to change a person’s schedule or environment, even in subtle ways, to possibly head off a period of sundowning.
“If sundowning happens often, it’s best not to schedule things that are upsetting when the patient is more likely to be upset, or to be vulnerable to becoming upset,” Dr. Blacker says. “And to the extent possible, it’s best not to schedule things that are critical in the evening, as they may be less likely to be handled well. For example, a major family event may be better earlier in the day than later.”
While sundowning isn’t always related to sleep problems, many caregivers find it helpful to prioritize the quality and quantity of a person’s sleep schedule. A comfortable mattress and a sleep-friendly environment are very important. If an early afternoon nap might help, encourage your loved one to get some rest, but not for too long. As much as possible, try to establish a regular bedtime and wake-up time that is right for the individual. If a person tends to sleep better in the early morning, try to let them sleep, and keep distractions and noise to a minimum.
Managing sundowning also should include a review of your loved one’s medication regimen with their doctor. The timing and dosage of certain medications can trigger side effects that may contribute to sundowning. Some medications may no longer be needed. It also might be possible to change the time of day the individual takes a sleep-interfering drug, such as diuretics that can lead to nighttime bathroom trips and interrupted sleep.
Getting some sunlight and fresh air whenever possible can help when dementia behavior changes. Sometimes a change of scenery at the start of a sundowning episode can change a person’s mood, though be careful not to force someone to do anything that seems to make them more upset.
Whenever possible, try to be a calming influence around a person who is sundowning. It can be difficult to see a loved one upset and anxious, but your presence may be exactly what’s needed to ease things. “Reassure and redirect,” Dr. Blacker advises. “If someone is worried, briefly reassure and then point them somewhere else. If they forget something, don’t be irritated, but remind them and move on. Try not to be angry even when it’s frustrating for you. If you are calm, it helps the person to be calm, too.”
She adds that in many cases, sundowning is simply a mild worsening of symptoms that may occur at any time of day. If your attempts at managing sundowning aren’t effective and agitation or severe anxiety significantly distresses the individual or puts them or their caregivers and visitors at risk, talk with a doctor about medication. Some sundown syndrome treatments include medications that can be given if episodes are bad or in anticipation if the episodes are predictable and severe.
Dr. Blacker also recommends that in the unlikely event that you feel that the individual or a caregiver or visitor is in acute danger, call 911 and go by ambulance to your local emergency room, or as directed by your doctor.
