The Caring Corner®
Caring for People with Sundowning in Chapel Hill and Durham
Sundowning is one of the most recognized terms in the dementia-care industry and one of the least understood dementia behaviors.
What is it? What are the symptoms? Why does it occur? And what can you do about it?
Sundowning is a term used to describe the increased confusion and agitation that some people with dementia experience in the late afternoon and evening, as the sun goes down. Studies have found that up to 80% of people with dementia experience sundowning at some point. It is not a disease, but a set of symptoms that can be caused by a variety of factors. And these include:
Changes in the brain: As the disease progresses, the brain changes in ways that can lead to changes in your loved one’s sleep-wake cycles, mood, and behavior.
Environmental factors: Changes in the environment, such as moving to a new home or being in a hospital, can trigger sundowning.
Physical factors: Sundowning can also be caused by physical factors, such as pain, hunger, or thirst that your loved one might be experiencing.
What are the symptoms of Sundowning?
They vary from person to person, but they may include:
- Agitation
- Confusion
- Disorientation
- Hallucinations, which means they see and hear things that simply are not there
- Pacing
- Wandering
- Sleep problems
Is there a cure?
Despite numerous studies on the sundowning phenomenon, there is no cure for it. The good news, however, is that there are things you can do to help manage the symptoms. A lot of these are behavioral, which means they are safe to try and have little or no side effects.
#1 Establish a regular routine: This can help to regulate your loved one’s sleep-wake cycle and reduce their confusion. Get them up at the same time each day. Stick with a consistent routine that includes the time they eat breakfast, lunch and dinner, the time they bathe, take a walk, play with family pet, and so on. If they have a favorite TV program, make sure you respect that schedule, too.
Generally speaking, people with dementia do not respond well to changes in their routine. It can lead to concern, fear and suspicion. It might seem boring for you To do the same thing day after day, but that’s the way it is.
#2 Provide a calm and familiar environment: This can help to reduce stress and anxiety. This is pretty obvious. You don’t need to have dementia to become annoyed and unsettled with loud, jarring noises or any type of disruption.
#3 Avoid changes in the environment: If possible, try to avoid making any major changes to your loved one’s environment. Like their daily routine, new things can lead to suspicion, misunderstanding and frustration on the part of your loved one.
If you do have to make any type of change in environment or routine, say to go to a medical appointment, try doing this earlier in the day before sundowning has set in. And make sure, to the extent possible, that your loved one understands what is going on. And make all these changes as smooth as possible, explaining to Mom or Dad that you’re going to a doctor, providing them comfort and assurance, holding their hand for reassurance, things like that.
#4 Make sure that physical needs are met: This includes making sure that they are getting enough to eat, drink, and getting enough sleep. Adequate food and rest are critical in the management of challenging dementia behaviors
#5 Provide activities: This can help to keep your loved one’s mind active and reduce their boredom. While we recommend keeping the same daily routine, empty hours can be an opportunity for people to become bored, distracted. Playing cards, or checkers, looking at photos or any physical activities like walking outdoors can all help.
#6 Manage pain: Pain is another frequent element for your loved one that can lead to challenging dementia behaviors. and it is not always easy to recognize. First of all your loved one may have had pain for so long that they do not complain about it.
Secondly, Even if it’s a new pain, they may be unable to express it because of their declining abilities to speak and communicate.
Pay attention to things that might be bothering them. Is some garment fitting the wrong way? Might a tag be itching therm? Do their shoes fit poorly? Do they seem to favor an arm or a leg? Figuring out pain can take a little bit of detective work
Finally, if all of these strategies seem unsuccessful,
#7 is talk to your loved ones’ doctor. There might be meds that can help. In my opinion, pharmacological solutions should always be the last plan of attack but there are indeed medicines that can successfully manage people’s behaviors and it is possible that these could help your loved one, too. Importantly, your loved one’s physician can help rule out any underlying medical conditions and develop a plan to manage the symptoms.
I always like to cite research studies when they are available and a remarkable number of studies have been done in the area of sundowning. What is equally remarkable is how inconclusive many of the studies are. They agree that many people with dementia experience sundowning, and they further confirm that there is no certain cause and there are no certain remedies. One of the most noteworthy pieces of research examined the impact of sundowning, not on the person with dementia, but on their caregiver.
Van Den Heuvel, E., Schuurmans, M. J., & Vernooij-Dassen, M. J. (2016). The impact of sundowning on the caregivers of persons with dementia: A systematic review. International Journal of Geriatric Psychiatry, 31(1), 11-20.
The authors found that sundowning can have a significant negative impact on caregivers. Caregivers of people with sundowning were more likely to experience physical health problems, such as fatigue, sleep disturbances, and headaches. They were also more likely to experience mental health problems, such as anxiety, depression, and stress. Sundowning can also lead to social and economic problems. You may have to take time off from work, which can lead to financial difficulties. You may have to limit your social activities, which can lead to isolation.
Like a lot of things related to dementia caregiving, you need to take care of yourself as well as your loved one. Things you can do include
Getting support. Join a support group..
Developing Coping strategies: Sometimes coping strategies can help you deal with the stress of caring for your loved one sundowning. These could include relaxation techniques, like deep breathing, or yoga, or hitting some care help so you can step away.
Getting Professional help: If you’re really struggling, don’t tough it out all by yourself. Don’t rule out counseling, and possibly medication.
As a final thought, I would like to share with you one research study which experimented with video with music for people experiencing sundowning
Rados, R., Kim, J., Kono, S. and Horton, J., 2021. Nature-Based Video with Music for Individuals Experiencing an Episode of Sundown Syndrome. Journal of Long Term Care, 0(2021), p.294–302.DOI: https://doi.org/10.31389/jltc.69
The study explored the benefit of a nature-based slideshow accompanied with classical music and its effect on the agitation of individuals with dementia during sundowning episodes. The findings show that short exposure to 6-minute videos that incorporate calming nature images like waterfalls, trees, lakes and the like, combined with classical music had a statistically significant impact on people with sundowning. The music they used was Mozart: Serenade No 10 for Winds ‘Gran Partita’, III. Adagio. There are a lot of studies that support the use of music to help manage challenging dementia behaviors. The best part of it is that so much of it is available free on the Internet and there are no ill side effects. if you’ve tried everything else and it’s been unsuccessful give something like this a try. What have you got to lose?
We hope you find this information helpful. Caregiving can be one of the most challenging things you will ever do and your loved one doesn’t come with an instruction manual. If you are interested in other non-pharmacological approaches to managing challenging behaviors please see this video here .
