Dementia and Sundowning

Welcome back to the place where we talk about everything dementia. 

Today I am talking about Sundowning. A common symptom of dementia that leads to a lot of caregiver stress. If you'd like to watch the video, I did on sundowning, you can watch it here. Otherwise, keep reading. 

Sundowning, or Sundowning Syndrome is not actually a diagnosis. It's a term used to describe a variety of symptoms that commonly occur during the evening for people who have dementia. The medical community does not have one agreed upon definition, but common symptoms include:

•  increased confusion
• anxiety
• agitation
• pacing
• aggressiveness
• disorientation 
• mood swings
• hallucinations
• an unusually demanding attitude

It’s called sundowners syndrome or sundowning because these symptoms typically occur in the late afternoon, evening, or at night. This often means your loved one will also have difficulty sleeping and may be an an increased risk for wandering. 

Sundowning can occur in any individual with cognitive impairment, but it tends to occur most often in those with moderate to severe stages of dementia. It is estimated that up to 25% of people with Alzheimer’s disease and up to 66% of people with any type of dementia experience sundowning. Rates tend to be higher for those living at home compared to nursing home environments.

I’m going to go over some ways you can try to reduce symptoms of sundowning in your loved one, but first I’ll do a quick review on reasons why researchers think sundowning exists.

Researchers aren’t exactly sure why sundowning occurs and a small number of researchers suggest that sundowning doesn’t really even exist.  However, the majority of research does support sundowning syndrome and I’d bet many of you careblazers would say the same.

One theory of why sundowning occurs is that a brain with dementia is constantly working extra hard to navigate the environment and maintain functioning levels throughout the day. Caregivers notice that dementia patients are at their best in the morning, when the brain is most rested, after hours of sleep. As the day progresses there is a noticeable decline in tolerance to the environment, with the brain struggling to cope with the stresses of conducting everyday activities.

At some point, the brain simply can’t cope anymore and appears to have a “melt down.” When that happens, there is an increased inability to differentiate reality from dreams and past memories. Sometimes it is accompanied by uncontrollable emotional outbursts and agitation, ranging from mild to severe.

Other possible reasons researchers think sundowning occurs.

• Neurobiological factors: Like changes in sleep patterns and brain activity
• Medical factors: sleep disorders and pain
• Environmental factors: Exposure to inadequate amount of light. Less availability of home caregivers, Caregiver fatigue
• Environmental overstimulation: too much noise or chaos

Let’s talk about what you can do if your loved one is showing signs of sundowning

Make a Routine

As much as possible, engage the person with dementia into a regular routine. Make a routine for when they wake up, when they eat, and when they go to bed. This will allow for more restful sleep at night. Routines aren’t only helpful to your loved one with dementia, but it is also helpful to you. Research shows that the more organized and structured a day is (so long as there are some pleasant events and time for rest included), the less likely your loved one will show signs of agitation or anxiety.

Sleep

Make sure your loved one gets sleep...but not too much sleep. Taking a regular nap in the early afternoon or right after lunch is a nice way to recharge the brain, so it can function better for the rest of the day. Try to avoid stimulants like nicotine, alcohol, and caffeine close to bedtime. You may also want to consider having a large meal at lunch and keep the evening meal simple.

Mind Yourself 

I almost hate to include this one because you already know this, but the mere act of being a Careblazer means that it is so difficult to do.  Be mindful of your own mental and physical exhaustion. If you are feeling stressed by the late afternoon, the person may pick up on it and become agitated or confused. Try to get plenty of rest at night so you have more energy during the day. Try to incorporate your own self-care and desires into the daily schedule and include your loved one if possible. If taking a daily walk is something you enjoy, bring your loved one along. When your loved one is taking a nap, see if you can catch a few snoozes as well. Caregiver stress and fatigue will impact your loved one. Make sure you have a calm voice and relaxed face.

Activity

This goes along with making a routine. You want to plan more active days. A person who rests most of the day and is not engaged in activity is likely to be restless at night which will also keep you up most of the night. Keep more challenging activities such as doctor appointments, outings and bathing for the mornings. Encourage regular daily exercise, but try not to do this close to bedtime. Bonus tip- Schedule the activities just before or during times the agitation/sundowning symptoms typically occur.

Lighting

Keep the home well lit in the evening. Older people and people with dementia tend to experience decline in their vision making it more difficult for them to accurately see things in their environment.  Adequate lighting may help reduce the agitation that occurs when surroundings feel dark or unfamiliar. Some research suggests that exposing someone with dementia to bright light for several hours in the morning can lead to improved sleep at night by helping with their circadian rhythm.

Relaxation Techniques

Try soothing therapies like listening to relaxing  music, aroma therapy, pets, massage,  and art. These can be very soothing and help reduce stress. Try to reduce environmental stimuli. Limit distractions, especially during the evening hours, such as TV, children arriving, lawn mowers, chores, loud music, etc. Some frightening or violent events depicted on television (like on the news), may be very stressful and disturbing for people with dementia. It's possible that they may believe that these events are actually happening to them in reality. As a result, these patients may express their fears in the form of agitation, confusion, or violence. Offer to stroke their hand or hold their hand for reassurance.

Play detective

Keep a journal write down everything that happened each time the person becomes agitated. What time of day was it? Who was present? What happened immediately before the outburst? Often a pattern emerges which can help doctors and caregivers identify sundowning triggers and better control the situation.

Medication

Talk to your loved one's doctor about best times of day for taking medication. When behavioral interventions and environmental changes do not work, some dementia patients may need medications including antipsychotics and antidepressants to take the edge off their agitation.

Medication should be administered under the direct supervision of a physician and sundowning symptoms should be taken in consideration when selecting the timing for medication intake. You can also talk to the doctor about melatonin being an option.

Offer Snack/Beverage

Sometimes a simple offer of a favorite snack or drink can help decrease sundowning symptoms.

Ensure there is no emergency

Finally, just because because a person with dementia is agitated in the evening, do not automatically assume it is sundowning. Sundowning usually follows a pattern and repeats itself at the same time of the day. If the behavior is new and appeared suddenly, have the doctor check for infections (especially urinary tract infections) and dehydration.

Many dementia patients are unable to report pain, so caregivers need to check for pain related to arthritis, constipation, heartburn, or sitting for long periods in an uncomfortable position. Temporary confusion (known as delirum) can be caused by flare-ups of chronic diseases such as diabetes or heart, liver, or kidney disease can also cause agitation. Additionally, the doctor should check for medication interactions that could also cause agitation.  

I hope that this has been helpful to you.  If you want to be alerted to new weekly dementia videos, be sure to subscribe to Careblazers on YouTube.