Understanding Sundowning Syndrome: Symptoms, Causes, and Strategies for Care

One of the challenging parts of dementia care is responding to new and often stressful behaviors. These may make little sense, especially to caregivers who are figuring things out as they go, without the benefit of much caregiver education.

One such phenomenon is sundowning syndrome, which is often associated with dementia, where individuals experience heightened confusion and agitation during the late afternoon and evening hours. In this article, we’ll delve into the symptoms of sundowning, explore its potential causes, and discuss practical strategies for providing care and reducing its impact on your loved one’s well-being.

Symptoms of Sundowning

Before delving into the causes and strategies for managing sundowning, it’s crucial to recognize the symptoms associated with this late-day phenomenon. Common signs include:

1. Mood Changes: Noticeable shifts from calmness to sudden irritability, impatience, or even aggression during the late afternoon.
2. Confusion and paranoia: As the sun sets, individuals may become nonsensical, experiencing confusion, paranoia, and potentially delusions or hallucinations.
3. Restlessness: A constant state of restlessness, pacing, and an inability to settle down.
4. Disorientation: Difficulty in recognizing surroundings or feeling disoriented about time and place. This may include the senior getting lost in a familiar environment or asking where they are.
5. Increased sensitivity. During the late afternoon and evening, seniors may become increasingly sensitive to some types of stimuli, like light or noise.
6. Suspiciousness: A heightened sense of suspicion or unease.
7. Increased dementia symptoms. Many symptoms of dementia may get worse towards the end of the day, including judgment, decision-making, cognition, and memory issues.

Some of these symptoms may have already been present, especially for patients in the mid to late stages of dementia. However, with sundowning, the symptoms may become notably worse in the late afternoon and evening.

The specific symptoms present, their severity, and what they look like will vary depending on the senior. For example, some may be largely restless and disoriented, while others may experience more paranoia, irritability, and even anger.

Sundowning is also difficult for caregivers, as it often occurs at the end of a long, busy, and stressful day. Your energy reserves may be all but depleted, which makes it much more difficult to respond with kindness and compassion.

Causes of Sundowning

While sundowning is often associated with Alzheimer’s, even those without dementia may experience some similar symptoms. Changes in light may play a role in the condition, along with changes to the body’s inner clock as dementia progresses. However, the exact causes aren’t known.

The following are areas that can increase the risk of sundowning or make the symptoms worse.

1. Exhaustion: Physical or mental exhaustion can prompt mood changes and agitation.
2. Hunger and Thirst: Being hungry or thirsty may contribute to the late-day state.
3. Environmental Triggers: Irregular lighting, shadows, or distorted perceptions of reality can be triggering.
4. Unfamiliar Environment: Being in an unfamiliar environment increases the risk of sundowning and may lead to increased demands that the senior wants to go home.
5. Some Health Conditions: Both mental and physical health conditions can play a role in sundowning. UTIs, insomnia, and depression are especially relevant, although can be significant too. As such, it’s crucial to check with the senior’s doctor about any areas of concern.

Strategies for Reducing Sundowning

Understanding that sundowning is a symptom rather than a disease is essential. There also isn’t a reliable way to prevent sundowning. However, the right strategies can reduce the symptoms of sundowning and may even stop it entirely for some seniors.

Simple, everyday routines can significantly contribute to reducing its impact. Here are practical strategies:

Establish a Routine

Routines are powerful for people with dementia. They help to provide a sense of structure, while also reducing stress and anxiety for the person with dementia. Some families even find it important to stick with the regular daily routine over Christmas and other special occasions, as any disruption can be stressful for both the senior and the caregiver.

Routines help with sleep too, as a good routine ensures that they’re tired at the right time of day. Indeed, when people sleep and wake at the same times each day, their bodies get into the habit naturally.

As part of this, make sure the senior is getting enough activity during the day so that they’re tired at night (notably, the amount of activity relates to their current abilities and needs, not what they may have done when younger). Avoiding naps may be important too.

Physical activity isn’t the only approach here. You’re also looking for things that keep the senior engaged, such as dementia puzzles. While people with dementia experience the world in a different way than they did previously, they still benefit from engaging activities and social connection. Such activities can also lower the risk of depression and boredom, and reduce sundowning symptoms in the process.

Promote Overall Health

Anything that helps with physical or emotional health could reduce sundowning risk or symptoms. This includes ensuring they get enough exercise, promoting a healthy diet, and limiting the intake of caffeine, tobacco, and alcohol.

Create a Safe Environment

A safe environment has multiple components. The first is to focus on things that you can remove, including bright lights and loud noises. These can be disconcerting and easily make sundowning worse.

Then, consider things you can add, such as soft lighting and gentle music. Basically, anything that makes the evening gentle and calming should help. This includes in the bedroom. Here, a well-made bed with nice sheets and familiar objects may help.

Lighting is especially important. The light shouldn’t be overly bright, but it should still be light enough to see clearly. It’s also important to avoid shadows, as these can become disorienting.

For seniors living in assisted living or a similar environment, ensure there are familiar mementos and pieces of furniture. This may help the senior to recognize that they are somewhere safe.  

Be Patient and Understanding

Respond with patience and understanding when signs of sundowning appear. Avoid reacting negatively to delusions or irritations, as it may exacerbate the situation.

Validation therapy and redirection are both useful approaches here. Validation focuses on connecting with the senior’s emotions (which may be fear or restlessness in this case), while redirection aims to place their focus elsewhere.

Consult with a Healthcare Professional

Seek the guidance of a healthcare professional to ensure the symptoms are attributed to sundowning and not another underlying issue. Discuss potential interventions or medications that may help manage symptoms.

Be certain to carefully research any medication recommendations, as some medications are misused in dementia care and can cause more harm than good for seniors.

Conclusion

Caring for someone experiencing sundowning requires a compassionate and understanding approach. By being proactive in creating a supportive environment, maintaining routines, and addressing potential triggers, you can significantly reduce the impact of sundowning on your loved one’s daily life.

Remember that seeking professional advice is essential to rule out other potential causes and tailor the care approach to your loved one’s specific needs. With a thoughtful and open-minded approach, you can navigate the challenges of sundowning and provide the care and support your aging loved one deserves.