Care assistants who support people with dementia will tell you their clients often behave differently in the late afternoon and early evening. This behavioural phenomenon is known as sundowning or sundown syndrome. Anyone with dementia can experience sundowning, but it happens more often in the middle and late stages.
Sundowning affects people with dementia and their families. It can be very stressful and it can affect the quality of life of the person with dementia, their family and friends, and even their carer. Understanding what sundowning is, what causes it and what you can do to manage it can help you to support your loved one when they’re experiencing sundowning.
The term sundowning describes a range of behaviours that often occur during the latter part of the day, especially in the late afternoon and early evening. Such behaviours can include confusion, agitation, anxiety and restlessness. For a person with dementia, these behaviours can escalate as the day goes on, becoming what some call ‘late-day confusion’ or ‘evening-hour agitation’.
It’s thought to be associated with the disturbance of circadian rhythm or "body clock", a natural process that helps a person regulate the sleep-wake cycle. As natural light dwindles in the evenings, those with dementia can become more agitated and disoriented. They may yell, pace, and even engage in aggressive actions. These behaviours are what’s called sundowning. Sundowning symptoms can include a wide variety of behaviours that are not limited to the evening, and their behaviours can differ from person to person.
Sundowning can be a feature of Alzheimer’s disease and other types of dementia. It is thought that up to 20% of people with Alzheimer’s experience sundowning. Many people who care for a person with dementia will likely encounter sundowning, and families are often left to manage these complex behaviours while also keeping their loved ones safe.
Although the precise reason of sundowning is unknown, it is thought to be the result of several elements. The change of the circadian rhythm, which influences wake cycles and sleep patterns, is one of the main factors. Changing light levels during the day could throw off the body's natural clock and cause more irritation.
Additionally, disturbances in sleep, which are common in persons with dementia, are another trigger for sundowning. Many people with dementia experience disrupted sleep, which can exacerbate sundowning symptoms. Fatigue, combined with the brain’s declining ability to process information, can lead to increased confusion and anxiety as the day comes to a close.
Other factors that can worsen sundowning include environmental changes, such as decreased light levels in the late afternoon and early evening, which can cause disorientation. Additionally, physical discomfort, hunger, or a need to use the toilet might trigger sundowning behaviour. Infections, such as a urinary tract infection, can also exacerbate symptoms. It's crucial to understand that each person is different, and what causes sundowning in one person might not be the same for another.
A lack of routine or any type of chaotic environment can exacerbate sundowning because the person with dementia is less likely to feel safe and secure in a confused and chaotic environment.
Although handling sundowning can be stressful, there are techniques you can use to assist your loved one in managing these behaviours. The key is to keep calm and to experiment with strategies until you find one that works well for them.
Reducing the factors that contribute to sundowning, such as an unpredictable daytime routine, reduces the likelihood of sundowning occuring. Have your relative take plenty of walks, do some light stretching, or even light housework – anything that helps to keep them physically active at regular intervals throughout the day can help to maintain a normal circadian rhythm. A structured day can also help reduce the likelihood of confusing day and night.
Pay attention to the environment that your loved one is in. Use lights in the afternoon – when natural light starts to fade – to keep the circadian rhythm steady and reduce noise and other disturbances in the evening. There are other things that can be done such as using soft, pleasant music or other familiar sounds to help soothe your loved one’s anxiety.
It’s important to maintain good sleep hygiene as much as possible. If your loved one tends to nap during the day, especially in the afternoon, try reducing their nap time as much as possible. Waking at the same time each day can also be helpful, as can going to bed at the same time each night. At night, avoid caffeinated drinks and big meals, which can make it harder for them to get to sleep. Instead, try offering a light snack and caffeine-free beverages, which can help create a relaxing atmosphere.
If your loved one starts to show signs of sundowning, stay as calm and relaxed as you can. Speak in a soft, gentle voice and use short, direct sentences. Don’t argue or try to explain their behaviour because they won’t understand, and this could make them even more upset. If you remain calm, they will probably calm down, too. Don’t insist on any changes in their behaviour. Reassure them, let them know you understand what they’re feeling, and try to be compassionate. Just being with your loved one can help. Consider holding their hand or sitting next to them.
Distraction is often an effective way of taking your loved one’s mind off their distress, whether that’s listening to a favourite piece of music, looking through a photo album or making a cup of tea together. If your loved one is pacing, taking them for a short walk in a secure environment may be an effective way of reducing their agitation.
Preventing sundowning from occurring in the first place can make caregiving much easier. Here are some practical tips to help you minimise the chances of sundowning behaviour:
Natural light during the day can help stabilise your loved one’s body clock, so try to get them outside in the morning or early afternoon, even for a brief walk. If outdoor exposure is not possible, make sure their living space receives a lot of natural light. Bright light therapy, which simulates daylight, can also be beneficial in managing sundowning symptoms.
As evening approaches, transition to a quieter evening routine by dimming the lights, playing quiet music, and engaging in an activity that doesn’t involve games but is still fun and low stress. These signals will give your loved one a sense of calm and indicate that it’s time to slow down. Avoid stimulating activities in the late afternoon and evening, such as TV, engaging games, or other activities associated with mental and physical ‘up-activation’ that add to agitation.
A cluttered or chaotic environment is likely to increase feelings of confusion and anxiety in someone with dementia, so ensure their space is uncluttered and clear of unnecessary items. In the evening curtains or blinds should be drawn to minimise shadows, which can be disorienting, and mirrors should be covered if reflections cause distress.
Sometimes, medications can cause or worsen sundowning symptoms. If you notice a link between your loved one having problems at certain times that coincide with medication, talk to your loved one’s GP about the medications and timing. The GP may be able to make some changes to the medications and timing to help control the sundowning symptoms. Remember to never make medication changes yourself.
Exercise is also a good way to encourage your loved one to get used to a regular sleep pattern and to feel less restless. Walking even 5 or 10 minutes a few times a day can help, as can stretching exercises.
Sundowning is a common and difficult part of dementia care. While it can be very difficult, having a good understanding of the underlying triggers can help you to support your loved one to cope with sundowning and improve their quality of life. Each person with dementia is different and what works for one person might not work for another. It can take time and patience to find the right solution, but in the end, it can make all the difference.
If you are struggling to support a love done with sundownng, Tiggo Care's dementia home care services are here to help. Our carers have experience and are knowledgeable about the special needs of those with the condition. We can provide compassionate, personalised support for them. We understand the obstacles you have to face, and we can help your loved one live safely and comfortably. We are here to help you care for your loved one. Contact us today to learn more.
Factors like fatigue, hunger, dehydration, or changes in daily routine can make sundowning worse. Low light levels in the evening, unfamiliar environments, and a lack of exposure to sunlight during the day can also contribute. Stress and overstimulation can further aggravate symptoms too.
Sundowning typically occurs in the middle to late stages of dementia. It’s more common as the disease progresses, though some may experience it earlier. The symptoms can intensify as cognitive decline worsens.
Consider home care when sundowning symptoms become difficult to manage on your own. If your loved one’s agitation, confusion, or anxiety increases, or if their safety is at risk during the evening hours, professional at-home support can provide relief and ensure their well-being.
Tiggo Care's at-home care options for dementia include night care, where support is provided during the night; live-in care, offering 24/7 assistance from a dedicated carer; and home care visits, where a carer visits regularly to help with daily tasks, ensuring comfort and safety in familiar surroundings.
Get in touch with Tiggo Care today to see how we can help you or your loved one.
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