Sundowning and dementia

We can all experience changes in our mood, energy levels and behaviour as the day goes on, but those living with dementia can be especially affected as daylight begins to fade. They can become increasingly anxious, agitated or confused throughout the day, starting in the late afternoon and worsening into the night. This is called ‘Sundowning’ or ‘late-day confusion’ and often happens in the middle and later stages of dementia. 

What is Sundowning? 

Sundowning is a term used to describe changes in behaviour that affect people living with dementia as the day goes on. Often, as the day progresses, the person living with dementia becomes increasingly agitated, confused, or aggressive. They may begin having hallucinations or start shouting. These are all signs that the person may be experiencing Sundowning.  

There are lots of reasons why Sundowning occurs, and it can be difficult to understand for anyone caring for somebody who is experiencing it. It’s important to note that the behavioural changes seen will vary from person to person, and that the duration of symptoms may be different each day. You may find that some symptoms stop abruptly, while others fade over time or change, and new symptoms appear without warning. You might also notice that the symptoms of Sundowning are worse if the person with dementia is tired, hungry, thirsty, or in physical pain. 

What are the symptoms of Sundowning? 

Common symptoms of Sundowning include: 

• Wanting to go home, even if the person is already at home 
• Saying they need to pick the children up from school or go to work, even when this is not the case 
• Becoming increasingly agitated in the afternoons  
• Pacing around the room 
• Becoming argumentative or aggressive, particularly later in the day 
• Getting increasingly confused 
• Suffering hallucinations 
• Shouting 
• Generally being in a bad mood 

What causes Sundowning? 

Nobody knows for certain why Sundowning occurs, but some researchers believe it is caused when the physical changes to the brain associated with dementia begin to affect the person’s circadian rhythm. The circadian rhythm is the body’s natural clock, which tells us when to go to sleep and when to wake up, and any disruption to this natural rhythm can have an impact on our mood. If you have ever been on a long-haul flight, you may have experienced a disruption in your circadian rhythm and will know that it can leave you feeling frustrated and irritable. People living with dementia are often unable to put these feelings into words and instead act them out through their behaviours. 

Other causes of Sundowning may include: 

• Loss of routine 
• Not enough sleep, or sleep that is disturbed 
• Too little or too much light 
• Prescription medication wearing off 
• Medications that cause increased confusion or agitation 
• Lots of noise 
• Conditions such as sight or hearing impairment 

How to support someone experiencing Sundowning 

Is it really Sundowning? 

Unfortunately, there is no test to determine if someone is experiencing Sundowning, and there is no clear way of predicting the onset of Sundowning behaviours. That means it’s important to remember that even if a behaviour looks like Sundowning, it could be something else entirely.  

If the person living with dementia is trying to meet a need, for example, they may be struggling to communicate this and they may begin displaying Sundowning-like behaviours. If it’s late afternoon and the person you are caring for becomes agitated or confrontational, think about what else might be causing this change in behaviour. Could they be hungry or tired? Do they need to go to the toilet? Might it be that their medication is wearing off and they are experiencing physical pain or discomfort? Always try and rule out every other possible reason for the person’s behaviour before putting it down to Sundowning. 

Create a safe space 

It can sometimes feel like the sensible option is to try and change the Sundowning behaviours, but this can often have the opposite of the desired effect. Trying to make the person feel better can actually make them feel like you are trying to control or manipulate them, and this may lead to them becoming upset or aggressive. Likewise, trying to argue or reason with them may increase their agitation. 

Instead, try and remember that any behaviours that don’t make sense to you might be exactly what that person needs in the moment to help them feel calm, happy or reassured. If they want to pace or do something repetitive with their hands, let them. Create a safe space where they can comfort themselves, and give them the freedom to do it for as long as they need to.  

Some other useful things to try include: 

• Asking the person what the matter is. Listen carefully to what they tell you and try to deal with the source of their distress.  
• Talking in a slow, soothing way. If it helps, you can hold the person’s hand, or sit close to them and stroke their arm. 
• Supporting the person to do something they enjoy doing at that particular time of day – that might be going for a walk, supporting them to have a bath, or watching a certain television programme. 

Validate, reassure, distract 

When caring for a person experiencing the symptoms of Sundowning, a good process to follow when supporting them is to validate, reassure and distract.  

Start by validating their feelings, as this will let them know that what they are going through is real and that you understand they are struggling. Saying something like, ‘It sounds like you’re feeling really anxious right now, and that’s OK,’ can be the beginning of helping to soothe them. 

Next, reassure them that everything will be OK, and do what you can to help them feel safe and comfortable. Remove anything from the room that might be causing the person distress or anxiety, and put on some music or a television programme that you know calms them. 

If this doesn’t work, try distracting the person by offering them a drink or a snack, looking at photographs together or getting them outside for a walk. As the caregiver, you know the person with dementia, so trust that you know the best way of supporting and comforting them through their Sundowning. 

Techniques for helping someone experiencing Sundowning 

Sundowning is not a simple condition, but it is a common one. As a caregiver, please remember that you are not alone, and that what works for one person may not work for another. Everyone’s experience of Sundowning is different, and the things that will help alleviate the symptoms will differ from person to person too. 

Some studies suggest light therapy can help reduce agitation and confusion in people with dementia and, although it is not proven, you could certainly try brightening the lights when your loved one begins to feel confused or agitated. If this technique works, you could consider doing this pre-emptively, closing the curtains and turning on the lights before dusk to ease the transition into evening. 

Some other techniques to try include: 

• Following a routine in the day that includes activities the person enjoys. 
• Supporting the person to get as much natural daylight as possible, as this can help. Go outside for a walk with them if they are able, and make sure curtains are open in the daytime. 
• Limiting the person’s intake of caffeinated drinks to aid better sleep. 
• Limiting the number and/or duration of daytime naps to encourage better sleep at night. 
• Introducing an evening routine that includes activities the person enjoys and that will provide comfort before bedtime. 
• Avoiding large meals in the evening, as this can disrupt sleep patterns. 

Talk and listen 

As a caregiver for someone living with dementia, you know that communication is the most important aspect of supporting them. If your loved one begins displaying behaviours you suspect are symptoms of Sundowning, it’s even more important to make sure they feel heard and comforted at every turn. 

For tips on how best to communicate with the person you are supporting, see our blog post Keeping connected: communicating effectively with people living with dementia. For further support, please get in touch with our experienced and friendly team. As a specialist provider of dementia care at home, Allied Hands delivers a pioneering and personalised service to people across Leeds, and we’d love to know how we can help you.  

Call us today on 0113 837 0133