Sundowning describes a pattern of increased confusion and behavioral changes that can occur in individuals with cognitive impairment, particularly those with dementia. This phenomenon typically manifests in the late afternoon or early evening and often extends into the night. It is not a disease itself, but rather a collection of symptoms that emerge at a specific time of day.
What Sundowning Means
Sundowning, also known as sundown syndrome, is characterized by an increase in confusion, agitation, anxiety, and other behavioral disturbances that typically begin as daylight fades and can continue throughout the night. These symptoms are most commonly associated with Alzheimer’s disease and other forms of dementia, affecting a significant portion of those diagnosed, with estimates suggesting that 20% to 45% of people with Alzheimer’s disease will experience some variation of sundowning.
Common behaviors observed during sundowning episodes include:
Restlessness, pacing, and wandering, sometimes with an attempt to leave the home.
Increased irritability, shouting, crying, or emotional outbursts.
Confusion about their surroundings, repetitive questioning, hallucinations, or delusions.
While some symptoms, like confusion, are generally present in dementia, their intensification and predictable timing in the late afternoon or early evening are what distinguish sundowning. The onset of these symptoms often occurs between 4:30 PM and 11:00 PM, worsening as day turns to night. Although sundowning can occur at any stage of Alzheimer’s disease, it tends to be most prevalent during the middle stages. The behaviors typically subside by morning, but they can be distressing and disruptive for both the individual and their caregivers.
Factors Contributing to Sundowning
Several factors can contribute to sundowning behaviors. One significant aspect relates to disruptions in the body’s internal clock, also known as circadian rhythm. Damage to the suprachiasmatic nucleus (SCN) in the brain, which regulates sleep-wake cycles, and decreased melatonin production can interfere with the body’s ability to differentiate between day and night.
Physical and emotional states also play a role. Accumulated fatigue throughout the day can diminish coping mechanisms and worsen cognitive function in the evening. Unmet physical needs, such as hunger, thirst, or pain, can exacerbate agitation and confusion. Emotional factors like anxiety, fear, insecurity, or depression can also trigger or intensify sundowning symptoms.
Environmental elements frequently act as triggers. Diminishing natural light and increasing shadows in the late afternoon can be disorienting and increase anxiety. Overstimulation from a busy environment or, conversely, understimulation and boredom can contribute. Additionally, side effects from certain medications can sometimes cause confusion or agitation, further contributing to sundowning.
Approaches to Managing Sundowning
Managing sundowning involves non-pharmacological strategies to create a more predictable and calming environment. Establishing a consistent daily routine for meals, activities, and bedtime provides a sense of security and helps regulate the individual’s internal body clock. Scheduling stimulating activities, such as doctor appointments, earlier in the day when the individual is more alert is also beneficial.
Optimizing the physical environment is another strategy. Maintaining good lighting in the evening can minimize shadows and reduce disorientation. Creating a quiet and calm atmosphere by reducing noise and clutter, and playing soothing music, can help prevent overstimulation. Ensuring the bedroom is conducive to sleep, with a comfortable temperature and nightlights, promotes better rest.
Engaging in appropriate daytime activities, including physical exercise and mental stimulation, helps improve sleep quality and reduce evening restlessness. Even simple tasks like folding laundry or going for a gentle walk are helpful. Addressing comfort and safety involves regularly checking for unmet needs such as pain, hunger, thirst, or the need to use the restroom, as these contribute to agitation.
Communication techniques are also important; approaching the individual calmly, speaking in a soothing voice, and using simple sentences helps reassure and redirect them. Limiting stimulants like caffeine and sugar, particularly in the afternoon and evening, supports better sleep patterns. If sundowning symptoms are persistent, severe, or suddenly worsen, consulting a healthcare professional is recommended to rule out other medical causes like infections or to discuss potential medication adjustments.