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Sundowning is an unexplained worsening of symptoms of dementia late in the afternoon and in the evening. People who have dementia may become more agitated as daylight wanes. Here are eight things you can do to make their care easier.

Sundowning is a complication of Alzheimer's disease and many other forms of dementia. The condition is sometimes termed "late day confusion." When someone who has dementia is sundowning, their symptoms tend to be worse later in the day and better earlier in the day,

There is no single accepted definition of sundowning. Some doctors use the term to refer to worsening agitation, while others characterize sundowning as the worsening of any symptom of dementia late in the day. However you define the term, there are many behaviors associated with dementia that can get worse later in the day:

  • Agitation
  • Aggression
  • Anxiety
  • Hallucinations (both auditory and visual)
  • Pacing
  • Compulsive masturbating
  • Resistance, screaming
  • Yelling
  • Wandering away
"Executive function" needed to make good decisions may be be worse in the evening and better in the morning. These symptoms sometimes emerge later in the evening, just before midnight.

Sundowning is very common. One study found that 60 percent of dementia patients who still live in their homes sundown. On any given day, about 20 percent of people in nursing home care for dementia may display the condition. The challenge of sundowning to caregivers is that symptoms are worst when the caregivers are at the end of their day shift, when they are most fatigued. Sundowning contributes to burnout in people who take care of dementia patients, and is associated with worse outcomes for the patients themselves.

What can be done about sundowning? Here are eight suggestions.

Minimize late-day stress

Save challenges for the middle of the day. Most dementia patients need a relaxed, regular morning routine to avoid agitation. They also need a predictable late day routine to unwind for the night. That leaves the middle of the day for doctor's appointments and changes in routine to minimize agitation. 

When there are signs of tension, take some time to do something relaxing with the patient. Read them a book. Play a game. Work on arts of crafts. Schedule a visit with a dog or a cat. Defusing stress and agitation early can prevent sundowning later.

Turn up the lights, turn down the lights

Two hours every morning in bright sunlight or about a meter away from a sun lamp resets the biological clock so the dementia patient is less prone to sundowning. It's important to have bright light in the morning, every morning. Then it helps to lower ambient lighting as the sun sets. At bedtime, it is particularly important to eliminate blue lights, which keep the brain awake. Nightlights need to be yellow. Should the dementia patient wake up near midnight and want to start the next day's activities, don't make bright lights available to them.

Stick to a routine

People who have dementia have difficulty maintaining old habits, much less learning new ones. Do things at the same time every day. Avoid "help" from well-intended people that disrupts schedules. Many people who have dementia react to changes in routine as threatening, with anger, anxiety, and acting out. Making needed changes to schedules gradually reduces the severity of their reaction.

Structure the patient's time

Many people who sundown are tired during the day because they are active at night. However, daytime activities in nursing care are not conducive to napping. The result can be a vicious cycle leaving the patient with very few opportunities for uninterrupted sleep at night and very few opportunities for uninterrupted activity during the day. This makes keeping doctor's appointments and interacting with visitors a challenge, too. 

You can help break this cycle by adding structure to the patient's day. This doesn't mean you come in with a checklist and a coach's whistle. What you can do is to add gentle structure to the patient's day. Come in for a visit at a regular time. Take a walk with them. Have a cup of tea with them. Enjoy some simple activity with them. Do this every day at the same time if you can. Of course, you have to achieve regular schedules in your own life to help with your loved one's schedule.

Provide familiarity

Make sure the patient has objects they recognize from their home. These don't have to be heirlooms. They shouldn't be breakable or capable of being used as weapons. Priceless photos should be photocopied and presented on a memories board. This is especially important for people who have dementia who are being placed in a new care facility or who have to go the hospital.

Pay attention to patterns

Different dementia patients have different triggers for sundowning. Sometimes it's stormy weather.  Sometimes it's the natural progression of the seasons as days get shorter. A loud incident with other patients, the arrival of an ambulance, a holiday celebration, or a challenging visitor can trigger sundowning and agitation. You may not be able to stop these triggers, but you can be prepared to compensate for them if you notice patterns.

And avoid your own overwhelming fatigue

Finally, don't forget to take care of yourself. Taking care of someone who has dementia can turn into a 24/7 job. You need to be rested to deal with your own stresses and provide better care for the elder you love.

  • Canevelli M, Valletta M, Trebbastoni A, Sarli G, D'Antonio F, Tariciotti L, de Lena C, Bruno G. Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches. Front Med (Lausanne). 2016 Dec 2.3:73. doi: 10.3389/fmed.2016.00073. eCollection 2016. Review. PMID: 28083535.
  • Khachiyants N, Trinkle D, Son SJ, Kim KY. Sundown syndrome in persons with dementia: an update. Psychiatry Investig. 2011. 8(4):275–287
  • Rathier O, McElhaney J. Delirium in Elderly Patients: How You Can Help. Psychiatric Times. 2005.
  • Photo courtesy of SteadyHealth

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