Caring for a loved one with dementia can be a difficult challenge, especially when they experience sundowning. Sundowning (sometimes called sundown syndrome, sundown delirium, or sundowning dementia) refers to a set of behaviors that tend to occur in the late afternoon or evening hours. These include confusion, restlessness, irritability, or agitation. Such behaviors can be difficult for caregivers to manage, but they are common among people with Alzheimer’s disease or other types of dementia. 

While sundown syndrome can feel overwhelming at times, the good news is that caregivers can take steps to reduce its impact. One of the most effective strategies is maintaining a consistent daily routine. A predictable structure helps people with dementia feel more secure within themselves and less confused, which can ease sundowning symptoms. 

In this article, we’ll explore:

• What sundowning is
• The causes of sundowning and its symptoms
• How establishing a routine can help people with dementia and their caregivers

Interested in learning about tools, support groups, and resources that can make a real difference to your caregiving practice and the lives of your care recipients? Check if you have free access to Trualta. 

What Is Sundowning?

Sundowning is a term used to describe a variety of symptoms that occur later in the day, mainly in people with dementia. These symptoms can range from mild confusion to more noticeable behaviors like pacing, yelling, or becoming upset. For caregivers and their loved ones, these behavioral disturbances can be disruptive, exhausting, and frustrating, especially after a long day. 

The symptoms of sundowning often begin in the late afternoon or early evening. Some care recipients may experience symptoms daily, whereas others may only have occasional episodes. The exact timing and severity can vary depending on the individual care recipient and their environment. 

Recent research has shown that sundowning is experienced by around 1 in 5 patients with dementia. Compared with those who don’t experience sundowning, these patients:

• Tend to be significantly older
• Have a later dementia onset
• Experience greater cognitive and functional difficulties
• Wake up more frequently during the night
• Have more pronounced hearing loss

Sundowning Causes & Triggers

Although the exact causes of sundowning are not fully understood, researchers believe it may be linked to several factors:

• Disrupted internal clock: Dementia affects the brain’s ability to distinguish between day and night. The person’s ‘body clock’ or sleep wake cycle is impaired. They may feel tired during the day and awake at night, causing sleep disturbance.
• Overstimulation: Noise, crowded spaces, or busy environments can overwhelm a care recipient with dementia.
• Disturbed hormones: Reduced production of melatonin, an important hormone that controls sleep rhythm, can contribute to symptoms. 
• Insufficient sunlight: A lack of exposure to natural light during the day can make symptoms worse.
• Sensory impairment or deprivation: A person with hearing or vision loss is more likely to experience sundowning symptoms.
• Disorganized daily structure: An unorganized daily routine can cause stress and confusion. Your care recipient is often forced to deal with unexpected changes to the day, which can cause stress and anxiety.
• Exhaustion: Fatigue from the day’s activities can lead to sundowning symptoms like agitation, irritability, and confusion. 
• Unmet needs: Hunger, tiredness, pain, thirst, or discomfort can intensify the symptoms of sundowning.
• Low lighting: Shadows or dim lighting can create confusion or fear, which is a feature of sundowning. Inappropriate ambient light can also disrupt the ‘body clock’ and can even lead to hallucinations. 
• Mood disorders: Existing conditions such as depression or anxiety can contribute to symptoms. 
• Medications: Some drugs have side effects that can interfere with the natural sleep cycle and contribute to other symptoms as well. 

Understanding these causes and triggers is an important first step in managing sundowning, for both caregivers and their loved ones.

What Are Common Signs Of Sundowning?

Sundowning symptoms can vary, but common behaviors include the following:

• Increased restlessness, such as pacing and wandering around.
• Sudden mood changes, for example, irritability, crying, or agitation.
• Repeating questions or phrases over and over.
• Difficulty understanding things or following directions.
• Trouble settling down for the night.

Research has shown that symptoms such as agitation, irritability, and anxiety are experienced by around half of sundowning patients with dementia. As caregivers, recognizing these signs early can help you step in with calming strategies before the situation can escalate further. 

How Can Routine & Consistency Help Manage Sundowning? 

Having a routine provides a sense of structure, order, and predictability, which can be especially important for care recipients with dementia. When each day observes a similar structure, it’s easier for patients to feel stable, secure, less confused, and more relaxed. In this way, each day will involve doing the same activities at the same time.

A stable routine like this helps your loved one for the following reasons:

• Reduces anxiety: Observing familiar daily patterns helps minimize uncertainty for care recipients and promotes a sense of stability.
• Improves sleep: Having a regular schedule for meals, events, activities, and bedtime can help maintain a consistent sleep cycle. 
• Minimizes decisions: Making decisions can be stressful and overwhelming for a care recipient with dementia. Having a predictable schedule can reduce the need for decision-making. 
• Supports caregivers: Having a routine in place makes planning and organizing easier for caregivers and helps you manage your own stress.

How Can I Help Build Consistency?

Creating a consistent routine doesn’t have to be complex or long-winded. The goal is to create a balance of events and activities that keep your care recipient engaged without provoking undue stress and anxiety. 

In the morning, encourage your loved one to wake up at the same time each day. Keep personal care tasks consistent and simple. Make sure they eat a healthy breakfast at the same time each day.

The afternoon routine can include things that they enjoy, such as listening to music, folding laundry, or working on puzzles. Light physical activity, such as a short walk, can improve mood and benefit many other health conditions, too. A nutritious lunch should be provided.

In the evening, avoid loud or busy activities. Gradually reduce the brightness of ambient lighting to signal that bedtime is approaching. Follow the same steps each night, like listening to relaxing music or reading a book. 

Even small adjustments can make a big difference in managing sundowning. These might be things like serving dinner earlier in the evening to allow time for digestion before sleep. Blackout curtains can be used to block shadows and reduce confusion due to low light. These small changes can help create a smoother and more peaceful routine. 

Addressing Common Difficulties   

Sometimes, even with a consistent routine, sundowning behaviors can persist. Adjusting the environment or schedule can help minimize these. Triggers for sundowning behaviors can be managed by:

• Adjusting activities: If your care recipient becomes restless after certain tasks, try switching them to a different time.
• Limiting stimulants: Avoid caffeine (tea or coffee), sugar, and heavy meals later in the day. 
• Monitoring patterns: As a caregiver, keeping a journal of when sundowning happens and what may have caused it can be helpful. Look for patterns in lighting, activities, or noise in the environment.
• Creating a calm environment: Use warm, dim lights as evening approaches and turn off the TV or other distractions when sundowning symptoms present themselves. This will help limit late day confusion and mood disturbances. 

The Impact On The Caregiver

The demands of caregiving for someone with dementia can be physically and emotionally draining. It’s vital to remember that your well-being is just as important as your care recipient’s. You can promote your own self-care by:

• Taking strategic breaks: Use respite care or ask family members to help so you can rest.
• Joining a support group: Connecting with other caregivers can provide emotional support and valuable practical advice.
• Practicing mindfulness: Deep breathing, meditation, or a short walk can help reduce stress and anxiety. 

If sundowning becomes severe or unmanageable, it’s okay to ask for help. A medical professional or dementia specialist can recommend therapies, medications, or additional resources.

Conclusion

Sundowning is a common challenge in dementia care, but it’s not something you have to face alone. Understanding the triggers for sundowning and using consistent routines can help create a calmer and more stable environment for your loved one. 

Caregiving is a demanding role. It’s also an opportunity to make a meaningful difference in a person’s life. By being patient and planning appropriately, you can manage the difficulties of sundowning and improve the quality of life for you and your care recipient. 

Remember that resources, tools, and support are available for caregivers. Check if you have free access to Trualta. Reach out to healthcare professionals or caregiver networks if you need additional support. 

References

1. Volicer L, Harper DG, Manning BC, Goldstein R, and Satlin A. (2001) Sundowning and circadian rhythms in Alzheimer’s disease. Am J Psychiatry, 158(5), pp. 704-11. DOI: https://doi.org/10.1176/appi.ajp.158.5.704.

2. Toccaceli Blasi M, Valletta M, Trebbastoni A, D’Antonio F, Talarico G, Campanelli A, Sepe Monti M, Salati E, Gasparini M, Buscarnera S, Salzillo M, Canevelli M, and Bruno G. (2023) Sundowning in Patients with Dementia: Identification, Prevalence, and Clinical Correlates. J Alzheimers Dis, 94(2), pp. 601-610. DOI: https://doi.org/10.3233/jad-230094.

3. Guu TW, Aarsland D, and Ffytche D. (2022) Light, sleep-wake rhythm, and behavioural and psychological symptoms of dementia in care home patients: Revisiting the sundowning syndrome. Int J Geriatr Psychiatry, 37(5), DOI: https://doi.org/10.1002/gps.5712.