Sundowning is also known as early evening agitation. It usually happens between half past four in the afternoon and eleven o’clock at night, particularly in the autumn and winter months when the nights are drawing in.
There’s no clear definition of sundowning, it’s not a diagnosis. That means that the person with dementia wouldn’t be diagnosed with sundowning from a GP. It’s a descriptive term for a collection of behaviours that seem to have something in common but it still isn’t fully understood.
Signs and behaviours
Generally, the person may be more confused, more agitated and they may behave slightly differently from usual.
For example someone may
- Want to go home even they are home
- Ask for relatives such as a Mum, despite Mum having passed away some time ago
- Want a particular friend
- Pace
- Seem restless
- Go out the door and wander
- Be agitated, anxious and resistant
- Be suspicious, confused, paranoid
- Appear disorientated – not quite knowing where they are
- Have increased hallucinations
Effect on the carer
All of this can be a lot to deal with and to manage at a time, when, as a carer you are also getting tired yourself.
This time of day your own hibernation mode is kicking in and you just want to sit and put your feet up. Or perhaps you may be just beginning to cook the dinner; you might have different generations living together in the house who also need help and support. Maybe you’re trying to get a younger child ready for clubs or do their homework?
Don’t underestimate how difficult it can be and the impact it can have on you as a carer.
Why does it happen?
We believe sundowning results from a combination of factors:
Circadian rhythms
The combination of exhaustion or tiredness and disruptions to the circadian rhythm. Your circadian rhythm is basically your internal body clock. It tells your body when it’s time to wake, when it’s time to rest, when it’s time to sleep, and when it’s time to get up. The circadian rhythms can be affected by the changes in the brain caused by dementia.
Body temperature
Body temperature also increases in the early evening and that may have a relationship with sundowning. The body is quite literally getting overheated and can’t regulate in the way it should.
Seasonal light
The fading light of autumn and winter are also likely to have an effect. We know that dementia doesn’t come by itself, and a lot of people also have other age-related conditions. So, the fading light makes it a little bit more difficult to see things; we can all develop eyesight issues, but when you’ve got dementia on top of that, then you may not be able to interpret light and dark contrast, and may misperceive shadows.
Hunger
We often refer to the term ‘hangry’, when you get a bit crotchety! When you get hungry your blood glucose levels as well as your blood pressure drop and may cause some of the changes you see.
Pain
Pain is another consideration. A lot of people suffer with pain, and sometimes what we refer to as breakthrough pain; this is that half an hour or hour before the person is due to take their medications and the previous dose is beginning to wear off. During that time the person begins to experience niggling aches and pains and is just not able to sit and rest.
Boredom
Boredom can also be a contributing factor: when someone generally has a lack of occupation, a lack of ‘doing’ – particularly after a busy working life when this would have been the time you travelled home from work or started dinner. But with someone with dementia there is a fine line of how much stimulation should be provided.
Managing sundowning
Routine
Start in the morning and use a routine suited to the person’s needs that you stick to everyday.
Sleep hygiene
As much restful and restorative deep sleep as possible is needed.
Sleep can be really affected by the changes in the circadian rhythms and reduce the amount of restful and restorative deep sleep that someone with dementia usually gets.
We know that managing sleep, or “sleep hygiene” is really important and may require a conversation with a professional such as a community mental health nurse to support you.
Pain management
If you think pain may be an issue then speak to your GP, the district nurse or your mental health nurse.
Meaningful activity
Create opportunities for meaningful activity throughout the day. For example, if somebody has been out for a walk and then spent some time involved in an activity that means something to them, then they tend to have fewer sundowning behaviours in the evening.
Lighting
Try to close the curtains before it gets dark, but ensure there’s enough light. Lamps in a room are often not quite enough light. You might need to switch to a higher wattage light bulb or maybe put the big light on or an extra light.
This can help to reduce shadows which people may misinterpret causing them fear. This fear can sometimes be interpreted by those around them as potentially a psychotic episode when it isn’t.
An example is the shadow of branches from a tree outside causing shadows on a wall as cars go past, which could look like large arms, giant animals or beasts coming into the room. This type of challenge may be helped by good lighting in the room and blackout blinds or heavy curtains. Sometimes it can take a little bit of work to understand what might be going on, but it can really help to reduce agitation and upset.
Always think of the person, not the dementia
Think about the reasons that people do things. Could it be Pain? Could it be medication? Could it be depression? Could it be physical? Could it be lighting? Could it be that it’s too hot or too cold?
Is it because the atmosphere in the house isn’t calm enough? Have they had too much caffeine?
Are you using language that is too complicated when they are tired in the evening? Keep sentences and instructions clear and simple.
Thinking about what the person used to do in the evening before dementia can be helpful. Try to replicate these where possible.
Therapies
There are alternative therapies that you could try. These have varying amounts of evidence – some of them are more evidence based than others, but they are often worth trying.
Aromatherapy
For example, a little bit of lavender gives that calming effect.
Soothing music
Calm, soothing music can be incredibly powerful, and sometimes headphones can really help with this.
Simulated Presence Therapy
This is when a relative or friend seems present to the person with dementia but isn’t actually in the room. So they may be on Zoom, video or audio recording etc. You could also watch family videos, family DVDs or ask someone close to record a WhatsApp message to playback.
Toys
There is also evidence that things like fidgets, spinners, twiddle muffs, blankets, pets, things to play with can be beneficial.