Sundowning in dementia patients describes the behaviour of people with mid to late-stage Alzheimer’s and dementia who experience greater confusion as the sun sets. Also known as late-day confusion, the different feelings and thoughts people with dementia can experience lead to various behaviour patterns.
Carers whose patients have sundowning dementia are trained to employ particular routines to help them through this difficult period.
What is sundowning?
Around 20% of people diagnosed with Alzheimer's experience sundowning. It is the name for a spectrum of behaviours, thoughts and feelings at sunset. As the dementia progresses, symptoms can get worse.
At this time of day, people with dementia can become agitated, hyperactive and confused. The symptoms can include pacing up and down, rocking in chairs, wandering, violence, shouting, crying and following their caregiver around very closely.
Symptoms can continue into the night, causing sleep disruption. People with Alzheimer's commonly have problems with falling and staying asleep. Their sleep schedule may change over time as their condition worsens.
Scientists don't fully understand why the sleep disturbances occur. However, different sleep patterns are caused by the impact of Alzheimer's on the brain.
Sleep deprivation is believed to be a trigger for sundowning, but there are other possible triggers such as the side-effects of medication, infections, dehydration, overstimulation during the day in a busy environment, physical illness and low lighting.
At what stage of dementia does sundowning occur?
While sundowning can occur at any stage, it's more likely to happen during the middle and later stages. Once it begins, it can potentially occur every afternoon and early evening.
A sundowning episode can last for many hours, greatly impacting sleep for the person with dementia and the carer. When the person with Alzheimer's is awake at night, the carer will have to remain alert to keep the patient safe.
Is sundowning only associated with dementia?
While it occurs in people with dementia and Alzheimer's, it can also affect older people in general. However, it is prevalent mainly among people with dementia.
Sometimes it can be hard to diagnose, as some of the behaviours may not be specific to the condition. They can also be present in people with Parkinson's disease, delirium and some sleep disturbances.
However, it can be distinguished from other conditions because of the time when the symptoms begin. Characteristically disruptive behaviours tend to begin specifically in the late afternoon, during the evening and at night.
Is there a treatment?
The primary method of managing sundowning is by addressing the root causes. As a carer, how you approach it largely depends on the individual patient. Every person with dementia is different, so it can help to keep a diary to help identify the symptoms and triggers. However, in general, you should stay calm, introduce positive routines, stick to good sleep habits and ensure the environment is peaceful.
Health workers have found a variety of options have been helpful for sundowning dementia treatment including light therapy, melatonin and encouraging behavioural modifications through positive reinforcement.
Improving the patient's general wellbeing has the twofold effect of reducing the strain on the caregiver and potentially delay institutionalisation.
Research is continuing into the risk factors of sundowning and potentially effective treatment options.
Geriatric clinicians have observed the symptoms of what is now called sundowning in elderly patients as long ago as the 1940s. Donald Ewen Cameron, a Scottish psychiatrist, described the condition as "nocturnal delirium" in 1941. He observed symptoms such as agitation and delirium that had set in "within one hour of darkness" among elderly patients.
Developments in research over the past 80 years have helped formulate treatment plans, but in many ways, the phenomenon of sundowning still remains something of a mystery.
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