Sundowning: Strategies to Help Seniors Manage

As dementia and Alzheimer’s disease begin to progress, some individuals may start to become more confused, anxious, or restless in the early evening hours to the in the day. This is referred to as Sundown Syndrome or sundowning.

Sundowning can be challenging for both caregivers and their loved ones – especially if the irritation leads to someone becoming more physically and verbally aggressive.

Our long-term care experts at Rochester Regional Health explain how to recognize the early signs of sundowning, how to avoid triggers, and ways you can reduce sources of agitation for your loved one.

Recognizing early signs of sundowning

Sundowning often begins in the later hours of the afternoon but can also be tied to disruptions to routine and growing fatigue throughout the day. As this transition begins, you may notice some of these changes:

• Difficulty sleeping
• Feeling disoriented
• Hallucinations
• Shadow misinterpretation (thinking someone or something is there)
• Increased agitation or restlessness
• Increased confusion and question asking
• Pacing or wandering

“It’s like a flick of a light switch,” said Gulsah Bay, RN, a nurse educator who works in long-term care at Edna Tina Wilson Living Center. “They will begin to have mood swings that seem to come out of nowhere.”

Causes or triggers of sundowning

While the exact neurological causes behind sundowning are not fully understood, there are many physical and environmental factors that influence sundowning episodes. Some of these include:

• Circadian rhythm disruption
• emotional factors
• environmental overload
• fatigue
• medication timing/side effects
• sensory changes
• unmet needs

Changes in the behavior of a dementia or Alzheimer’s patient can often be linked to the ongoing changes in their brain combined with their environment and needs that are not being met.

Ways to reduce the likelihood of sundowning

The first steps you can take to help your loved one manage sundowning is to create a consistent routine and environment for them.

Do things early: Schedule daily activities such as doctor’s appointments, grocery shopping, or other regular events during the morning or early afternoon hours.

Make sleep a priority: While older adults need less sleep, getting enough rest is important to avoiding aggravation. Setting a consistent sleep schedule can help with emotional regulation. Avoid napping in the afternoon.

Bring in natural light: Natural light has a calming effect for most people, including older adults. Opening the curtains to let light in and sitting near a window can make a difference.

Support routines: Create a routine and stick to it. One of the sources of frustration for people with dementia and Alzheimer’s is constantly living in the unknown. The more secure they feel, the less irritated they will be.

“If possible, have an evening routine that includes the same individuals so they aren’t confused even more,” said Ali Smetanka, lead nurse educator with Rochester Regional Health’s Long-Term Care program.

Do physical activities: Moving your body helps to reduce dementia risk, according to research. Whether it’s a walk, lifting weights in the living room, riding a bicycle, or another form of exercise, moving your body is a good and healthy thing.

Identify patters & triggers: Noticing the environment around a person with dementia and what their routine looks like consistently can help you figure out when something different is happening that may throw them off. If meal times, social schedule, or the number of interactions with people change drastically, taking note of what is normal and what is not can help return your loved one to a state of better emotional regulation.

Things that may make sundowning worse

Some people may have specific habits or activities that make their agitation or irritation worse. These may include:

• Dark, poorly lit rooms
• Drinking alcohol or caffeine late in the day
• Going out into loud public spaces
• Long days with packed social schedules
• Loud activities such as blaring music, TV shows, or other forms of stimulation
• Medication interactions
• Taking long naps
• Tobacco use

If you start to notice your loved one becoming more frustrated or agitated later in the day, take note of what may have led up to the situation.

What to do when sundowning irritates someone

It is normal to feel frustrated during sundowning behaviors. Before you react, take a breath and remind yourself that the behavior is a symptom, not intentional.

The most important thing to remember is to avoid being irritated or short with your loved one. They are already stressed, confused, and frustrated.

First, check on their basic needs and see if there is anything that may not be met. Are they hungry, thirsty, in pain, or uncomfortable? Are they overstimulated or need a quieter environment, or understimulated and need something to do?

Always try to be a neutral source of calm for them. Approach them calmly and ask them what they need.

“We encourage caregivers to say the phrase, ‘Tell me about it,’” Smetanka said. “Instead of arguing or correcting, encouraging them to share their story or concern of what's going on helps to reduce their anxiety and better meet their basic needs.”

Reassure your loved one that they are safe, and everything is okay. If they need to walk around and pace, give them the space to do so. Redirect them gently and offer a familiar task or calming environment for them to focus on that will help to bring them to a place of feeling more emotionally regulated.