Caring for a person with Alzheimer’s disease or dementia is challenging, and you may find it becomes even more difficult later in the day, due to a phenomenon known as “sundowning.”
Sundowning is not a medical diagnosis but rather a description of symptoms that can happen to some people with dementia in the late afternoon and evening.
“People can have agitation, irritability, confusion, anxiety and aggression as a reaction to their environment and because of an unmet need,” says UNC Health family medicine physician and geriatrician Philip Sloane, MD, MPH.
Dr. Sloane explains why these symptoms tend to happen near the end of the day, and what you can do to help someone experiencing them.
Understanding When and Why Sundowning Symptoms Occur
Paying attention to when sundowning symptoms occur can help you identify what might be triggering them.
Between 3 and 5 p.m. are common hours for sundowning symptoms in nursing homes, Dr. Sloane says.
“A shift change traditionally happens around 3 p.m.,” he says. “Staff are having meetings; some people are leaving. There can be a lot of commotion, and that can affect mood or cause confusion. Someone might worry that no one is taking care of them, or they might think, ‘I should get up and go home, too.’”
This change in staff also coincides with a typical lull in activities and interaction as well as the time that a person may be feeling most tired. Fatigue combined with that lack of attention can be upsetting.
“At nursing homes, activities tend to peak in the mornings, with a much lower number of activities in the afternoon,” Dr. Sloane says. “People with Alzheimer’s disease often have a problem initiating meaningful activity, so they can get restless for this reason as well. Or they might just be tired, and that makes them agitated.”
Even if your loved one isn’t in a care facility, they may feel that same late-afternoon exhaustion, and it might be combined with changes in a household, such as children coming home from school or an adult coming home from work.
Sundowning symptoms also tend to occur around the time of the actual sunset, typically after dinner. As with late afternoon, the after-dinner hours usually don’t offer much in terms of activities, and a caregiver’s attention can be divided if they have other people to put to bed. If a person with dementia is left to their own devices, they may pace, wander, follow their caregiver, cry or yell.
Lastly, you may observe sundowning symptoms throughout the night.
“Some people with dementia just don’t sleep well,” Dr. Sloane says. “We know from studies that people with Alzheimer’s disease have an inherent circadian rhythm that’s very chaotic, so they’re just as inclined to be active at midnight as they are at noon. If they’re not sleeping, they might get up and become agitated that nothing is going on.”
It can take only a moment of distress for these symptoms to start.
“If a person with dementia can’t remember what happened last and isn’t sure what will happen next, they’re very rooted in what’s happening at that moment,” Dr. Sloane says. “If the moment gives them fear, anxiety or confusion, they’ll show these symptoms.”
Preventing Sundowning Symptoms
Paying attention to the environment and a person’s schedule can help to prevent symptoms of sundowning. Some nursing homes have become more mindful about how they conduct shift changes so that the environment is less disruptive, Dr. Sloane says. Similarly, family caregivers at home can work to support more traditional circadian rhythms in people with dementia.
“Exposure to light in the morning resets our internal clock, but people with dementia often don’t go outside very much, even when they’re cared for at home,” Dr. Sloane says. “It can help them sleep better at night if they get some daylight in the morning, and then stay active and stimulated throughout the day.”
Caregivers should consider whether a short afternoon nap is beneficial to improve the person’s fatigue, or if they’d be better served staying up so they’ll be more tired at night. It’s also important to consider when there are gaps in a person’s schedule that could benefit from activities or more one-on-one attention. (Of course, as a caregiver you might not have any more time or attention to give; talk to the patient’s doctor to identify more resources and don’t be afraid to ask for help.)
A regular bedtime routine and a soothing sleep environment is important at night, but it’s not always enough. Ask for a doctor’s help if your loved one has trouble sleeping.
“Caring for people with dementia at night can be the hardest part,” Dr. Sloane says. “Nothing consistently works to help them sleep, and then something that does work can no longer work when the disease changes. Being a caregiver takes ongoing problem-solving and lots of patience.”
Helping a Person Experiencing Sundowning Symptoms
If someone is showing symptoms of sundowning, the best approach is to remain calm and provide undivided, one-on-one time, even if it’s not always the easiest.
“Engage with them, talk with them, figure out if they have an unmet need, like hunger,” Dr. Sloane says.
If the symptom is new, see if you can identify what might have caused it, so you can anticipate or prevent it in the future.
“Be a detective about what in the environment led to this response,” Dr. Sloane says. “Maybe they needed help going to the bathroom but couldn’t verbalize it, so they became agitated. Maybe the telephone rang, and they used to have a job where they answered phones, so that sound caused anxiety.”
Even if you can’t stop every phone from ringing, seeing the cause and effect can help you to remember that these symptoms aren’t a personal response to you, which can help on days when caregiving is especially tough.
“Consider the external things, like people, lights, sounds, and the internal things, like hunger or fatigue,” Dr. Sloane says. “There’s not always a solution, but try to see the big picture of their environment at that moment.”
If you’re concerned about symptoms of dementia, talk to your doctor. If you need a doctor, find one near you.