What Is Sundowning in Dementia? Where Symptoms of dementia get worse at night | Causes & Treatment

[0:00]If you're caring for someone with dementia, you might have noticed that they've become confused, agitated, or even frightened just as the day starts to wind down. Often in the late afternoon or evening. This is a phenomenon referred to as sundowning. Sundowning is one of the most distressing behaviors linked to dementia, but with the right strategies, it can be understood and managed. By the end of this video, you should feel confident in knowing what sundowning is and how to better deal with it? I'm Dr. O'Donovan, a medical doctor here in the UK working in dementia care services. I've also looked after both of my grandmothers who had Alzheimer's disease, so I do understand how distressing some symptoms can be, both for the person living with dementia and for those who care for them. In this video, I'm going to explain what sundowning is, why it happens, what you can do to reduce it, and when to seek help if it gets worse. So first of all, what is sundowning? Well, sundowning refers to a pattern of increased confusion, restlessness, or distress that happens in the late afternoon, evening, or during the night. It might include agitation or aggression, hallucinations, which are when someone sees, hears, or feels things that aren't really there. So, for example, they might report seeing people or animals that no one else can see, or delusions, which are false beliefs that feel very real to the person, such as thinking someone is stealing from them or that a loved one has been replaced by an imposter. They might also be pacing or wandering, have difficulty sleeping, or even be disorientated or anxious. Now, although it's called sundowning, it isn't always tied to sunset and it can sometimes happen earlier or later, and it's most common in the middle to later stages of dementia. So now that you hopefully have a better idea as to what sundowning is, well, what causes sundowning? Well, the exact cause isn't fully understood, but several factors can contribute. These could include fatigue or exhaustion after a busy day, hunger, thirst, pain, or even needing the toilet. Low light and shadows can also cause confusion, as well as overstimulation or too much noise, a disturbed body clock or disrupted sleep cycle, hearing or vision problems, and emotional stress from carers or the environment can also contribute to sundowning. Now, the key point to note is that each person's experience is different. Observing the person closely can help identify possible triggers. If you know the person well, try work your way through some of these causes and try figure out which it might be, noting that it could also be more than one reason. So now that you hopefully have a better idea of what sundowning is, well, let's cover some tips to try and help reduce sundowning. Well, sometimes what seems like sundowning is actually the person just trying to communicate a need. So here are some tips that can help, which I've split down into what to do during the day, what to do in the evening, and then what to do if the person becomes agitated. So during the day, try to keep a regular routine for meals, activities and bedtime, plan busy or stressful tasks for earlier in the day. Encourage daylight exposure by going outdoors or sitting near windows, try to offer a larger lunch, but then a lighter evening meal, and try to avoid long naps in the afternoon, if nighttime sleep is disturbed. Now in the evening, you should try to keep the home well lit to reduce shadows, close curtains and cover mirrors or screens, avoid noisy or overstimulating activities like TV or loud music. Try to offer calming routines like looking through photos, soft music or gentle conversation, and avoid caffeine, alcohol and nicotine. And importantly, try to stick to the same routine each evening. Now things won't always work out the way that you hope and that is fine. You need to give yourself grace and understand that this is not yours or their fault. And if the person you are caring for does become agitated, try to do the following. Firstly, stay calm and speak gently. If your loved one is agitated or confused, try to keep the tone of your voice steady and soft. For example, if they're shouting because they might have thought you've stolen their purse, instead of reacting sharply, you might calmly say, let's have a look together. I'm sure it is somewhere safe. Keeping your own emotions in check can help deescalate the situation. Now next, try to avoid confrontation or arguing. Even if what the person says isn't true, arguing usually makes things worse. For example, if they insist they need to leave to pick up their children, even if their children are now adults, don't correct them. Instead, try saying something like, that sounds important. Let's have a cup of tea or coffee first and then we can talk about it. This approach respects their reality without increasing their distress. Next, try to offer reassurance and redirect attention. So when someone is anxious or upset, reassuring them and gently shifting focus can be very effective. For example, if they're frightened because they don't recognize their surroundings, you might say, you're safe here. I'm right here with you, and then offer to sit together and look at a favorite photo album or listen to calming music. This can help them feel more secure and less focused on their fear. Next, supervise pacing if needed, but avoid physical restraint. If the person is walking up and down restlessly, try to stay nearby in case they need help or become tired, but don't try to force them to sit down. For example, you might say, shall we walk together for a bit, or gently offer a drink and a seat after a few minutes. Physically restraining someone can increase fear or even cause harm. And finally, try to check for basic needs, things like the toilet, hunger, temperature, and importantly, pain. Sometimes distressing behavior is actually caused by a really simple unmet need. For example, if they're fidgeting or trying to leave the house, they might just need the toilet, so you could gently ask, do you need the bathroom? Or if they're unusually irritable or confused, check whether they might be hungry, too hot or cold, or in discomfort from something like back pain or sore feet. Meeting these basic needs can often ease agitation without needing any other intervention. And finally, when should you speak to the care team, including the doctor? Well, the first thing to state is that you should always feel able to approach the care team and you shouldn't have to do this whole thing alone. But it is especially important to talk to a doctor if sundowning becomes frequent or severe, the person you're caring for has sleep difficulties or becomes very distressed at nighttime, or you suspect an underlying health problem like an infection such as a water infection, constipation, or pain. The doctor may review medications or check for other causes. Now, most experts recommend non-drug approaches first, but sometimes medication may be considered for severe symptoms. I do understand and know from firsthand experience that sundowning can be a very distressing part of dementia, but it is manageable. With a calm environment, a consistent routine, and personalized care, many people find that it becomes more predictable and easier to handle. If you found this video helpful, please do reach out and leave a message in the comment section. It would be great to hear from you and I would welcome the chance to say hi and welcome you personally into this community. Finally, if there are other topics that you'd like me to cover, please do let me know what they are and I'll aim to make a video on these. Take care and please do remember that support is always available and you're doing a great job.