Sundowners Syndrome and Dementia

What is Sundowners Syndrome (Sundowning) and Its Relation to Dementia

Sundowners syndrome, or Sundowning, is the increased confusion, agitation, and restlessness of people with dementia during the late afternoon or evening hours. It is not a disease; it is a complex symptom, all too common to Alzheimer’s disease and other types of dementia. Knowledge of Sundowners syndrome is important to the care provider and healthcare workers because it influences the quality of life both for the person with dementia and for the care provider themselves.

What is Sundowners syndrome?

Sundowners syndrome is characterized by a noticeable behavioral change over the course of the day. Individuals with dementia might be relatively calm and coherent during the day, but they become extremely anxious, confused, or even aggressive as the sun sets. It is this shift in behavior that usually occurs in the late afternoon or early evening and can prevail throughout the night.

Symptoms of Sundowners Syndrome

The symptoms of sundowners can vary from person to person. However, there are certain signs that the attending family members or caretakers can be aware of to manage the behavior changes:

Increased Confusion

• Memory Lapses:

  An affected individual might forget what time it is, where they are, or why they are in a particular place. This kind of thing can escalate to the extent that they become frustrated or even start to panic.

• Difficulty Identifying Faces and Places:

  An individual might misidentify some people well known to them and sometimes misunderstand places. Such incorrect identification of places and people can lead the person to feel totally lost, even in familiar surroundings.

Agitation and Restlessness:

• Pacing:

  This will involve walking up, down, or around the house in a repetitive manner. This might be their way of trying to cope with anxiety or restlessness.

• Fidgeting:

  Moving the hands, picking at clothes, or tapping fingers might portray that the individual is agitated or uncomfortable.

• Cannot Stay Calm and Relaxed:

  Even when a person is tired and wants to rest at night, they might not be able to calm down and relax.

Mood Swings:

• Sudden Irritability:

  A person who has been calm the whole morning may suddenly get irritated, snapping at caregivers at the slightest instances.

Read More about Dementia and Mood Swings.

• Anger or Aggression:

  Individuals from this group may react to their confusion and frustration with anger at their caregiver, family members, or objects around them.

• Depression or Withdrawal:

  On the other hand, some individuals may become very quiet and often become depressed, feel hopeless, or want to be left alone.

Read in detail about dementia and mood swings.

Hallucinations and Delusions:

• Visual Hallucinations:

  This is also a common symptom where a person with dementia may see things that are not there. Such things may include animals, shadows, or people around the room or outside. These hallucinations can be disturbing for the person and may cause more agitation.

• Auditory Hallucinations:

  This includes hearing sounds that do not exist, such as voices or noises. This can also confuse or distress the person.

• Delusional Thinking:

  The person may have very strong beliefs that are not based in reality. These can include perceiving danger to themselves, someone meaning to hurt them, or a need to leave the environment immediately.

Sleep Disturbances:

• Disturbances of Sleep:

  The anxiety and restlessness can make it difficult to start sleeping, even when fatigued.

• Waking Up Frequently:

  Some people wake up several times per night. At such times, they may feel fear or even disorientation.

• Nightmares/Night Terrors:

  One can get up and panic from bad dreams, leading to sleep disorders.

Causes of Sundowners Syndrome

Even though the real cause of Sundowners syndrome (Sundowning) is not known, several factors are believed to contribute to its onset. The different underlying causes that are known can help one manage and mitigate the symptoms associated with Sundowners syndrome. These include:

Disruption of Circadian Rhythms:

• Internal Clock Impairment:

  The internal clock situated in the brain, which forms a person’s sleep-wake pattern, can get impaired in those suffering from dementia. Disruptions in the internal clock make the body unable to tell between day and night, causing confusion and disorientation in the evening hours.

• Melatonin Production Decrease:

  As one ages and the dementia state progresses, the regulation of sleep by the hormone melatonin gradually decreases. This results in a disturbance of the sleep cycle and causes difficulty falling or staying asleep.

Environmental Factors:

• Low Lighting:

  As the daylight fades, the decrease in natural light introduces darkness and shadows that can be disorienting or even scary for someone with reduced vision or cognitive impairment.

• Longer Shadows:

  The combination of light and shadows at these times of day can cause optical illusions. These optical illusions result in a misinterpretation of what he or she sees, and that can be terrifying or extremely distressing.

• Reduced Noise and Activity:

  The relative calmness of the night, with fewer opportunities for distraction or diversion, may further enhance feelings of loneliness, boredom, or anxiety.

Fatigue:

• Mental Exhaustion:

  The cognitive demands of the day can tire a person with dementia, making it difficult for them to adapt to changes in their environment or schedule.

• Physical Exhaustion:

  The contributing factor could be physical exhaustion. If the body is extremely tired, it may not be able to handle stress or anxiety, and agitation or restlessness can increase in the evening.

Decreased Sensory Perception:

• Vision Changes:

  Clear vision might not be as easy as the day progresses. It can lead to the misinterpretation of things that are viewed. This can cause fear or anxiety, especially if the person is not able to clearly identify an object or person.

• Hearing Loss:

  A reduced ability to hear may make a person not understand events taking place around them. Hence, it causes confusion or misinterpretation of a sound or a voice.

Social Isolation:

• Lack of Activity:

  As day turns into evening, with a reduction in social activities, the person becomes increasingly alone, which can be emotionally painful.

• Fewer People/Activities:

  With less hustle and bustle of people and activities to occupy their mind, it is then free to start wandering without distraction, and negative or confused thoughts are easily felt.

Sundowning Syndrome and Coping Strategies

Management of Sundowners syndrome is done through environmental and lifestyle changes, and if necessary, a few medications after a proper diagnosis can also help. These strategies can be helpful in managing symptoms and improving the situation for the individual and their caregivers:

Keeping a Routine:

• Daily Routine:

  A regular routine as the day progresses reduces confusion and provides a sense of security. Activities such as meal times, exercise, and bedtime should all occur at the same time every day to establish routine predictability.

• Evening Routine:

  Create a soothing evening routine. Include calming activities like reading, soft music, or quiet conversation in preparation for sleep.

Increase lighting:

• Light Up the Home:

  Keep the house lightened up, especially in the late afternoon and evening. Utilize bright, white lights to reduce shadows and make the environment more inviting.

• Nightlights:

  Place nightlights in the hallways, bathrooms, and bedrooms to reduce the disorienting effects or fears during the night. Soft, warm light can help to create an atmosphere of comfort.

Encourage Physical Activity:

• Daily Exercise:

  Engage in regular physical activities such as walking, stretching, or light exercises. These activities will seem to decrease restlessness and promote nighttime sleep. However, the exercise should be performed earlier in the day so it does not overstimulate the body before sleep time.

• Engage in meaningful activities:

  Being busy keeps the mind and body from being bored during the day, which can decrease the potential for agitation later in the evening. Gardening, puzzles, and light housework are great and can be quite useful.

Avoid caffeine and sugar:

• Don’t use stimulants:

  Both caffeine and sweet foods will increase agitation and make it harder to calm down in the evening. It’s best to avoid these, particularly in the late afternoon and evening.

• Healthy snacks:

  Healthy and soothing foods are encouraged. They may include whole grains, fruits, and vegetables for better health and sleep.

Provide Reassurance:

• Gentle Communication:

  Talk to the person in a soft and reassuring tone. Provide simple explanations about what’s going on and offer comfort by gentle touch or holding hands.

• Stay Close:

  Physical presence gives a person security. Sometimes, just accompanying a person quietly, especially during times of stress, confusion, or even restlessness, will help to calm down.

Use Relaxation Techniques:

• Soothing Music:

  Playing relaxing music or natural sounds can create an environment that promotes relaxation. Use very familiar tunes that are known to be comforting to the individual.

• Deep Breathing Exercises:

  Encourage slow and deep breathing to help relax the mind and body. You can do this by breathing together in a slow, rhythmic pattern.

• Aromatherapy:

  Smells such as lavender or chamomile have a calming effect. Use of essential oils in a diffuser or even as part of one’s bedtime routine could help with relaxation.

Discuss Medication with Doctor:

• Consult with Professionals:

  Your doctor may also discuss medications to help control the symptoms of Sundowners syndrome. This can mean anything from sleep aids to anti-anxiety medications or even antipsychotic medications.

• Monitor for Side Effects:

  It is important to carefully weigh the risks and benefits and decide if the proposed treatment benefits outweigh the risks.

The Role of Caregivers

Caregivers are the most important aspect of managing Sundowners syndrome. Caregivers need to practice self-care, as the behaviors related to Sundowners can be extremely challenging and exhausting. Support groups, respite care, and professional counseling can provide much-needed respite and emotional support. Educate yourself about dementia care at Deter Dementia.

Conclusion

Sundowners syndrome can be mitigated and less impactful in the lives of persons with cognitive impairment and caregivers through an understanding of symptoms and causes and fostering supportive management strategies. Responsive person-centered care with early intervention, a consistent routine, and a compassionate approach can help ease the distress from sundowning and increase positive outcomes for both parties. Deter dementia provides awareness and support for people with dementia and caregivers.