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Sally has noticed that her husband with dementia, Bob, seems to turn into a different person after supper and throughout the night. Instead of sleeping in bed, he walks around the house at night and even tries to cook. Sally is getting no sleep because of it. If she tries to stop him or get him to lie down, he becomes very angry with her. Last night, Bob left the house and a concerned neighbor was able to help Sally find Bob a block away from their house.

What Bob is experiencing is something called “sundowning,” a phenomenon that occurs in the late afternoon and throughout the evening due to brain changes caused by dementia. It can be quite stressful for the loved one with dementia as well as the caregiver.

We know that dementia affects the “internal clock.” This causes confusion, anxiety, and agitation and affects the ability to discern night from day. Sometimes people will describe their loved one as a different person with an aggressive or very anxious personality in the late hours of the day, while during the day they seem more like their normal selves. Many caregivers struggle with their loved one consistently getting out of bed, wandering around the house, or even leaving the house.

We must remember that dementia is doing irreversible and progressive damage to different parts of our loved one’s brain. With that in mind, it makes sense that they may struggle to communicate their needs and anxieties as the day goes on.

So how do you prevent and/or address sundowning for your loved one? While sundowning may be a daily occurrence for some, it is helpful to know the common causes of sundowning, especially if this is a new and sudden behavior.

If sundowning occurs suddenly…

Your loved one may be in pain or hungry/thirsty and cannot express these needs. Confusion can also be a symptom of an infection, especially a urinary tract infection.

The first step is to rule out these causes by offering your loved one food or drink or asking questions about pain (upset stomach, headache, etc.). Look for non-verbal responses to your questions or point to different areas of the body and see what response you get from them.

Certain medications can cause sundowning. A physician’s visit can help you rule out infection or side effects from medication as the cause.

If sundowning is a consistent behavior…

Different factors can contribute and sometimes they compound upon one another. Some example situations that can cause the anxiety and boredom of sundowning:

• Spending the day in unfamiliar surroundings
• Hospital visits
• Running lots of errands during the day
• Daytime naps
• Caffeine after lunch
• Low light and watching lots of TV during the day
• Darkness and shadows in their bedroom at night
• Trouble separating dreams from reality at night

How to lessen the effects of sundowning:

• Keep a consistent schedule of mealtimes, activities, and bedtime as much as possible.
• Close drapes when it gets dark.
• Provide adequate indoor lighting during their awake time.
• Encourage exercise during the day, like a walk, to get your loved one sleepy enough for bed.
• Spend some time outside when the weather is nice to help orient them to day and night and get some much-needed sunlight.
• An hour before bedtime, avoid TVs, loud music, or other loud sounds (like vacuuming).
• Play calming music, nature sounds, or white noise at bedtime.
• Use a nightlight in the bathroom and bedroom, so that if your loved one wakes up, they can clearly see.
• If your loved one must visit or stay in respite care or another unfamiliar environment, send pictures and decorations from home to help them feel more comfortable.
• Schedule outings for their “best time” of the day – usually the morning or early afternoon.
• If they become agitated, do not restrain them. This will cause more agitation.
• Figure out things that calm them – a certain picture, item, type of music, or time outside.
• Speak calmly and clearly to them.

Observe your loved one when sundowning occurs. What did their day look like? What was the last thing that happened before they started showing symptoms? What seems to aggravate or ease the symptoms? This may help to anticipate how to avoid sundowning occurring. If changes at home don’t make a difference, a physician’s visit may be in order to discuss medication or strategies to aid in sleeping and easing anxiety and agitation.

Sundowning is one of the many changes caused by dementia that can be a challenge for caregivers and the person with dementia. It is important to know you are not alone. As always, if you need guidance for your specific situation, please give us a call. We would be happy to help.

Written by Katie Fowler, RN