Men’s Health

Shedding Light on Sundowning

04-Jun-2021

By Nadia Hlebowitsh

Note: This article is intended to be informational only. If you think your loved one is experiencing sundowning, you should schedule an appointment with his/her primary physician to get diagnosed and receive a customized care plan.

Twilight can be a difficult time of day for dementia patients. After hours of sensory stimulation, your loved one may become overwhelmed in the late afternoon or early evening. That’s when symptoms of sundowning are most common, including increased confusion, agitation and restlessness – all of which may get worse throughout the night. In severe cases, patients may even experience wandering, paranoia and delusions.

These behavioral changes can be upsetting for both patients and caregivers. They may also bring up safety concerns for your loved one. Unfortunately, sundowning can become aggravated over time, as patients and caregivers lose sleep. Sleep deprivation makes many symptoms worse, creating a cycle of exhaustion and frustration.

Sundowning is common in dementia patients, with 1 in 5 patients affected. However, seniors without dementia may also experience signs of sundowning. While there’s no cure for sundowning, you can minimize it with a few key tips. Let’s shed light on sundowning and guide you through how to manage it in your loved one.

Signs of sundowning

First of all, sundowning is a sudden mood change. You may notice your loved one become anxious, fearful, agitated, restless, stubborn, angry or sad. Increased confusion is also common, including a lack of reason.

Common symptoms

In addition to these mood changes, you might notice agitated reactions, such as:

Repeating questions
Trouble speaking clearly
Pacing
Wandering
“Shadowing” their caregiver around
Crying
Rocking
Hiding things
Having trouble falling asleep

Severe symptoms

In more severe cases, sundowning can cause more aggressive and serious behaviors. Sometimes patients with sundowners may experience:

Yelling
Emotional outbursts
Feelings of paranoia
Delusions or hallucinations
Aggressive and/or violent behaviors

In particular, these severe symptoms can strain the patient-caregiver relationship and be more difficult to manage.

Causes of sundowning

Sundowning isn’t completely understood by the medical community. One theory is that sundowning occurs when a patient is overwhelmed after a day of sensory stimulation. Once night arrives, your loved one is unable to handle things in the same way, resulting in behavioral changes such as agitation.

Sundowning may also be the result of unmet needs in the patient, including exhaustion, hunger, thirst, depression, pain or even boredom. In particular, patients with sleep deprivation may be prone to sundowning symptoms. When the body’s “internal clock” is disrupted, hormonal imbalances are common. These disruptions can heighten confusion and restlessness.

There’s some evidence that underlying medical conditions can make sundowning worse as well. For example, UTIs in seniors can cause behavioral change and aggression. Medications may also be the culprit. If your loved one is taking multiple prescriptions, certain side effects can aggravate sundowning. In particular, medications for incontinence, depression, or insomnia can make agitation worse. At the same time, sundowning symptoms can also be the result of prescription medications wearing off towards the end of the day.

Triggers of sundowning

Sundowning triggers may be unique to every patient. It’s important to stay attentive to learn what may be triggering certain symptoms.

Here are some common triggers to look out for and avoid, especially during sundowning hours.

Low light: Your house should be well-light to avoid increasing confusion. Shadows may become a source of fear in sundowning patients. Add extra lighting to your rooms, as well as nightlights along frequented hallways.
Sleep deprivation: Without good rest, sundowning symptoms can get worse. Patients may struggle to separate reality from dreams, which causes distress. It’s important to create a sleep routine as much as possible. Avoid naps in the late afternoon and try to make a bedtime routine that’s relaxing.
A new unfamiliar place: Perhaps your loved one recently experienced hospitalization or has moved to a new unfamiliar place. He/she might even become stressed by an unfamiliar appointment during the day. This can be a trigger for sundowning symptoms.
Caregiver mood: The caregiver’s mood, especially when frustrated, may also impact sundowning symptoms such as agitation. Though caregiving can be taxing, it’s important to stay calm and not raise your voice.
Seasonal changes: The shorter days in winter may also trigger sundowning. In winter months, it’s essential to make the most of daylight. Make sure your loved one gets lots of light therapy. For example, take a long walk in the morning to get exposed to light.

If you notice any of these triggers, try to minimize them as much as possible. While not all these factors are within your control, reducing them may make a difference in daily living.

The dangers of sundowning symptoms

Sundowning can be distressing for both patients and caregivers. First of all, caregivers may worry about their loved one’s well-being and want to minimize symptoms of agitation.

At the same time, sundowning symptoms that involve aggressive behaviors may result in injury. Falling, experiencing outbursts or wandering in the street can occur if sundowning isn’t managed. In the process, patients may harm themselves or others.

For this reason, managing sundowning symptoms is essential. Below, we’ll go over some tips for reducing it and boosting your loved one’s daily wellness.

Treating sundowning

There’s no treatment for sundowning. Most caregivers will work to minimize symptoms and make their loved one as comfortable and calm as possible. You should absolutely talk to your loved one’s primary physician about sundowning to get a personalized care plan.

Reducing sundowning symptoms is often done by creating routines and guiding behavior during the day. This can help both the patient and caregiver be prepared for any issues as the sun goes down.

Sundowning symptoms are rarely treated by prescription. That’s because most seniors already take several prescriptions and side effects can be challenging to manage. It’s best to avoid adding another prescription whenever possible.

For this reason, the majority of sundowning cases will need to be managed, not medicated.

Managing sundowning

Every patient is unique. It’s key to understand your loved one’s triggers and routines to find out the right way to manage sundowning.

Caregiver behavior

Stay calm. Your mood as a caregiver can influence stress in your loved one. Try not to yell, argue or be aggressive. The way you act towards your loved one can make a huge impact in his/her well-being.
Don’t use logic, especially if your loved one is experiencing delusions or paranoia. Doing so will make agitation worse. Focus on feelings instead. Try to comfort him/her and ensure his/her safety. Use reassuring and calming words.
Avoid triggers that you notice. Every patient is different. Keep an eye out for what is triggering your loved one. (Check out our list of common triggers above.)

Routine

Get into a daily routine. Schedules are great for dementia patients, as they know what to expect during the day. Sticking to a routine, especially before bedtime can help relieve anxiety.
Keep your loved one active during the day. Create a schedule of activities that are engaging. You might even try dementia toys for seniors, or an adult day care program to enrich daily quality of life. This will help him/her get good rest at night.
Change up your loved one’s diet to avoid sugar and caffeine in the afternoon. You might even try having a large lunch and a smaller dinner. Avoid alcohol altogether.
Add personal items such as photos to your loved one’s bedroom. Seeing familiar items can help orient him/her when confusion hits.

Natural therapies

Use light therapy during the day. Make sure your loved one is exposed to light through walks outside or well-lit rooms. This will help regulate his/her sleep cycle. In particular, natural light is great for helping manage sleep.
Try music therapy. Soothing, simple music can be relaxing to patients with dementia. Classic music is a good choice because many pieces are soft and gentle.
Use aromatherapy. Scents can encourage calm. You might try aromatherapy with your loved one. Lavender, rose, ylang-ylang and chamomile are good natural relaxers.

Home modifications

Create a safe space that’s free of noise and sensory stimulation. You can bring your loved one to this peaceful space whenever he/she gets agitated.
Keep your loved one safe from wandering by locking dangerous items, installing locks and setting up stair barriers.
Try using a baby monitor, motion detectors or door sensors. This way you’ll be aware if your loved one is wandering at night.

Medical care

Schedule a doctor’s appointment. There may be underlying medical conditions that trigger sundowning. Getting a professional diagnosis and care plan is essential.
Consider a melatonin supplement that helps regulate sleep routines. It doesn’t require a prescription, but you should always consult your loved one’s doctor first.
Get respite care. Every caregiver deserves a break. Schedule some well-deserved respite care, whether through a program or a friend.

Don’ts for managing difficult behaviors

Sundowning often involves difficult behaviors. Staying calm and helpful as a caregiver can take a lot of energy and practice. When learning to deal with challenging behavior, caregivers should try their best to avoid these don’ts.

Don’t physically restrain your loved one.
Don’t approach your loved one from behind or in the dark.
Don’t yell or respond with aggression.
Don’t argue or go into long explanations.
Don’t talk negatively about your loved one in front of him/her.
Don’t accuse your loved one or blame him/her for dementia behaviors.
Don’t make all decisions on your own – try to work together.

Your loved one will pick up on these negative behaviors and moods. If you’re feeling overwhelmed, find out if respite care is available nearby. All caregivers deserve regular breaks from the demanding job of dementia caregiving.

Supplements and medications for sundowning

Seniors are rarely medicated for sundowners. That’s because most symptoms can be reduced with changes in routine and behavior. At the same time, seniors experiencing sundowning often already take many medications. The side effects from medications can also negatively impact sundowning. For this reason, doctors don’t typically recommend medications for sundowning alone.

Of course, you should speak with your loved one’s primary physician to get a medical opinion. In the case of severe sundowning, the doctor may look more closely at underlying conditions and see what could be managed with supplements or medications. Underlying conditions can make sundowning worse, so resolving them can make a big difference in symptoms.

In the case that a doctor recommends supplements or medication, the recommendation will likely be one of the following options.

Supplements

Melatonin: Melatonin is a hormone that regulates sleep. Often seniors have low melatonin, which may impact their sleep cycle, mood and behavior. Melatonin supplements may help restore some sleep regulation and positively impact daily life.
Herbs: Some supplements are known to be stress-reducing and may help patients stay calm. Typical herbal supplements include lemon balm, valerian, chamomile, kava and holy basil. In the case of vitamin deficiency, magnesium or B, C and E vitamins may also be appropriate.
Cannabinoids: There is very little research about how cannabis supplements may help relieve pain and manage mood in seniors. Talk to your doctor to see if cannabinoids would be a good option.

Prescription medications

Antipsychotic medications: These medications are used to reduce agitation and aggression in dementia patients.
Acetylcholinesterase inhibitors: Patients with dementia may also take these inhibitors to slow cognitive decline.
Antidepressants: Finally, antidepressants have sedative properties that may help manage sleep disruption, depending on the patient.

Important note: all medication management should be done with the expertise of a doctor. Schedule an appointment to talk about medication for sundowners, as well as potential negative side effects. Your loved one’s primary physician or geriatric specialist will know whether supplements or medication is appropriate or not, and what combination may be most suitable.

FAQs about sundowning

Sundowning is a puzzling syndrome. There’s still so much we don’t know about sundowning and the underlying causes behind it. Here are some of the most common FAQs about sundowning to help guide you in caregiving.

What’s the difference between sundowners and dementia?

Sundowners and dementia are distinct conditions. Dementia is the loss of memory and thinking abilities, impacting a patient’s daily behavior. Most dementia patients have Alzheimer’s, but there are other types as well.

In contrast, sundowning is a state of confusion that leads to distressing behaviors. It’s a set of symptoms triggered by the time of day. Often dementia patients show symptoms of sundowning, with around 20% experiencing it.

Can a patient have sundowners without dementia?

Yes, there are cases of patients who experience sundowners without dementia. While it’s most common in dementia patients, it can also impact seniors in general. If you notice sundowning symptoms in your loved one, you should schedule an appointment with his/her primary physician and also make sure there are no other underlying conditions.

What should I do around Daylight Savings to avoid symptoms worsening?

Daylight Savings is a difficult time for patients experiencing sundowners. Symptoms may be worse after the clocks change, but you can minimize disruptions by planning ahead. Stick to a regular schedule before and after Daylight Savings to keep your loved one feeling as safe and secure as possible. Try to get lots of natural light during this time, especially outdoors. You might also consider turning on the lights in your house before it gets dark to prevent confusion and fear of nightfall.

Can surgery trigger sundowners syndrome?

Unfamiliar places can be a trigger for sundowners syndrome. In particular, returning home after surgery or hospitalization can result in confusion and distress.

However, sundowning is distinct from the delirium that many patients face after surgery. Delirium is a specific state of confusion and disorientation during hospitalization, especially in seniors. It’s characterized by altered mental functioning, starting right after surgery and during recovery. Sometimes this is the result of medications.

Typically delirium will go away and the patient will return back to a regular state of mind. You can help reduce delirium symptoms by staying to visit as much as possible, doing engaging activities such as walking (if possible), having glasses and hearing aids on hand, keeping him/her well hydrated and orienting your loved one when he/she shows confusion.

In contrast, sundowning is a more long-term syndrome. While it’s made worse by unfamiliar places, it’s not specific to surgery or hospitalization. Sundowning usually occurs on a daily basis, even when a patient has a regular home routine.

Is there a relation between sundowners and alcoholism?

States of confusion and cognitive impairment are made worse by alcohol. While more studies need to be done on the link between alcohol and dementia, it’s thought that extensive alcohol use can complicate cognition and dementia in general. If your loved one drinks excessively, it may help to eliminate alcohol from his/her diet.

Is there a relation between sundowners and depression?

Depression can also have a serious impact on sundowning because of the way it impacts mood. If your senior suffers from depression, sundowning symptoms could be more severe than in other cases. Side effects from depression drugs can also play a role in sundowning. It’s important to talk with your loved one’s primary physician to get a sense of whether depression and sundowning symptoms can be managed together.

Is sundowning a sign of end-of-life?

Sundowning does typically develop in mid-to-late stage dementia. However, it’s not necessarily a sign of end-of-life. It may indicate that dementia is getting progressively worse, with more severe symptoms.

End-of-life looks different for every patient. However, a person near death will experience a range of changes, including:

Physical changes including loss of appetite, weight loss, more sleep than usual, incontinence, cold hands and feet, drop in body temperature and blood pressure.
Breathing changes, including the “death rattle,” periods of rapid breathing, coughing or noisy breathing.
Emotional changes such as withdrawal from loved ones, unresponsive periods or terminal restlessness. They may also experience hallucinations and delusions.

As you can see, sundowning isn’t necessarily a sign of end-of-life.

Final takeaway

Sundowners syndrome can be a source of distress and frustration in caregivers. With this guide, we hope you’re able to better understand sundowning and what can be done to reduce symptoms. Follow our tips for managing sundowning to prevent symptoms and make your loved one safer and more comfortable.

No matter what, you should talk to your loved one’s primary physician to get a customized care plan for sundowning and check for underlying conditions. While supplements and medications are available for severe cases, your doctor will often try to find management solutions that don’t involve prescriptions.

With this guide, we hope to improve quality of life for patients experiencing sundowning, as well as their caregivers.

Sources:

Sundowning: Late-day Confusion, Mayo Clinic, https://www.mayoclinic.org
Sleep Issues and Sundowning, Alzheimer’s Association, https://www.alz.org
Tips for Coping with Sundowning, National Institute on Aging, https://www.nia.nih.gov
10 Ways to Manage Sundown Syndrome, AARP, https://www.aarp.org
Treatment Options for Sundowning in Patients with Dementia, MHC, https://meridian.allenpress.com

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This post was previously published on My Caring Plan.

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