Understanding sundowning in dementia

What is sundowning in dementia?

Sometimes, a person with dementia may experience unpleasant feelings during late afternoon or dusk - commonly referred to as sundowning. Unpleasant feelings can include a growing sense of agitation, anxiety and hallucinations. According to Frontiers in Neuroscience, approximately 1 in 5 people with dementia experience sundowning, affecting people with different forms, including Alzheimer’s and Lewy body dementia. As dementia progresses, the more likely a person is to experience sundowning.
 

When does sundowning usually happen?

Sundowning usually occurs when the light conditions change from light to dark, for example, in the late afternoon. Episodes can vary, lasting anywhere from a few minutes to a few hours. Sometimes, they can last into the night, making it more difficult for a person to sleep.
 

How is sundowning different to other symptoms of dementia?

It's important to note that there are distinct differences between sundowning and dementia. Sundowning is usually time-specific - worsening confusion, agitation, anxiety, or aggression that happens in the late afternoon and sometimes progresses into the night. On the other hand, dementia symptoms have no time-based patterns. Symptoms such as memory loss and speech problems usually persist throughout the day or progress gradually over time. Sundowning episodes can be triggered by external factors such as tiredness, low light or disruption of routine, while dementia is more neurologically based and persistent.
 

Causes of the phenomenon of sundowning

There are several reasons why sundowning happens. The reasons are not well understood, but there are various causes. Some may be contributing causes, while some may be simple things that make episodes and behaviours worse.
 

Body’s internal clock

As dementia progresses, it can disrupt the circadian rhythm, which is responsible for regulating sleep-wake cycles, resulting in sleep deprivation. Sundowning gets worse when a person is sleep-deprived. It's common for people with dementia to feel tired during the day but more awake at night.
 

Daily routine and surroundings

If there is no adequate lighting in their surroundings, this can cause sundowning because of the lack of serotonin production and a disruption in their internal clock, triggering nighttime symptoms. Adequate lighting is proven to increase the production of serotonin, the body's natural feel–good chemical, as well as regulate its biological clock. Exposing yourself to natural light is best, but artificial lighting also offers benefits too.
 

Mood disorders

Any periods of anxiety or depression can trigger sundowning. Any negative changes in a person's mood expose them to experiencing sundowning. An episode can still happen even if no mental health disorders, such as stress or anxiety, are present.
 

Recognising symptoms of sundowning

Sundowning is not something that a person will see within themselves. Usually, caregivers or their loved ones notice changes in their behaviour and mental state. According to the Alzheimer Society of Canada, sundowning can happen at any point in a person’s dementia journey, typically peaking in the middle stages of dementia. It's best to be aware of the sundowning symptoms so you can respond appropriately when people have episodes.
 

Behaviour changes and symptoms of sundowning in dementia:

• Aggressive behaviour, lashing out verbally or physically
• Changes in how they walk or move, unusual movements
• Difficulty understanding or comprehending their speech
• Loss of interest in activities they enjoy
• Pacing or wandering around, not being able to sit still
   

Emotional changes to look out for during sundowning:

• Anxiety
• Irritability
• Mood swings
• Stress
• Depression
• Sadness
   

Physical symptoms associated with sundowning:

• Sleep disturbances
• Difficulty sitting still
• Disorientation with time and space
   

Tips for reducing sundowning:

Sundowning can be a scary experience. Rest assured, there are ways to calm people with dementia at night:
 

Create a calm evening routine

Helping your loved one to stay calm in the evening is always best. Make sure they choose activities that aren’t too difficult or scary, as this can add to their confusion. Certain activities, especially highly stimulating ones during the evening, may be too overwhelming for someone with dementia, for example, watching TV or reading a book. An alternative would be to play calming music to design a relaxing and quiet space for them. It may be that looking at photographs of themselves and loved ones brings them comfort and joy and helps them cope with this difficult time in life.
 

Encourage physical activity during the day

Physical activity does wonders for your mental health. Exercising releases ‘feel-good’ chemicals, such as endorphins and serotonin, in the brain. It also promotes nerve cell growth, which improves brain function and increases mood, reducing the likelihood of sundowning episodes. Any form of exercise is a good sundowning dementia treatment, whether it is low-impact, such as walking, or higher-impact, such as swimming, which helps to improve sleep and reduce restlessness later.
 

How does light therapy help sundowning?

Light therapy is the exposure to direct sunlight or artificial light at controlled wavelengths, designed to help with various medical disorders. According to the American Medical Association, light therapy was able to reduce agitation and restlessness in individuals with Alzheimer’s disease by up to 50%, illustrating its promising effect.
Exposure to light regulates the circadian rhythm, contributing to an increase in serotonin levels – a natural mood stabiliser, influencing emotional well-being and overall mental health. As light therapy is used to mimic the effects of natural sunlight, it's an effective tool that you can use throughout the day to delay the production of melatonin – the hormone that promotes drowsiness, leading to a more gradual and natural transition into nighttime.
 

Support and resources

We’ve provided a list of support and resources that can help you with any aspect of dementia:

Dementia helpline

Help and support for dementia carers

Dementia types and its symptoms

How to provide family caregiver support

You can find out more about how we support people with dementia in our homes and the daily enrichment activities we have on offer. Feel free to speak to our friendly team today; we’ll always be happy to chat.