If you are caring for someone with Alzheimer’s disease or dementia, you may notice consistent changes in your loved one’s behaviour in the later afternoon or evening. Sundowning, also known as sundown syndrome or late-evening confusion, is a symptom of dementia that can cause behaviours like anxiety, agitation, aggression, pacing and wandering to become more severe later in the day.

Sundowning can significantly impact the quality of life for people living with dementia and place them in dangerous situations. It can also be exhausting for caregivers, as this behaviour typically begins right when they need a break near the end of a long day and can often continue into the night. If you are caring for a loved one experiencing the symptoms of sundown syndrome, here are possible triggers, lifestyle changes and coping strategies that may be helpful.

What Causes Sundown Syndrome?

Sundown syndrome is not a disease but a group of symptoms that affect people with Alzheimer’s and other types of dementia. The exact cause isn’t known, but researchers suggest that dementia-related changes in the brain can damage circadian rhythms leading to confused sleep-wake cycles. There are other factors that are believed to aggravate late-day confusion, including:

• Insomnia or other sleep disorders
• Boredom, hunger, thirst or pain
• Infection or physical illness (e.g. urinary tract infections)
• Side effects from medications
• Hormonal imbalances
• Overstimulation or changes in routine
• Inactivity or lack of sun exposure
• Low lighting–shadows can cause fear and confusion
• Hearing or vision impairments
• Mood disorders including depression and anxiety

Talk to your loved one’s health care provider if you notice sundowning behaviour—especially if it develops quickly. You doctor will first rule out an infection, medical condition or any potential side effects from prescription drugs and then can help you find effective strategies.

What are the Signs and Symptoms of Sundown Syndrome?

People living with sundown syndrome may experience any combination of the following symptoms, usually increasing after sunset or in the evening:

• Confusion and disorientation
• Increased anger, irritability or restlessness
• Paranoia
• Visual or auditory hallucinations
• Difficulty doing things that have been done easily earlier in the day
• Pacing, wandering or attempts to leave home
• High levels of anxiety
• Increased demands
• Impulsive actions

What Are Some Tips and Strategies?

Sundowning behaviours are more likely to occur if a person living with dementia has unmet needs that they can’t identify or are struggling to express. If your loved one seems agitated, first consider that they may be hungry, tired, in pain or have bathroom needs. In some cases, winter’s shorter days can also increase sundown symptoms. If you can’t find an obvious cause, responding to sundowning behaviour may take some trial and error. Here are some strategies and adjustments that can be helpful:

• Keep a journal of activities and behaviour to help identify triggers
• Follow a daily routine as much as possible with consistent meal and sleep times
• Discourage afternoon napping or keep naps short
• Plan activities and appointments in the morning or early afternoon
• Go for walks during the day to get more sunlight and help reset internal clocks
• Avoid exercise in the four hours before bedtime
• Offer additional food and drink before sundowning behaviours begin
• Minimize noise and stimulation in the evening hours
• Try relaxing activities during the times your loved one normally becomes more agitated
• Let in natural light during the day and use softer lighting in the evening
• Try to limit caffeine, alcohol and nicotine—particularly during evening hours
• Try to use a calm and reassuring voice and try to be as patient as possible

Sundown syndrome can be very difficult for your loved one and for you as their carer. Make sure you are seeking support from family, friends or community respite services and be sure to get regular exercise, eat well, and get as much sleep as you can.

If you’re looking for extra support in the evening for your loved one living with dementia or Alzheimer’s, VHA Home HealthCare may be able to help. Contact VHA’s Enterprise Health Solutions team at (416) 489-2500 ext. 4649 or by email at ehs@vha.ca for more information.