With babies and young children, it can be referred to as ‘the witching hour’. In dementia and old age, this time of evening restlessness and agitation is referred to as ‘sundowning’. Anyone who works closely with dementia sufferers, as we do in our specialist dementia care home in North Devon, knows there’s definitely something about the twilight hours that post a challenge.
Sundowning is the term to describe the change in behaviour that occurs in some dementia patients in middle to later stage dementia, when this change happens on a daily basis at around dusk. The individual may, along with the onset of the evening, experience greater agitation or anxiety.
It is not unusual, for a resident experiencing a ‘sundowner’, to get more confused, or insist they need to go home, or even to bed (even if they are already there).
Doctors and scientists aren’t really sure what causes sundowning. However, there’s no doubt that it is correlated with fading light and darkness. The most common explanation given, therefore, is often that it is something to do with the body clock and circadian rhythms, and specifically changes in the brain associated with dementia.
However, it’s unlikely that it is solely triggered by one thing alone. Throughout the day, a person with dementia gets more tired. With tiredness, symptoms can worsen. Indeed, often sundowning is attributed to tiredness.
There are other things which could contribute including boredom, depression, thirst, hunger and pain. We are also highly aware that the evening darkness, bringing with it shadows, seems to make things worse. That’s why we have dementia-friendly lighting and carefully positioned furniture, to minimise any sense of confusion that shadows bring.
An individual, who is experiencing a sundowner, largely looks like they are experiencing an intensification of their usual dementia symptoms.
You may notice that in the evening, someone with dementia becomes more upset, anxious or agitated. They may be more irritable and restless. Confusion and disorientation may be more noticeable than at other times in the day.
As a result, individuals who are sundowning may appear suspicious or argumentative. They can be demanding. It’s not unusual for them to pace, or even become aggressive. None of this is personal; it is symptomatic of the dementia in the twilight hours for some people.
We’ll come on to what you can do ‘in the moment’ when someone is experiencing a sundowner shortly. However, it is important to take some steps to try and lessen the likelihood of the twilight time posing a problem.
It’s important for an individual with dementia to get regular and routine sleep. A good sleep routine helps them to manage tiredness, thought to be a sundowner trigger.
Different individuals may have different triggers. Try to learn what these triggers are, and manage them. For example, if your loved one becomes anxious when a certain light is switched on in the evening, and starts asserting that they want to ‘go home’, then make sure they are settled in their room, before this time of day.
Routines are hugely beneficial for individuals with dementia. The routine should include roughly set meal times and activity, according to the individual’s ability. Make sure there is plenty within the routine that the person enjoys. While daytime naps may be necessary, these should be minimised so as not to impact on night time sleep. It can also be beneficial to have the main meal of the day at lunchtime, with a smaller light meal in the evening.
Reducing caffeine and alcohol can help an individual be more settled and calm in the evening. Many people do not notice the difference between caffeine and alcohol free options and their counterparts, so these can be easy to substitute.
Don’t wait for it to start becoming dark to shut curtains. Instead, close them before dusk and switch on the lights. This actually makes the transition easier and can help to prevent shadows. It’s also worth covering any glass doors, and maybe mirrors, which can reflect the light in a disconcerting way.
Try to eliminate as much stress as possible from someone with dementia. Unfortunately, they are not able to process information as they once were, and so even the simplest things can become distressing. Therefore, avoid activities in the evening which may become stressful.
Even with the best preventative steps, sundowning can still happen. Again, try not to be alarmed, as this is a relatively common aspect of dementia. There are some things which you can do to help:
Confusion can sometimes be redirected with some distraction. Try to encourage the individual to move to a different room, watch some TV with you, or have a drink or snack.
Try not to argue back with the individual, no matter how unreasonable or nonsensical they may seem. Instead, show them that you are listening, and try to offer reassurance, without directly contradicting them.
Try not to rush the individual, or dash out instructions. Instead, speak very calmly and in a slightly slower manner than usual. By soothing the individual with your voice, they can begin to regulate their responses.
If the individual feels comfortable, you may want to hold their hand. This can help them to feel soothed and reassured, without them having to interpret language. Even just being nearby can help them to feel comforted, and like they aren’t alone.
Have the lights on, and keep them on, until the individual is calmer. Use overhead or wall lights, rather than standing lights, as these cause shadows. There is also some evidence to show that putting a full-spectrum fluorescent light close to your loved one, even during the day, can make a difference to sundowning.
A common aspect of sundowning is the individual’s sense that they are ‘in the wrong place’. You can help to alleviate this by showing them cherished items and photos, or offering them their favourite blanket.
If you are looking after your loved one at home, it is understandable that sundowning can be one of the hardest aspects of dementia to deal with. You are probably tired yourself at the exact time you need to be fully focused on your loved one. It can also be very hard to implement all these strategies day after day.
A specialist dementia care home will be experienced with sundowning. They will have staff who become familiar to your loved one and who have nothing else to do, except care for them. They can help to put in place all the steps to minimise sundowning, and handle it appropriately. Find out more about our dementia nursing care home in North Devon by calling 01769 573166.