Tips for coping with sundowning in dementia patients

Due to the shelter in place order, everyone is experiencing confusion and anxiety – emotions already familiar to those suffering from Alzheimer’s disease and their caregivers.

Behaviors associated with sundowning are particularly difficult. Sundowning describes a state of increased confusion and anxiety that presents in the late afternoon and continues through the evening. For some, it extends into nighttime. Signs include aggression, pacing, confusion, wandering and repetitive behaviors. Some people experience hallucinations, delusions and paranoia.

According to the Alzheimer’s Association, sundowning occurs in as many as 20 percent of persons with Alzheimer’s. It’s also common with other dementia-related illnesses such as Lewy Body Disease, Fronto-Temporal Dementia and Vascular Dementia. In middle and late stages of dementias, sundowning usually occurs each day.

The exact cause of sundowning is not known, but some experts believe it is related to disturbances of the circadian rhythm resulting from dementia-related brain changes. Additionally, the Alzheimer’s Society reports possible stimuli include lighting (often too little), noise, effects of medications and disrupted daytime routines. Sundowning is usually a daily occurrence, not a periodic symptom.

It is important to realize that a person may display behaviors that are identical to signs of sundowning, but he or she may actually be trying to communicate an unmet need. For example, a person with dementia may display agitation due to their need to use the toilet or from boredom. Identifying the need may stop the behavior.

Ways to manage sundowning

With actual sundowning, turn your focus on acceptance that these challenges are part of the patient’s dementia journey and explore ways to cope.

Helping the person in your care cope with the effects of sundowning requires great effort. Finding the right combination of environmental adjustments is specific to the individual. Try out these common solutions:

• Before the sun sets, close the blinds and turn on the interior house lights. For some, this needs to be as early as 3 p.m.
• Assess the environment to be sure it is well lit; vision difficulties will worsen agitation.
• Turn off the television; it tends to contribute unnecessary noise that increases confusion.
• Provide activities that are soothing or enjoyable for the person during this time of day. Playing soft music, flipping through a large photo-heavy coffee table book and painting are low-stress activities.
• Ideally, one-on-one interactions are best. Limit visitors to two or three at most.
• At times, the person may be insistent about illogical or incorrect subjects. Don’t waste energy on trying to convince the person they are wrong – it just makes the situation worse. Put yourselves in their world and go with flow.
• Provide reassurance and comfort.
• Take note of certain activities, such as bathing, that seem to be most difficult in the afternoon. Try to tackle those earlier in the day when the patient is less agitated.

Help from the experts

When I provide education and support to family care partners, I always preach two particular best practices. The first is a principle discussed in “Dementia Beyond Disease”

by renowned gerontologist Allen Powers, who educates about the importance of being attentive to the person’s well-being.

Promote meaning in a person’s life by providing them opportunities to help others with their special talents. For example, let them, if able, help young children with their spelling words or basic math drills; generously dole out appreciation for their “help.”

Second is some practical advice from Teepa Snow, an experienced occupational therapist and worldwide expert on caring for those living with dementia. Snow teaches that all human beings need four to five meaningful activities per day to experience quality of life. These activities may only be five or 10 minutes long, but the emotional experience they produce may last many more minutes or even a few hours past the actual activity.

Consider the person’s interests (art, crafts, gardening) and create activities for them to engage in what they enjoy. On Sunday night, plan your patient’s upcoming week or at least compose a list of possible activities to pull from. This takes some of the stress out caregiving, since you’ll have ideas on hand of how to engage with your person.

Jill Smith, RN, is a dementia specialist and community education manager at Hope Hospice. For more information, visit hopehospice.com/dementia.