Sundowning: What to know if your loved one with dementia experiences late-day symptoms

Sundowning is a common behavior in people with dementia, including those with Alzheimer's disease. If your loved one with dementia has sundowning syndrome, there are things you can do to help.

What is sundowning?

Sundowning is a term that describes certain behaviors linked to late-day confusion, agitation, and mood swings in people with Alzheimer's disease or another form of dementia. These behaviors occur in late afternoon and at night, when the sun goes down.

People who experience sundowning may have good days with few symptoms and difficult days with more severe symptoms. The personality changes associated with sundowning syndrome can be difficult and distressing for caregivers.

Who may experience sundowning?

Sundowning can happen to anyone with dementia, but it is more common during the later stages of the disease. Almost all people with Alzheimer's disease will have some form of sundowning.

Recognizing signs and symptoms of sundowning

Sundowning signs and symptoms include:

• wandering
• pacing back and forth
• rocking in a chair
• confusion
• agitation
• crying
• closely following a caregiver around (shadowing)
• problems falling asleep or staying asleep
• seeing or hearing things that aren't there (hallucinations)
• becoming alarmed or frightened for no apparent reason
• aggression, yelling, and in some cases even violence.

It can be difficult for caregivers not to take sundowning behavior personally. It may help to understand that the behavior is due to changes in the brain that result in emotions that the person can't control.

What can make sundowning worse?

Events or changes in a person's surroundings, as well as unexpected changes in a person's routine, often play a role in triggering sundowning symptoms.

Physical factors such as not getting enough sleep, constipation, or a urinary tract infection can make sundowning behaviors more likely. So can pain, depression, and stress. Sundowning may also become worse if there is too much noise or confusion, or too many people in the room.

Many people with dementia experience sundowning if they are pushed to do something that they can no longer do, such as bathing, dressing, or being asked to remember people or events.

Sometimes a feeling of loss, such as no longer having the freedom to drive, can contribute to sundowning symptoms. Feeling lonely and not having enough contact with other people also can play a role, as can uncorrected problems with hearing or vision.

In addition, interactions between medications can make sundowning worse.

How to manage sundowning behavior in a loved one

Tips to help avoid sundowning behaviors include:

• Try to keep a predictable routine. For example, serve meals at the same time each day.
• Keep noise and clutter to a minimum.
• Play soft music and let in natural light.
• Keep familiar objects and photos around the home.
• Avoid alcoholic drinks and caffeinated beverages late in the day.
• Discourage long naps or dozing late in the day.
• Schedule doctor appointments and other activities earlier in the day, when the person with dementia is more alert.

To help manage sundowning behaviors once they've started, caregivers can:

• Try to distract the person with a snack or an activity, like taking a walk or watching television.
• Speak slowly and calmly, and avoid arguing.
• Try not to show frustration. Take deep breaths and count to 10 if you feel impatient.
• Reassure the person that they are safe and that you are there to help.
• Avoid trying to restrain the person, unless it is necessary to keep them safe.
• Try gentle touches, such as a light back or foot rub, to help them settle down.

To remain safe in cases of aggressive behavior, hide or lock up car keys, guns, and kitchen knives, and keep yourself at a distance. Contact your loved one's doctor if aggression gets worse. In an emergency, call 911, but be sure to say that your loved one has dementia.

Medical treatments that may help

A medication approved by the FDA to treat sundowning symptoms is brexpiprazole (Rexulti). This atypical antipsychotic is FDA-approved for agitation associated with Alzheimer's dementia. It works by targeting the serotonin and dopamine chemical pathways in the brain.

Other medical treatments the doctor may prescribe include antidepressant, anxiolytic, or antipsychotic medications. Never give the person over-the-counter sleep medicines without talking to their doctor first, since many sleep aids can make confusion worse.