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25th September 2018

Sundowning (Late Day Confusion)

 

It’s early evening and there are lots of jobs to do, but Bill has decided he wants to “go home”. He has been quiet and settled all day but now needs to “find mother”. Mary has had a great day singing and dancing to the residents’ entertainer but now she has removed most of her clothes and is pacing up and down. Eddie is shouting and getting cross. He can see Indians in the garden and they are trying to get in! Does this sound familiar? This could be Sundowning.

What is it?

It sounds like such a gentle word for such frustrating and anxiety provoking behaviour. It affects up to 65% of people in the mid to late stages of dementia. Symptoms manifest in the late afternoon or evening and include:

  • Increase in agitation and aggression
  • Feelings of anxiety and insecurity
  • Pacing and Wandering
  • Hallucinations and delusions
  • Difficulty doing tasks that were done without difficulty earlier in the day
  • Difficulty understanding others.
What Causes It?

Someone with dementia may have a disrupted Circadian cycle (sleep/wake pattern). They have difficulty distinguishing day from night. Being tired at the end of the day particularly if they have been over stimulated during the day can lead to an inability to cope with stress. On the other hand, lack of activity during the day particularly if there has been napping can lead to restlessness later. Low lighting and more shadows in the evening can create confusion and hallucinations especially if eyesight is already poor.

What Can We Do?

Finding a way to respond to sundowning may take some trial and error. Every person is different and may have different behaviours. There’s no definitive answer. It’s easier to try to head off sundowning or at least minimise its effects.

Rule out obvious causes of distress which may be heightened in the evening such as thirst, hunger, pain, needing the toilet.

Avoid large meals in the evening as this can increase agitation. Instead offer a substantial meal at lunchtime and a hearty snack for tea. Restrict caffeine after lunch, try substituting decaffeinated drinks. Similarly restrict alcohol in the evenings too as this is another stimulant.

Encouraging walks or exercise during the day may reduce restlessness and the need to wander later. Discourage napping if possible (This could help Bill who had spent a quiet day snoozing in his chair.)

Maintain familiar routines as much as possible to provide comfort and reduce anxiety. (When Bill asks for his mother this could be an unmet need for security and reassurance.) Close the curtains, put on a favourite TV or radio show or soft music, offer a soft blanket or soft toy to snuggle.

Prevent over stimulation from activities, visitors and TV or radio. (This could help Mary who had been singing and dancing all afternoon … in several layers of clothing.  No wonder she was excitable and stripping off!)

Provide adequate lighting to lessen the shadows in dark corners, close the curtains to reduce reflections and cover mirrors if necessary. (This could help Eddie who thought he saw Indians in the garden.)

Speak to family/friends about symptoms of sundowning and see if they can offer any advice on comforting routines, distraction techniques. Maybe this is a time of day that they could visit and help with the night time routine or just provide reassurance.

Keep calm, use a reassuring tone and speak in short sentences giving simple instructions.

Above all remember that sundowning is exhausting for all concerned. Be kind to yourself too. You will have earned that glass of wine when you get home!

*All information is correct at the time of publishing

Topics: Dementia

Katie Farrar

Occupational Therapist

Katie qualified as an Occupational Therapist in the year 2000. For most of her professional career she has worked in the field of older people’s mental health services within community mental health teams. As part of this she has had extensive involvement with people with dementia and their carers, both in the community and in care home settings. Katie is currently working with the Dementia Pathway Team supporting people with dementia in the care home setting and particularly with advanced care planning for end of life care. She has also recently completed the Mental Health Act Best Interest Assessor Course at Leeds Beckett University. Katie has developed and delivered training to care homes on dementia awareness, managing delirium and managing challenging behaviour. As well, she has supported carers to offer meaningful activities and experiences and provided guidance to care homes on improving environments to become dementia friendly. Read more

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