Sundowning symptoms and how they are experienced
Sundowning is a phenomenon that is associated with increased confusion resulting in a variety of behaviors that you may not see other times of the day. It can happen with any form of dementia. Up to about 50% of persons diagnosed with some form of dementia may experience sundowning. I have my own personal theories about why it happens when it does. Keep in mind that for each person, sundowning may occur at different times of the day - it's called sundowning because it happens later in the day for a lot of people.
Some of the symptoms of Sundowning
- Increased confusion
- "Exit seeking" (wanting to leave or go home-even if they are home)
The specific cause for sundowning has never been proven. Many studies have suggested that this phenomenon happens because of a disturbance in the circadian rhythm or a "built-in clock".Which means activity and behaviors are triggered by time of day, amount of daylight, change in season, full moon (and if you have never been in a memory care unit around dinner time during full moon, you don't know what you are missing!) My co-workers and I always knew when it was full moon by observing behaviors without looking out the window!). Plants, other animals and creatures have been observed to be affected by a circadian rhythm.
Here's my own personal observations, thoughts on sundowning and theory, based on my years of working with the memory impaired.
For some, especially in a facility, I don't always consider the behaviors exhibited around dinner time "sundowning" but rather a result of a day full of activities, visitors, visit with the doctor - simply over-stimulation and the need for a "time out" spending a bit of time earlier in the afternoon (before the sundowning typically starts) simply relaxing - smaller groups, soft light, soft music, maybe a hand massage with some lavendar lotion. While facilities have great intentions in providing a full activity schedule, it may be too much for some. At home it may be over-stimulation or just a need to slow down later in the afternoon - turning off the tv, asking visitors to respect a need to limit time visiting or coming earlier in the day if possible.
Before I give examples, if you have a loved one or someone in your care who sundowns, think about what they did for a living before the disease and what their routine was like. Keeping their former profession and routine in mind, think about what they would have been doing at that time of the day. For someone who has problems with short term memory, as the disease progresses, the only memories that are left are the older memories of their life and routine, going back to when they were in their 30s. 20s, or earlier.
Everyone experiences sundowning at different times of the day. Here are some examples:
A farmer typically starts their day before the sun is even up! I have observed dairy farmers experience sundowning earlier in the day than most. When I look at the biography that I had the family fill out prior to admission and saw what they did for a living and that their day typically started at 3 or 4AM, it made sense to me when they began getting a bit agitated in the early afternoon, even though all their needs were met (they had lunch, perhaps a snack, they were toileted, etc) that 3 or 4 pm was the time of day they would be winding down their day, Moving equipment back in a barn, tending to herd, and after a day in the elements - the sun, the rain, the snow, they were ready for dinner and bed! At times I'd observe my farmer walking in and out of the building, agitated. Could he possibly be thinking, "This isn't my farm!" "Where are my cows, my corn field, where is my tractor?"
A housewife took care of the home, cooked, cleaned, cared for children, their husband. Think about a routine for someone who had children and who's responsibilities were to make sure their children came home directly after school, dinner prepared and on the table when their husband was due home. When 4pm rolls around and they can't find their children (and I have observed ladies asking where their children are), they are supposed to be preparing dinner because their husband will be angry if it's not on the table. Where are my children? where is my kitchen? At that time of day we would see ladies wandering through the facility, asking for their family, asking what they should do repeatedly, maybe even crying without being able to tell us why.
Office Worker/ Executive
A 9-5 job for some. A commute by bus or train for some to get to and from work. I cared for a gentleman who was a CEO of a major company that flew him around the country and beyond. Since I was almost always in a dress, he thought I was his flight attendant and would ask when his flight to Houston was boarding. For others, around the end of a typical work day, in addition to observing some anxiety, agitation we would hear comments like, "I need to get home", "Where is my car", "How do I get to the bus/train station?"
My favorite was the people asking when happy hour starts or gave me their drink order.
When you think about their behavior in those terms, it may be easier to comfort or calm them during that "sundowning" period. For the housewife - let her help set the table, tell her the kids are fine, they'll be home soon. For the commuter - (we had little indoor porches with benches) take them to a spot to sit and tell them this is the bus/train stop. Bring some other "commuters" to the same sitting area. Hopefully they will begin interacting and they forget why they are sitting there. I've heard some interesting comversations at the"bus stop".
A person who is sundowning may not be able to tell you what is wrong, what they want or need - they may just feel like there is something they should be doing but can't communicate what that is which is why they are so anxious or agitated or sad.
Whatever the case, whatever the time of the sundowning, the goal is to try to put their mind at ease. Sometimes just slowing the day down for them before dinner and trying some soothing one-to-one attention may be the trick. For some that become very anxious, sad, agitated if all other interventions have been tried and still feeling those unpleasant feelings, perhaps their doctor needs to take a look at their current medications and even though I don't like to suggest it, I hate more to see someone crying inconsolably, anxious or agitated to the point that they may hurt themselves or others - sometimes an anti-anxiety medication may help. If they have been prescribed an anti-anxiety medication already - look at the time of day they are getting it. Sometimes it doesn't mean that something needs to be added but the time of day it is given needs to be changed.
My biggest piece of advice is determine what time of the day they have had heightened anxiety. If it is a fairly consistent time of day (as sundowning usually is) be proactive in toileting them before that magical time of day, find soothing activities that you could engage them in - soft music, looking at a picture book and have them tell you about what they see and what they know and always be impressed by their story! Keep them or get them into a regular routine. Keeping them active throughout the day is important but wind down the level of activity as the day goes on.