Sometime during the late afternoon or early evening, something changes. A loved one with dementia may become more irritable, agitated or disoriented. Or maybe they have some sense of paranoia, such as thinking their house is being invaded.
These nightly psychiatric symptoms are collectively known as sundowning syndrome. And while disruption to someone’s internal body clock is a common factor, the cause of the syndrome — which affects as many as 2 in 3 dementia patients — is not clear.
Dementia is not a normal part of aging and has no known cure. More than 7 million Americans older than 65 live with Alzheimer’s disease, the main type of dementia, with North Carolina and South Carolina accounting for 23% of that population.
Dementia patients lack self-awareness and often forget that they forget, which can be especially challenging for their caregivers. The often unexpected (and unpaid) task of caregiving can feel jarring and frustrating, with more than half of the 11 million caregivers in the U.S. reporting high stress, according to the Alzheimer’s Association.
Here, neurologist Dr. Nan Jiang of Novant Health Neurology - Brunswick Forest in Leland, North Carolina, answers common questions around sundowning syndrome and offers guidance for caregivers.
Memory care for you and your family.
How is sundowning defined? Is it a diagnosis or a symptom?
Sundowning is a common clinical symptom of dementia, which we think has to do with an interruption of circadian rhythms. For some reason, right around late afternoon toward nighttime, some people with dementia get more confused and more agitated, and sometimes more difficult to control.
As a caregiver, what are some ways to help a loved one experiencing sundowning?
As caregivers take on this role and navigate new daily terrain, the National Council of Certified Dementia Practitioners recommends following the “Four R’s” of dementia care:
- Reassure: Speak calmly and reinforce that your loved one is safe with you.
- Routine: Maintain a consistent daily schedule broken up into manageable steps.
- Reminisce: Look at photos from their past to evoke and discuss memories.
- Redirect: Steer their attention elsewhere. If they say they want to go home, even though they’re already home, try responding with, “Let’s have a cup of tea and look at this book first.”
Caregivers should prioritize their own well-being, and the Centers for Disease Control and Prevention recommends steps to reduce caregivers’ risk of memory loss. If you know a caregiver, offering support by checking in regularly or helping with small errands can make a big difference.
The main tactics we teach caregivers are de-escalating and redirecting. That means saying something like, “Hey, let’s watch a little bit of TV,” or “Let’s go for a walk,” or “Let’s listen to some music.” We caution caregivers from saying, “We already talked about this,” which is not helpful. Don't argue; it’s not going to get anywhere.
We also ask caregivers to make sure that patients are not napping during the day. Catnaps mess up their circadian rhythm and can affect how they sleep at night.
What should the next step be when de-escalating and redirecting prove unsuccessful?
I meet with a lot of caregivers who say their husband or wife is sundowning. We always start with non-drug interventions. But when sundowning becomes a safety concern by escalating consistently, we may start the patient on medicines, such as antipsychotics, at very low doses.
Support groups for Alzheimer’s and other types of dementia are a helpful resource for caregivers. I encourage them to access this type of personal support for the best insight into the day-to-day questions around sundowning. They’re often more helpful than I can be.
What should caregivers be asking about memory care?
Don't dismiss forgetting as just normal aging. It isn’t. People who feel forgetful might sometimes enter a room and not remember why. That can be a sign of normal aging, but someone experiencing that consistently should get their memory evaluated. Talk with your primary care provider, who can offer memory screening and refer an abnormal finding to a neurologist. If you have any concern about your memory, don’t put it off.
