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‘Sundowning’ in Dementia Care

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approaches to dementia care, dementia awareness, research

‘Sundowning’ or Sundown syndrome is a broad term describing a set of neuropsychiatric symptoms which worsen at or around sunset and may persist throughout the night. In dementia patients, sundowning is a relevant clinical phenomenon, with a prevalence rate of up to 66% dependent on the setting (Canevelli et al., 2016). In institutionalised dementia patients, sundowning is reported to be the second most common type of disruptive behaviour as it causes confusion, anxiety, agitation and/or wandering (Canevelli et al., 2016).

Indicated as one of the leading causes for institutionalisation of dementia patients, sundowning is hard to predict and manage. Unfortunately, there is a relationship between the occurrence of sundowning and the perceived stress of dementia caregivers (Gallagher-Thompson et al., 1992), which can influence the quality of care given to the patient. Sundowning behaviour is particularly challenging for caregivers because it occurs near the end of the day when they are already fatigued. The risk of caregiver ‘burnout’ is also increased because disrupted sleep patterns in dementia patients can make them more prone to wander. One study also found that dementia caregivers lose 2.42 to 3.5 hours of sleep each week compared to non-caregiver controls (Gao et al., 2019). Caring by a fatigued and stressed caregiver may lead to wrong management strategies and exacerbate neuropsychiatric symptoms experienced by the patient. Thus, there is a need to better understand sundowning and develop effective strategies to improve caregiver treatment and mentality.

There is no single cause for sundowning behaviour, and it is largely unpredictable, however, there are a few environmental factors which can be managed to reduce the risk of triggering sundowning in dementia patients. Unfamiliar environments and environmental overstimulation (such as noise and chaos) can instigate sundowning behaviours, so increasing the availability of home caregivers, where the patient feels most comfortable, is extremely important. Stimulation during the evening hours may also serve as distractions which add to the person’s confusion, so minimising these can aid in preventing sundowning.

Lack of exposure to an adequate amount of natural light can also initiate sundowning – often because reduced lighting can increase shadows and cause the person living with dementia to misinterpret what they see. Keeping the home or environment well lit during the evening and encouraging walks or time outside during the day can help the patient better understand their surroundings and feel less confused by their environment.

I think the general consensus is that sundowning is something that ‘just happens’ with dementia, and there is little that can be done for it. However, improving public knowledge and caregiver knowledge on how to recognise, approach and manage sundowning may significantly improve the wellbeing of patients and reduce the risk of sundowning behaviour. For example, The Alzheimer’s Association (2021) suggests that accompanying the dementia patient when they wander around can reduce their restlessness. This is one of many examples of how relating to the person with dementia can improve their wellbeing.

References:

The Alzheimer's Association. (2021). Sleep Issues and Sundowning. Available: https://www.alz.org/help-support/caregiving/stages-behaviors/sleep-issues-sundowning. Last accessed 22nd Nov 2021.
Canevelli M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, & Bruno G (2016). Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches. Front Med 3: 73.
Gallagher-Thompson D, Brooks JO, Bliwise D, Leader J, Yesavage JA. The relations among caregiver stress, “sundowning” symptoms, and cognitive decline in Alzheimer’s disease. J Am Geriatr Soc (1992) 40: 807-810
Gao C, Chapagain NY, & Scullin MK (2019). Sleep Duration and Sleep Quality in Caregivers of Patients With Dementia. JAMA Netw Open 2: e199891.

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