Doctors Say This Nighttime Behavior Can Be A Sign Of Dementia
There are plenty of reason you might feel off in the late afternoon and evening. Maybe you’re mentally wiped after socializing all day, or your brain is fried from hours of work. If you got up early, it could simply be that you’d rather crawl under a blanket and watch Netflix than interact with other people—all of these are legitimate reasons to feel cranky during this time.
But in people with dementia—which is an umbrella term for mental decline and can be related to a number of diseases such as Alzheimer's—there’s a phenomenon known as “sundowning,” where symptoms (such as being agitated or anxious) ramp up later in the day and evening.
As you head into the holiday season, you’re likely spending more time than usual with older loved ones. With that, it’s worth it for any adult to better understand how sundowning presents, and what it might mean for the cognitive health of your loved one. We tapped two health care providers who treat older adults for more information.
Meet the experts: Shannel Kassis Elhelou, PsyD, is a geropsychology and neuropsychology fellow at the Pacific Neuroscience Institute’s Brain Wellness and Lifestyle Programs at Providence Saint John’s Health Center in Santa Monica, California. Fred Kobylarz, MD, is co-director of the Center for Healthy Aging at Rutgers Robert Wood Johnson Medical School.
‘Sundowning’ is a term that refers to behavior changes in people with dementia that occur at a particular time of day.
Also known as “sundowner’s syndrome,” sundowning is a set of symptoms or behaviors that can be seen in some people with Alzheimer’s disease and dementia, according to the Alzheimer’s Association.
“This usually happens as the dementia progresses,” says Fred Kobylarz, MD, co-director of the Center for Healthy Aging at Rutgers Robert Wood Johnson Medical School. “It is not a disease, but a symptom of dementia.” Unfortunately, doctors “don’t really know the cause of this,” he adds. It's possible that sundowning in dementia patients is caused by a combination of hormonal changes, brain deterioration or damage that has occurred, environmental factors, disruption to a person's circadian rhythm, and more.
Symptoms of sundowning can vary by person, but they can include:
Anxiety
Agitation
Pacing
Disorientation
Hallucinations
Trouble sleeping
Sundowning “typically occurs in the late afternoon and evening in individuals diagnosed with dementia,” says Shannel Kassis Elhelou, PsyD, a geropsychology and neuropsychology fellow at the Pacific Neuroscience Institute’s Brain Wellness and Lifestyle Programs at Providence Saint John’s Health Center in Santa Monica, California. However, Dr. Kobylarz notes it can start as early as 1 p.m. for some people.
What Sundowning Looks Like
There’s a difference between being totally over your day and sundowning. In addition to the symptoms listed above, sundowning can include verbal or even physical outbursts, Elhelou says. That may mean lashing out when dinner isn’t what they thought it would be or getting frustrated when they can’t find something.
Some people may even want to be physically closer than usual to loved ones, following them closely “for reassurance,” Elhelou says.
For others, sundowning can show up as confusion. “They will not remember conversations from earlier in the day or what they ate,” Dr. Kobylarz says. That can including wanting to eat dinner again right after finishing a meal they don't remember. People also may not remember where their home is or the loved ones who take care of them, Dr. Kobylarz says.
“You can see [the person with dementia] change at a certain time of the day and almost become another person,” he adds.
Can sundowning be a sign of early dementia?
Sundowning is often a symptom that happens after someone is diagnosed with dementia or a dementia-related disease, but it can also be an early sign of mental decline itself. “There are changes taking place in the brain,” Dr. Kobylarz explains, that lead to the onset of dementia and continue as it progresses. So, it is possible for someone to exhibit sundowning behaviors who has not yet been diagnosed with dementia.
But Elhelou stresses that if you notice a loved one showing signs of sundowning, it doesn’t necessarily guarantee that they have dementia. “While sundowning is more common in dementia, it is not exclusive to it,” she notes. “Similar symptoms can occasionally be seen in older adults without dementia, particularly when they are ill or experiencing delirium.”
How To Distinguish Sundowning From Typical Aging
Again, it’s completely normal to feel like you’re not the best version of yourself when it’s later in the day, especially for older adults. That goes double over the holidays, when everyone is stressed and overstimulated. But sundowning has some unique signs that make it stand out from just being tired.
“Fatigue can occur at all times of the day. Sundowning is truly confusion,” Dr. Kobylarz says. “If you have fatigue, you can take a catnap and feel refreshed. With sundowning, they are not usually fatigued, and they are ready to go.”
Sundowning also tends to happen consistently around the same time of day, Elhelou says. “It often includes cognitive effects such as significant disorientation or impaired judgement,” she says. If someone is experiencing actual sundowning, they’re also likely to still display symptoms even after they rest, Elhelou points out.
How To Help A Loved One Manage Sundowning
Managing sundowning means trying to figure out your loved one’s new rhythm. “Managing sundowning should include a regular routine with scheduling and caregiving—essentially knowing their best time of day,” Dr. Kobylarz says.
While Elhelou says it can be “challenging” to manage sundowning, she recommends creating a calm environment and routine as best you can. “Start by maintaining a consistent daily routine to reduce confusion and fatigue,” she says. “Encourage activities and exposure to natural light during the day to support healthy sleep-wake cycles.”
It's also crucial to try to avoid overstimulation in the evenings by limiting loud noises, bright screens, or large gatherings. “Address physical needs, such as hunger, thirst, or discomfort to ensure they feel secure,” Elhelou says.
Again, showing symptoms of sundowning doesn’t automatically mean that your loved one has dementia—but it is something to get checked out. “As soon as you suspect sundowning changes in your loved one, bring this this up with [their] doctor,” Dr. Kobylarz says.
The doctor can look for potential underlying causes, including dementia, medication effects, or environmental factors, Elhelou says. From there, they can suggest effective ways to help you manage the behavioral changes.
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