“Coping with Sundowning, Practical Tips and Support for Dementia Caregivers” by Dr. Kirk Christie

Sundowning refers to increased confusion, agitation, anxiety, restlessness, or disorientation that occurs in people with dementia as daylight fades and during the night.

Behavioural Psychological Symptom Disorder (BPSD) is the scientific term for the aforementioned constellation of symptoms.

Sundowning Features

Key features include:

• Increased confusion or memory difficulties in the late day

• Agitation or irritability

• Pacing, wandering, or yelling

• Resistance to care or difficulty following instructions

• Sleep disturbances, such as trouble falling asleep or staying asleep

What is Dementia?

Per the DSM-5: it is a major neurocognitive disorder for which there is no cure. Further, it is a chronic progressive disorder, whose onset is insiduous in nature.

Syndrome of acquired, persistent decline in several realms of intellectual ability:

• problems with memory

• problems with language

• visuospatial problems

• decreased problem-solving, abstraction and other executive functions

• reduced attention

• decreased ability to recognize faces, objects, etc.

• decreased ability to perform complex tasks

• plus functional impairment

Assessment of BPSD symptoms by Caregiver

Ask the following for each BPSD:

• timing: how often? how long does it last? how long has it been present?

  
  

• severity of symptoms: dangerous? distressing? at risk of escalating? other risks (e.g., losing housing)? interfering with care?

  
  

• antecedents: precipitants? patterns?

  
  

• consequences: how do caregivers respond? what works and doesn’t work?

  
  

• history: new behavior? if not new, is it different?

Assessment by Primary Care Physician (Required if symptoms are distressing to patient and the patient's behaviour becoming chaotic or dangerous)

Screen for all BPSD:

• depression

• apathy

• verbal aggression

• physical aggression & agitation

• wandering

• refusing medications or assistance with ADLs

• disturbances of sleep-wake cycle

• anxiety & irritability

• delusions & hallucinations

• elation, euphoria & disinhibition

• pathological laughing or crying

• alterations in appetite & eating

Tips for Caregivers

Environmental Strategies:

• Maintain a consistent routine: keep daily activities and bedtime consistent to reduce confusion and anxiety.

• Optimize lighting:

Increase indoor lighting in the late afternoon and early evening to reduce shadows and help maintain orientation to time.

→ Bright light therapy (morning or early afternoon exposure to natural or artificial light) can help reset the sleep–wake cycle.

• Reduce noise and stimulation:

Keep the environment calm in the evening — lower TV volume, avoid loud conversations, and minimize visitors.

• Familiar surroundings:

Use familiar objects, photographs, and furniture to promote comfort and reduce disorientation

Behavioural and Lifestyle Modification:

• Encourage daytime activity: Gentle exercise or engagement during the day helps promote nighttime sleep and reduce restlessness.

• Avoid daytime naps, especially in the late afternoon.

• Simplify evening tasks:

  Keep evening routines quiet and soothing — listening to calm music, reading, or gentle conversation.

• Avoid caffeine, nicotine, and alcohol in the afternoon and evening.

• Provide comfort and reassurance:

  Stay calm, speak softly, and offer reassurance if the patient becomes agitated or fearful.

Medication and Clinical Management:

• Assess for physical causes:

Check for pain, infection (especially urinary tract infection), constipation, hunger, or medication side effects that might worsen confusion.

• Review medications:

Some drugs (e.g., stimulants, certain antidepressants, or corticosteroids) can interfere with sleep or increase agitation.

• Report immediately to the family members/primary caregiver/ legal guardian of the patient and or surrogate decision maker of the patient and the primary care physician, any distressing symptoms that the patient may be experiencing: that is, depressive symptoms, chaotic or violent behaviour, acts of self-harm or self-injury and any attempts to elope from the carer facility/hospice facility/geriatric facility and to wander off from the residence/home. Consequently, the patient should be accompanied to their primary care physician or medical clinic for a thorough medical evaluation

DICE REGIME:

Describe: caregiver describes problematic behavior: context, environment, patient perspective, degree of distress

Investigate: provider investigates possible causes: meds, pain, medical conditions, psychiatric comorbidity, sleep, sensory changes, loss of control, boredom

Create: caregiver and team collaborate to create and implement treatment plan: respond to physical problems, strategize behavioral interventions

Evaluate: provider evaluates whether interventions have been implemented, and have been safe and effective

Psychologic, Behavioural and Environmental Interventions that are proven effective:

Most effective interventions for patients are:

• structured activities

• music therapy

• reminiscence therapy

• problem-solving therapy

• most effective intervention for families is supporting family caregivers

• most effective interventions for facilities are:

• training programs for formal caregivers

• dementia care mapping or other quality improvement tools

  
  

Summary

Sundowning refers to increased confusion, agitation, anxiety, restlessness, or disorientation that occurs during dusk in persons with Dementia

BPSD is the scientific term for the constellation of symptoms in Dementia patients

The severity of Dementia Disorder can predict what BPSD symptoms will be apparent in the person diagnosed

BPSD symptoms which appear acutely in the person with Dementia should not be ignored and a medical cause should be ruled out

Caregivers play a critical role in describing the sundowning symptoms/BPSD symptoms to clinicians and play a role in the acute management of these symptoms

If you have any additonal questions or seeking more information on Dementia Disorders, do contact Dr. Kirk Christie at Info@kirkchristie.com or at www.kirkchristie.com