Is Sundowning Dangerous? Safely Navigate Evening Agitation

As a caregiver, you might be concerned about whether sundowning syndrome in people with dementia is dangerous. The short answer is, it can be. Sundowning refers to increased confusion and restlessness, usually in the late afternoon or early evening. It can lead to risky behaviors like aggression or wandering away from home. 

These changes can be dangerous for your loved one and others. It’s important to recognize and manage these behaviors safely. In this article, we’ll review:

  • Aggression during sundowning & tips to help
  • Wandering during sundowning & tips to help 
  • When to seek medical attention 
  • Management of sundowning

Interested in learning more about dementia, its symptoms, and caregiving? Check if you have free access to Trualta’s learning library.

Aggression During Sundowning 

Individuals experiencing sundowning may become more aggressive. This can show up as:

  • Verbal aggression: Yelling, swearing, or making threats.
  • Physical aggression: Hitting, pinching, throwing objects, or other violent behaviors.

Aggression during sundowning is often a response to restlessness, fear, or frustration, and it’s not a reflection of your loved one’s feelings toward you. They might feel unsettled by changes in their surroundings or a decreased ability to recognize the people around them, leading to outbursts. 

Aggression can also occur if they’re trying to express an unmet need, such as hunger, thirst, or pain. When they can’t communicate these needs, frustration builds, which can lead to aggressive behavior. 

This aggression can be dangerous, potentially resulting in injury for both the caregiver and the person experiencing sundowning. Recognizing the cause of the aggression can help you respond more effectively.

Tips For Coping With Aggression

When dealing with aggression and experiencing sundowning behavior, staying calm is key. Here are some helpful tips to manage the situation:

  1. Speak gently: Speak calmly and be mindful of your facial expressions and body language. Your loved one will often mirror your behavior, so keeping a peaceful demeanor can help them feel more at ease.
  2. Reassure them: Let them know they’re safe and that you’re there to help. It can be helpful to agree with them or validate their feelings, showing that you understand and are on their side.
  3. Ask if they need anything: Anger can sometimes be caused by unmet needs, like hunger or thirst. Offering something they need, like a snack or a drink, can help calm the situation.
  4. Use distractions: Redirect their attention to something they enjoy, like a favorite activity, TV show, or piece of music. Distraction can help reduce feelings of being overwhelmed.
  5. Give them space: If aggression escalates, step back and maintain a safe distance. Sometimes, stepping away for a short time can help them calm down.
  6. Reduce stressful triggers: Identify any factors that may be contributing to agitation, such as loud noises or too much clutter. Minimizing these triggers can help lower stress levels and prevent further agitation.
  7. Remove dangerous objects. Store dangerous and sharp objects in a locked cabinet or other secure location to prevent the person with dementia from getting them.  

If aggression becomes more frequent or severe, talk to a doctor. They may recommend medications that could help. In an emergency, call 911 and tell responders the person has dementia.

A man sits on the edge of a bed, resting his head on his hand with a distressed expression, while a woman places a comforting hand on his shoulder.

Wandering During Sundowning

Wandering is a common sundowning behaviour associated with late day confusion. People with dementia may leave the house, either searching for something familiar or because they’re disoriented. They might head toward a place they remember and become confused and lose their way. This can lead to your loved one getting lost or injured.

According to the Alzheimer’s Association, about 6 in 10 people with dementia will wander at least once, and many do so repeatedly.  For caregivers and family members, the worry about wandering can be incredibly stressful. If wandering happens often in your household, it’s important to take proactive steps to keep your loved one safe.

Tips To Handle Wandering Safely

Wandering is dangerous and usually occurs during the evening hours when sundowning occurs. If your loved one is missing, start search-and-rescue efforts immediately. Most individuals who wander are found within 1.5 miles of where they disappeared. If they’re missing for more than 15 minutes, call 911.

If wandering does occur, here are some practical steps to help reduce the risk of harm:

  1. Neighborhood awareness: Inform your neighbors that your loved one has dementia. They can watch for wandering and alert you if they see your loved one alone outside their home.
  2. Install safety measures: If your loved one wanders, consider using door alarms, or using medical ID bracelets that can help locate your loved ones.
  3. Safety plan: Have a plan in place if wandering occurs. Search the areas your loved one is most likely to go. Keep a photo of your loved one handy to show to others.
  4. Enroll in a safety program: Many areas offer programs like MedicAlert, which can help locate a missing person with dementia. 
  5. Monitor driving: If your loved one is in independent living and can still drive, consider using a GPS device to track them in case they get lost. If they’re no longer able to drive, remove access to car keys. People with dementia may forget they can no longer drive and could wander off in a car.
  6. Avoid locking them inside: Never lock your loved one inside their home. This could create an unsafe situation if they need help or try to leave during an episode of confusion.

When to Seek Medical Help

While sundowning can be managed with behavioral strategies, there are times when you should reach out to your healthcare team. Here are a few signs that it’s time to get help:

  • Escalating aggression: If your loved one’s aggression becomes violent or dangerous, it’s important to consult a doctor. Medications may be necessary to help manage the behavior.
  • Signs of physical pain: If your loved one is in pain or discomfort, you should seek medical attention. Untreated pain can worsen sundowning.
  • Sudden or severe changes: Sudden, severe increased confusion or changes in behavior could indicate delirium. Delirium is a medical emergency that requires immediate attention. Delirium comes on suddenly and can be caused by infections or other serious health conditions.

Delirium Vs. Dementia

Delirium and dementia can look similar, especially during sundowning episodes. Understanding the difference is crucial for proper care. Delirium is an acute condition that causes increased confusion, rapid mood swings, and fluctuating alertness. It’s often triggered by an underlying medical issue and requires prompt medical attention. Unlike sundowning, delirium symptoms can occur at any time of day and do not improve on their own.

If your loved one suddenly becomes more confused, drowsy, or hard to wake, contact a doctor right away. Any sudden change in behavior that doesn’t improve with usual management strategies should also be addressed by a medical professional. Delirium can cause long-term damage if untreated, so seeking medical help as soon as possible is essential.

Managing Sundowning

A good strategy to reduce the risks associated with sundowning is to address the behaviors that trigger it. Strategies to reduce the risk of sundowning include:

  • Maintain a consistent routine: A regular schedule, especially in the early evening, helps reduce confusion and stress.
  • Reduce sleep disturbance: Promote good sleep habits to ensure restful sleep and minimize disruptions. Avoid napping late into the afternoon.
  • Ensure adequate natural light: Make sure your loved one gets plenty of natural light during the day and bright light as evening approaches to regulate their sleep wake cycle.
  • Encourage activity: Regular mental and physical activity can help reduce boredom and restlessness.

Don’t forget to check if you have free access to Trualta’s learning library for more information about managing sundowning behavior and other dementia symptoms.

Conclusion

Sundowning can trigger dangerous behaviors, such as increased aggression and wandering. It’s important to recognize these signs and respond quickly to ensure safety. If your loved one becomes more aggressive, shows sudden behavior changes, or appears to be in pain, seek medical attention to rule out delirium or other health issues. Proper management techniques can reduce risks associated with sundowning and help protect you and your loved one’s well-being.

References: 

  1. Bryn Mawr Communications. (n.d.). Wandering & Sundowning in dementia – Practical Neurology. Practical Neurology. https://practicalneurology.com/articles/2022-june/wandering-sundowning-in-dementia 
  2. NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center. (2024). Tips for managing agitation, aggression, and sundowning. https://order.nia.nih.gov/sites/default/files/2024-12/nia-sundowning-agitation-aggression.pdf 
  3. Wandering | Alzheimer’s Association. (n.d.-a). Alzheimer’s Association. https://www.alz.org/help-support/caregiving/stages-behaviors/wandering 

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