behaviour

Sundowning: Late-Day Confusion for People with Dementia

Over the holidays, my brother and I tried to visit our mother on a daily basis.  My brother mentioned that he preferred to visit in the morning, because her behaviour changes significantly after the sun goes down.

This neurological phenomenon is known as Sundowning or Sundown Syndrome, which I witnessed firsthand while working at an assisted living facility.

Sundowning is an ailment of Alzheimer's Disease and other forms of dementia, and is most prevalent in the elderly, that causes symptoms of confusion after "sundown."

Dementia sufferers purport periods of extreme anxiety, increased confusion, delusions or paranoia during mid-afternoon to early evening, although specific behavioural changes are unique to the individual.

Interestingly, the specific causes of sundowning is considered somewhat of a medical mystery and has not been empirically proven to date. There are several theories on the exact cause, but some evidence suggests that disruption to the circadian rhythm can directly impact sundowning behaviours. 

Some doctors believe it’s an accumulation of the sensory stimulation from the day which begins to overwhelm and cause stress, while others speculate that Sundown Syndrome is caused by hormonal imbalances that occur at night. 

According to the Alzheimer Society of Canada, it is thought that sundowning can be a problem for as many as 66% of people with Alzheimer’s disease or other dementias.

These changes in behaviour can be very difficult and frustrating for caregivers. The good news is that there are several ways of coping with the confusion and irritability 

Here are some tips to help come with caring for your loved one after sunset. 

Link Between Brain and Behaviour

There is a direct link between our brain and how we behave. This is because the brain acts as the control centre for the actions and reactions to stimuli in the environment. For a person living with Alzheimer's, the link is disrupted and the brain's messages are no longer relayed. 

It is important to know alterations in a person's behaviour can be an indication of specific physical changes to certain areas of the brain. 

The main areas of concern in Alzheimer disease:

Limbic system controls memory and emotion; it links the lobes of the brain, enabling them to connect behaviour with memories. It also controls emotion and daily function such as sleeping and eating. The Limbic system is affected early on in Alzheimer disease. 

A common example of what can happen when the limbic system is involved is that the person may not be able to find an object having forgotten where it was put. He/she may immediately assume it has been stolen. The person may become very emotional and may blame others for taking it. To diffuse the situation, do not argue, but rather suggest a plan of how to retrieve the missing object.

Temporal Lobes contains the major memory centre of the brain called the hippocampus, also part of the Limbic System, where verbal and visual memory are processed.

Verbal memories are words. Memories related to what we read, say or hear, whereas visual memory is what we use to recognize objects, faces and places, to guide us around our environments.

The Temporal Lobes also control new learning and short-term memory. We know the Temporal Lobes are affected when the individual begins to experience lapses in short-term memory. That is to say, something that happened five minutes ago is quickly forgotten. There is no ability to retain memories of the recent past and therefore the person lives in the present moment. What is seen now is reality.

For example, if you have been for a visit and left, the person that is beyond the early stage of the disease will have no memory of your visit to them. You were never there, because you are not there now. The person will no longer be able to connect time and place to the present reality.

The person may lose vocabulary skills and have difficulty understanding what words mean. He/she may go out to a familiar place and then not know how he/she got there or how to get home again.

Damage to the temporal occipital part on both sides of the brain may also cause Agnosia, that is not recognizing familiar faces, objects or places.

For the person with Alzheimer disease, losing the connection to familiar faces must be terrifying. And for caregivers, this can be one of the most heart breaking symptoms of the disease; the moment when their loved one no longer knows who they are.

A useful tip is to have photos of special people prominently displayed with their names clearly shown. This can be used to help the person reminisce about special times with people who are important to them.

The condition also applies to objects. The person may no longer recognize a familiar object or its purpose. For example, not understanding what a hair brush is for.

Part of the Alzheimer Journey is about discovering how the progressive degeneration of brain cells will impact an individual's behaviour, mood and emotions.

When supporting a person with dementia who is behaving out of character, try and look beyond the behaviour itself to discover the root cause. Sometimes behavioural changes can be a result of frustration, a sense of being out of control, or a feeling of not being listened to or understood.

Personality changes could be the earliest sign of Alzheimer's, so here are 10 early symptoms of dementia to be aware of.

Wandering during Dementia

Imagine going for a walk during the day, getting lost, and not being able to find your way back home. Or one of your loved ones wanders out in the middle of the night with no coat or socks. This is a reality the people living with dementia and their caregivers face. 

Wandering is a common behaviour for people with dementia and can occur for numerous reasons, including confusion, delusions, escape from a real or perceived threat and agitation.

It can be very scary for all involved and may lead to stress and concerns for safety.  Wandering may result in highly dangerous situations including elopement, in which the person leaves an area and is unwilling or unable to return. Six in 10 people with dementia will wander.

The easiest way to put yourself in the shoes of someone that has dementia was excellently described in an article on Fisher Center for Alzheimer's Research Foundation website.

For the wanderer himself, the experience is much like going out into a mall parking lot and not knowing where you parked—without knowing why he’s out there.
— Maria Wellisch, R.N., vice president of corporate education for Morningside Ministries in San Antonio, Texas. 

Figuring out why a person living with dementia wanders can be difficult, because each person is different. We do know that wandering is a direct result of physical changes in the brain. Research has determined that it is more common in the middle or later stages of dementia, although it can occur at any point during the disease.

The risks of wandering can be minimized through proactive steps, strategies and services.

Here are 10 ways to prevent wandering