Managing Sundowning in Dementia - Practical Strategies

Today is a very exciting blog post, at least to me because it's about managing sundowning. In the last blog post we talked about understanding sundowning, what it is, and some of it's contributing factors. If you haven't read that blog post yet, I'd strongly recommend you read that one first and then meet me back here. But of course, the choice is yours. If you've already read the first part of this series, then you know that you had some homework. 😬

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We were to keep a five day log of your partner's activities from the time they woke up until the time they went to bed. Right? And we wanted to try to identify the time or time range that the behavior started and then make a special note of anything going on around that time and what your partner used to do at that time. So, if you are just now finding our blog and didn't get a chance to keep a five day log, then it's never too late. You can always come back.  

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Now, if you did keep a log, then you're going to want to pull it out so we can kind of go through this together. So first question: were you able to identify the pattern of what time the behaviors normally started? For most people, this time will be from around 2:00 p.m. to 8:00 p.m. Not to say that it can't or won't start earlier or later, just typically, it'll be between those times. Now, what was going on around this time, specifically? If there was a lot going on, like movement or noise, such as talking or loud music or loud TV or banging around, then you'll want to make a special note. In the evening hour, it's very easy for people living with dementia to become overstimulated when there's too much going on. In the evening, you'll want to engage the person in activities that require low cognitive demand and is, in a sense, winding them down for the night. So simple activities could include going for a walk, reminiscing through a photo album, watching a show or anything like that. But it should be simple and not require too much effort as that could open the door to frustration and anger. You also want to keep things quiet and settle. So less is definitely more in the evening.

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Now, let's also look at this time from another angle. What did your partner used to do around this time? Did they exercise, maybe pick up children from school, go to work, start cooking? What did they used to do and what were they doing around the time the behavior started in the present? What were they doing? In most cases, they likely weren't doing much of anything. And then all of a sudden, boom, they want to be active. They want to move around. They may start wandering or pacing or get anxious because they have something they need to do and that may even require them to go home or go somewhere else. So if this is your partner, you may try planning an activity around this time—something to keep their mind lightly preoccupied.

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So depending on the time, can they help you prepare dinner? Can you go for a walk together? Can you have them help you fold clothes? Can you sing songs with them—something to distract them from that time trigger of. "Oh, wait, there's something I should be doing."  

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Now let's rewind a bit, because the morning routine or lack thereof can be the source of a lot of problems. It's important to establish a predictable, consistent routine. People living with dementia tend to respond best when they know what to anticipate—when things feel familiar.  

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Now, did your partner wake up on their own or did you wake them up and if you woke them up, did they give you a fuss about it? Sometimes people tend to do better during the day when they naturally wake up on their own, because we can never be too sure what part of the sleep cycle we are waking a person up in when we just abruptly wake them up from their sleep. That can really throw a person off and for the rest of the day. Just think about when you're abruptly startled awake. It can kind of throw you off and make you feel funny, you know? Now, if they are already awake but just don't want to get out of bed, then that's a different thing. But, I'm talking about sleeping restfully and then, boom, time to wake up.

Now, sometimes this is necessary if there's like an appointment to get to or something that has more of a time restriction that must be met. However, typically is possible, it's usually better to let the person wake up on their own. But once their eyes are open, then it's fair game because as we know, some people can literally sleep on and off all day long if you never encouraged them to get up.

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Another thing to be mindful of is medications, whether they are taking them or refusing to take them. As I mentioned in the last blog, you always want to keep a medication log so that you can notice if changes in your partner's behavior may be related to the medications. If your partner is missing multiple doses due to refusal, or if it's causing a lot of distress for both you and your partner, then I strongly recommend that you ask the doctor if the medications come in a different form or if the pill is able to be crushed, dissolved or mixed with something else to help increase the chances of your person taking their medications.

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Now, food and water intake is the next big thing that we want to look at, if your person has a good appetite and eats, eats, eats— this likely isn't your biggest issue unless they like sweets or caffeinated drinks or alcohol. If this is the case, see if their sweet tooth can be satisfied by sweet fruits or smoothies versus sweet treats that are high in artificial sugars. Even if your person is diabetic, fruit is usually still a safe, healthy option.

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But you definitely, want to try to avoid fruit juices or dried fruits with added sugar or canned fruits with sugar syrup, which can cause spikes in blood sugar. If your person is a caffeine fiend, then you can try rotating between caffeinated and decaffeinated cups of coffee and you definitely want to make sure that you are giving them caffeine too late in the day, let's say, after 3:00, 4:00, 5:00 at the latest. And alcohol, if they are big on drinking, try to limit the alcohol.  

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If your person is on the other end of the spectrum because they skip a lot of meals due to a refusal or they are constantly complaining about being hungry, then you have a different challenge. If they say they're hungry, you may want to schedule in a simple, at least semi-healthy but still desirable snack option. These snacks will depend on what your person likes, but it's usually not going to be enough to tell them, "What do you mean you're hungry? You just ate?" I mean, I have this issue myself. I could eat and literally like an hour later be hungry again. Sometimes we just need something else, you know? And we shouldn't be punished for it or made to wait for five hours until we can eat again. Ok? So try to identify a few snack ideas that can be prepared ahead of time and kept in the fridge or pantry. When they say they're hungry, you say, "you're hungry? Would you like this or that?"

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Now, if your person often refuses food, then we really have a unique challenge up our sleeves and this could be our issue. As dementia progresses, it can alter the way a person perceives hunger. Sometimes they just don't feel hungry or they can't assign how they feel to something like hunger, like, "I feel this sensation, but I don't know what that means."

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But there also can be a slew of other reasons why your person is refusing to eat. If the person is not eating or not eating enough and therefore not getting the proper nutrition, we can have issues with blood sugar, blood pressure, weakness, general feelings of unwellness, we can run into problems with dehydration, which, of course, causes its own issues, and it can just really be a mess. Do the best you can to get them to eat more by offering frequent snack meal, especially finger food options and drink options, including soups. You can also try smoothies, protein shakes or boost ensure, things like that.  

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The next thing we want to take a look at is sun, light and activity. Does your person get adequate sunlight exposure during the day or do the blinds stay closed and the person stays inside. If your situation is the latter, I would definitely recommend you open those blinds up. If your partner's sensitive to light, then adjust accordingly. But open those blinds and get them outside for a little bit, at least 10 minutes. It doesn't have to be much, but sunlight increases the amount of vitamin D that the body produces, which is good. It can improve the person's level of alertness. It can improve their mood and help reset the body's internal clock, which we learned in the last blog post, that disruptions in the circadian rhythm can be a contributing factor to sundowning.

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Now, when it comes to activity, the late morning is usually the best time to do more active things. You, of course, want to start slow from the time they wake up and kind of buildup. But it's usually the best time for like appointments and the best time to engage the person in any task that requires more cognitive demand. And you'll want to keep a record of the success of these activities. Success, meaning engagement and enjoyment, not accuracy or correctness. So some activities may be just right and some activities may be too taxing or demanding, causing frustration and agitation, or they may just not enjoy it. So you'll want to adjust accordingly. Some activities you could try is clipping coupons, craft projects, chair yoga, gentle exercises, going for a walk, playing board games, things like that. But you definitely don't want to try to do too much because you may pay for it later in the day when they're really tired and they get agitated with you.

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Then we have the infamous nap time, which there's nothing wrong with taking a brief nap, say, before or after lunch. But, excessive napping can do more harm than good. And you'll have to ask yourself whether they are napping so much because they are truly tired or because they are truly bored. That's really the million dollar question. OK? Now, if your partner takes a routine nap during the day, then you'll want to try to keep the nap between 30 and 90 minutes. Anything less than thirty minutes is really just a tease and anything longer than 90 minutes can make them wake up more groggy, throw them off a bit, or make it just more challenging for them to go to bed at night, which we already know can be a big issue for a lot of people living with dementia—going to bed at night. Also, if you notice, your partner gets thrown off if they don't get their daily nap, then you want to make sure that an important must of their routine is a daily nap. You got to fit it in there.

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Now let's jump back into the evening. So we already talked about the importance of keeping things simple and quiet. But, another thing you want to do is make sure that you close the windows when the sun is setting and then turn on the lights in the house, because this will help reduce shadows in the house that can be confusing or scary and cause misperceptions for your partner. And, if the house is kind of cluttered, then you may want to take some time to clean up a bit and make sure that the pathways are clear because clutter can become confusing. And you may even consider seeing if your partner would help you work on this maybe during the day, because it'll give you guys something else to do together.  

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Now, something important that I want you guys to remember is that when a person paces or starts moving all throughout the home, the goal is not necessarily to keep them from pacing, but to create a safe environment in which they can pace. So, if there is loose cords, cluttered pathways, hazardous objects chillin' out in the open or easily accessible, breakables or valuables laying out in the open— this will only increase the risk for fall or injury or increase your anxiety because you'll feel like you'll need to follow them around everywhere or constantly tell them to sit down and stop messing with things, OK?  

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Another thing that we want to take a look at is the night routine. Is there even a night routine? There should at least be a gradual winding down to the day. There should not be this abrupt "well, party's over, go to bed." Ok? The environment should move into a soothing, quiet vibe, maybe some soft music. If your partner prefers showers in the evenings and you can help them clean up, maybe massage them down with lotion, warm them up. If your person likes the smell of lavender or chamomile, then that can be a thing. But just make sure it's not too potent because that stuff can give people a headache if you overdo it. If they don't shower at night, maybe you have a routine where pajamas go on and they just sit and watch TV for a little bit. If they do watch TV, though, try to stay away from like action movies or high energy TV shows, where it kind of works you up. Like for me, reality shows before bedtime is a no no because I get so irritated and worked up and I'll be up literally all night thinking about all the silly things these people do in these reality shows.  

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The last thing you want to consider are any of the more like medical or physiological factors. So make sure that you're addressing pain, any continence issues, including incontinence and constipation, because that's enough to stir anyone up. You know, that feeling of needing to use the bathroom, but you can't or that feeling of being wet—that is just not a good feeling, ok? You also want to be mindful of infections, especially UTIs, so sudden behavior changes, strong urine, smell, dark urine color sediments or blood in the urine, frequent need to urinate or feel like they need to urinate more frequent, fidgeting with their private areas — things like that. And, make sure that they feel safe and secure. Maybe consider things like nightlights, make sure that the temperature is comfortable for them, hold their hand, lay down with them, sing them a song, comfort and reassure them—whatever is necessary.

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If you haven't read to part one of this series on Sundowning about understanding sundowning please, please, please go check it out. I think you will really find it helpful again.  

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