Sundowning
Increased confusion, agitation, and behavioral symptoms in late afternoon/evening. Common in dementia (up to 25%). Causes: circadian rhythm disruption, fatigue, low lighting, increased shadows, hunger, pain, overstimulation. Signs: restlessness, pacing, agitation, calling out, aggression, paranoia, hallucinations. Worsens with: unfamiliar environment, sleep deprivation, pain, infection, medications.
Sleep Disturbances
Sleep changes with dementia: fragmented sleep, decreased REM, increased nighttime awakenings, daytime napping. Contributing factors: neurodegeneration of sleep centers, circadian disruption, medications, pain, nocturia, restless leg syndrome, sleep apnea, environmental factors (noise, light, temperature). Impact: worsens cognition, behavior, mood; increases caregiver burden; increases fall risk.
Nursing Interventions
Non-pharmacological: maintain regular routine, morning sunlight exposure (reset circadian rhythm), increase daytime activity, reduce daytime napping, evening quiet environment (dim lights, reduce noise, familiar music), address pain and elimination needs, avoid caffeine and heavy meals at night, ensure safety (bed alarm, low bed, mats). Medications: avoid sedative-hypnotics (increase falls, cognition decline), consider melatonin, trazodone (low dose). Address reversible causes: infection, pain, constipation, urinary retention, medication effects.
Important Notes
- Sundowning: increased confusion and agitation in late afternoon/evening — common in dementia, worsens with fatigue, shadows, and unfamiliar environment.
- Avoid sedative-hypnotics (benzodiazepines, Z-drugs) in elderly with dementia — increase falls, cognitive decline, and mortality.
Clinical Tips
- Morning sunlight exposure helps reset circadian rhythm — open blinds, encourage outdoor time if safe.
- Reduce daytime napping and increase daytime activity to improve nighttime sleep — but avoid overstimulation in the evening.
Summary
Sundowning and sleep disturbances in dementia are managed with regular routine, morning light, daytime activity, quiet evening environment, and avoiding sedative-hypnotics (which increase falls and cognitive decline).
