Sundowning in dementia: what nurses can do to support patients

Continuing our series highlighting recent presentations from Nursing in Practice 365 events, GP Dr Amonia Gasper describes the phenomenon of sundowning in people with dementia and outlines some key steps that community nurses can take to manage and prevent the symptoms

What is sundowning in dementia?

Sundowning describes a very common phenomenon that occurs commonly in the middle and later stages of dementia. It describes new or worsening neuropsychiatric symptoms (NPS) such as hallucinations and delusions in the late afternoon or evening,¹ causing extreme anxiety and distress for people living with dementia and their caregivers.

With dementia rates rising, the total annual cost of dementia is also growing; in England this was estimated to be £24.2 billion in 2015. This annual burden on UK healthcare requires our focused attention, especially because it remains the primary catalyst for institutional care decisions, with huge economic consequences for people living with the illness, their carer givers and society as a whole.

Sundowning stems from complex brain changes that occur in dementia, resulting in disrupted circadian rhythms causing internal biological processes to desynchronise from the external world. As a result, sleep architecture undergoes dramatic alterations, with deep restorative sleep reduced by up to 70% in advanced stages of dementia.

The glymphatic system, crucial for amyloid clearance from the brain, subsequently becomes compromised, creating a bidirectional relationship whereby poor sleep leads to worse cognition, which in turn causes poorer sleep.

How can community nurses identify sundowning and support patients?

Given these complex mechanisms, community nurses need detective skills for effective assessment. I recommend using sleep diaries (proxy-completed by carers), the STAR-VA ABC Card System to identify activators, behaviours and consequences, and modified versions of the Pittsburgh Sleep Quality Index. After all, we cannot manage what we don’t measure.

Beyond these traditional treatments, however, cultural sensitivity is also required, especially with African Caribbean patients whose past trauma and migratory experiences may cause evening anxiety, with different cultural connotations associated to sunset and darkness. According to one study,² the cultural milieu has a significant impact on the mental health of African Caribbean immigrants, revealing that their views of racial settings might contribute to symptoms like anxiety and sadness.

I’ve witnessed these principles in action through my mother’s journey with Alzheimer’s and vascular dementia. As a former Sister and midwife, her primary challenges centred around circadian rhythm disruption and sundowning. The professional who once confidently navigated hospital corridors now experienced evening confusion and nighttime hallucinations of the babies she once delivered.

Through systematic implementation of morning light therapy during breakfast, regular outdoor walking, strategic nightlights, and consistent routines, we significantly reduced her symptoms – though occasional nighttime hallucinations remain, requiring family presence.

My own experience has influenced my use of the life narrative approach, which gives valuable context for treating sundowning tendencies. This customised approach entails documenting individual evening routines, identifying historical triggers such as shift work or childcare patterns, including culturally significant practices, and developing tailored evening protocols based on familiar music, foods, and activities. This method closes the gap between neuronal understanding and practical intervention.

What other measures can nurses take?

Once properly assessed, evidence supports a range of non-pharmacological interventions as first-line treatment. Morning bright light therapy (>1,000 lux for 1-2 hours) delivers a 27% reduction in nighttime awakenings, directly addressing the circadian disruption mentioned earlier.

Complementing this morning approach, evening modifications should include reduced stimulation, adequate lighting to minimise shadows and calming routines.

Environmental optimisation further enhances these interventions, for example by maintaining temperature between 18-20°C, keeping noise below 30 decibels, and establishing consistent routines.

Is there ever a place for medication?

While non-pharmacological procedures should be the priority, pharmacological approaches are occasionally considered, but with considerable caution. A Cochrane evaluation revealed very small benefits: melatonin adds only 10.7 minutes of sleep, while trazodone adds only 42.5 minutes.³

Meanwhile, benzodiazepines are not suggested because they can raise the chance of falling by as much as five times. These numbers support what I have seen time and again: medications frequently promise more than they provide, and 42 minutes of extra sleep is just not worth five times the risk of falling.

What actions can nurses take now to address sundowning?

Drawing these elements together, I encourage every nurse to commit to three actions:

Audit your care environment for sleep disruptors and sundowning triggers.
Implement one evidence-based environmental modification from those discussed.
Document sleep patterns systematically.

By taking this comprehensive approach from sundown to sunrise, your nursing intervention could literally change the course of dementia – not just managing symptoms but potentially modifying disease progression itself. This shift from symptom management to disease modification represents the future of dementia care.

Dr Amonia Gasper is a GP in North West London

References

Canevelli M et al. Sundowning in dementia: clinical relevance, pathophysiological determinants and therapeutic approaches. Front Med 2016; 3:73
Watson J et al. Rules of engagement: predictors of Black Caribbean immigrants’ engagement with African American culture. Cultur Divers Ethnic Minor Psychol 2013 Oct;19(4):414–23
Mccleery J et al. Pharmacotherapies for sleep disturbances in dementia. Cochrane Database Syst Rev 2016 Nov 16;11(11):CD009178

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