Published on 20 February 2022

    It is common for people with Alzheimer’s and dementia to experience sundowning – an increase in agitation, confusion or restlessness – that begins at dusk and lasts into the night.

    Dementia is a growing global public health concern. In Singapore, about one in every ten people aged 60 and above has dementia. The rate is even higher in those above 85-years-of-age, where 50% of people have the condition.

    According to Dr Tan Li Feng, Consultant, Healthy Ageing Programme, Alexandra Hospital, there were about 78,000 people diagnosed with dementia in 2017 and this number is projected to increase to over 130,000 by 2030.

    Dementia, she explained, is a neurodegenerative disease caused by abnormal protein growth that in turn damages brain cells and interferes with the ability of brain cells to connect and send signals properly. The most common cause of dementia is Alzheimer’s disease, which makes up about seven in ten cases of dementia. Vascular dementia is another type of dementia that is caused by stroke disease. Less commonly, dementia is caused by frontotemporal dementia and Lewy body dementia; both of these conditions are due to brain cells degenerating at a faster rate than normal.

    Forgetfulness or dementia?

    In the early stages, dementia may seem like short-term memory loss, but though the signs are not immediately obvious, some noticeable and common symptoms include:

    • Memory loss, particularly of short-term events. This may include not remembering what one just ate or why one entered a room. A person may also no longer recognise a familiar face or place

    • Forgetfulness that affects daily function and activities

    • Difficulty communicating simple thoughts or wants, or finding the right words

    • Mood swings, depression or shifts in personality

    • Loss of ability to do familiar tasks and chores; misplacing things

    • Confusion and disorientation

    • Difficulty doing familiar tasks or getting lost in a familiar neighbourhood

    • Having impaired judgement and difficulty planning or solving problems

    • Withdrawing from work or social activities

    Strategies to Cope with Sundowning

    In people with Alzheimer’s or dementia, sundowning is a behavioural shift that commonly happens during the transition from day to dusk. It is marked by confusion, irritability, restlessness and repetitive behaviour.

    The causes of sundowning are not clear, but is believed to be due to changes in the brain that affects the ‘biological clock’. This leads to confused sleep-awake cycles.

    COMMONBEHAVIOURS Agitation Heightenedirritability Yelling EmotionalDistress Being quick to anger TRIGGERS &CAUSES Fatigue Disruptionsto routine Over-stimulation Medicine side effects Changes in the braindue to the disease Physical pain ordiscomfort STRATEGY Set up a daily routine with regular times for meals, sleep and other daily activitiesPlan light exercise and activities during the day, ideally in the morningsand early afternoonsSpeak slowly and clearlyBuffer in time to process changes Reduce clutter, unnecessary/unfamiliar noise Avoid reasoning/arguing and raised voices. Instead of reacting, listen and try to uncover the emotion or cause behind the agitation Reassure the person and distract them from stressful or upsetting events Manage pain appropriately COMMONBEHAVIOURS TRIGGERS &CAUSES Pacing orwandering Memory loss Anxiety about abandonementand separation Unfamiliarenvironments Boredom Physical needs such as hunger ortoileting that they cannot express STRATEGY Remain patient and calm and speak slowly and clearly Use appropriate physical touch to reassure them Re-direct their energies to another activity such as a walk, music or a familiar or enjoyable task Engage them in another topic of conversation Use large clocks and calendars to remind them of the time and day If the repetitive action is not harmful, allow them to continue Repetitivebehaviours:openingandclosing doors, touching things or movingtheir hands Asking questions over and over again STRATEGY COMMONBEHAVIOURS TRIGGERS &CAUSES Over-stimulationlate in the day Cognitivedeclinecan affect sleep cycles Establish a regular and relaxing sleep routine Integrate daily activity and exercise Avoid naps, too much time in bed and caffeine Ensure that they are comfortable, clean and fed before bed Create a conducive sleep environment Lack of physicalactivity andmental stimulation during the day Hunger, thirst orphysical discomfort Unfamiliarenvironment Difficultygoing to sleep at night

    Light therapy is believed to be helpful to counteract these behaviours as well. Getting enough sunlight early in the day may help lower the sense of disorientation.

    If you or a loved one is experiencing these symptoms, it is helpful to seek medical advice. Dementia diagnosis comprises a comprehensive assessment that may involve blood tests, brain imaging and a series of questions to assess brain function.

    Though dementia is a progressive disease, early diagnosis, symptom management, education and changes to lifestyle and the home can help patients live safely and independently.

    In consultation with Dr Tan Li Feng, Consultant, Healthy Ageing Programme, Alexandra Hospital.

    Click here to download the full infographics.

    Related Articles