This blog is a continuation of our series on Behaviors as Communication. To read other entries in the series, please click through to one of the following links below:
- Behaviors as Communication (Introduction)
- Behaviors as Communication: Agitation
- Behaviors as Communication: Collecting
- Behaviors as Communication: Wandering
As the sun sets, many think of their day winding down into a relaxing evening. For those with loved ones affected by Alzheimer’s disease and related dementia, they know all too well that a relaxing evening is not always in store. More often than not evenings are particularly difficult for those affected by memory loss due to a state called, Sundowning.
Although not a behavior or method of communication, we decided to include Sundowning in the series because of its interconnectedness to behaviors. In fact, all of the behaviors discussed in this blog series can be driven by Sundowning. It is our hope that this blog will educate, empower, and encourage others to better care for their loved ones affected by Sundowning and its associated symptoms and behaviors.
What is it?
Sundowning refers to a group of symptoms and/or behaviors that typically occur late in the afternoon and evening. Associated behaviors can include, but are not limited to:
The resolution to each of these behaviors will help at the moment by addressing the symptom, but if the driver of each behavior is Sundowning, chances are that these resolutions will not address the root of the issue. By identifying the specific causes of Sundowning, it is possible to improve and reduce the frequency of these behaviors.
Identifying the Cause
It is believed that the overall cause of Sundowning is based upon the changes in the brain and how the mind works, although the exact cause has not yet been identified. What is known is that the changes in cognition and the brain’s physical makeup lead to many behaviors and communication challenges throughout the disease progression. Below are a few helpful suggestions for evaluating the cause of Sundowning. This is not a comprehensive list but should offer some good suggestions on where to start.
As always, a good place to start when identifying the cause of a behavior is to look at what the individual is attempting to communicate. Start by reviewing if the individual has any unmet needs by tracing back to Maslow’s Hierarchy of Needs. A frequent cause of the behavior is that an individual is tired or fatigued and in need of rest. This exhaustion can be physical, especially in cases of those who exhibit wandering behaviors. Or in many cases, fatigue is more of a mental nature.
For those who are overwhelmed by large crowds, noisy rooms, or other stimuli, being overstimulated can quickly deplete mental energy and lead to fatigue. Whatever the cause of fatigue, it is always a good idea to relocate the individual to a place where they can find rest and relaxation. Sometimes all that is needed is the opportunity to get some sleep and recharge. However, with sleep disturbances made common by the disease process, many will find it difficult to gain restorative sleep.
Changes in Circadian Rhythms
Part of the challenge with gaining restorative sleep is simply getting enough quality rest. The aging process and physical changes in the individual can affect restlessness through aches and pains, or even new or previously existing medical conditions. And as the composition of our brain changes due to memory loss, sleep disturbances become more common and can even interrupt our rest and waking cycles. We’ve all experienced a change in our internal clocks, whether from traveling to a different time zone or from staying up too late and then waking too early.
When sleep becomes a challenge for someone affected by memory loss, it is always recommended to talk with a doctor to address this concern. As Sundowning is affected by tiredness, and sleep is an ongoing issue, to resolve one will help in addressing the other. The Sleep Foundation has some interesting information on Circadian Rhythms that may help guide the conversation with your loved one’s physician. One of these components addresses lighting as a potential way to improve sleep patterns.
Darkness/Lack of Adequate Lighting
Without the rising and setting of the sun each day, many of us would need to check our alarm clocks to confirm whether it is morning or evening. Whether too bright or too dark, the lighting of our surroundings can contribute to our rhythms of sleep and mental perception of day and night. If you believe that your loved one is experiencing Sundowning, ask yourself the question: Is their environment too dark or too bright?
Chances are that lighting – especially in the afternoon/evening hours – is inadequate and brightening up the space may help with Sundowning behaviors. A well-lit space will help reduce anxiety for those who are fearful of the dark, and also provide more clarity and confidence when walking or moving around the living space. Sundowning may be brought on for some, by hallucinations that are caused due to changes in their brain’s composition and/or medication side-effects, all of which can be made worse with inadequate lighting. What is in front of us may not always be what the individual is seeing based on their mental perception.
Changes in Perception often lead to behaviors that are based on the misinterpretation of the information presented. Perception challenges can lead to, paranoia and agitation, anxiety and fearfulness, reality orientation challenges, and others. Sundowning can amplify these behaviors, but the good news is that there are ways to adjust your communication style in order to help with how you are perceived.
Communication styles will need to be adjusted from early, to the middle, and late stages in order to maximize their effectiveness. As always, nonverbal communication and the approach is vitally important to the perception of the individual. Imagine speaking in a joyful tone of voice while crossing your arms and scowling – this doesn’t feel authentic and would be concerning to most individuals. Be aware of your approach and your complete style of communication when interacting with those affected by memory loss.
Approach Resolutions with Safety in Mind
When approaching an individual to resolve a behavior, safety is the number one priority. Interact cautiously and respectfully while keeping the individual, those around them, and yourself safe at all times.
Resolutions and strategies are wide-ranging and there is no one-size-fits-all solution. It is from this uniqueness and individuality that our exclusive Meaningful Moments programming was developed. At JEA Senior Living, our team utilizes our signature Meaningful Moments programming to encourage and engage residents with purposeful interaction each day. As residents experience Sundowning symptoms and related behaviors, our Team Members are able to redirect and provide comfort for each resident by incorporating their life story into the care they deliver. Prior to admission, our Care Teams get to know each resident, by visiting with them directly (if possible) or by talking with their family members. This process allows us to prepare a biography and documented life story for each and every resident.
From here, we create customized biography boards to display outside each resident’s room. This process not only helps residents identify their rooms, but also allows for connection between residents, families, and our Team Members. It is from these connections that our Team Members are able to redirect residents while creating Meaningful Moments by incorporating their life stories.
As an example, if Mr. Smith is starting to exhibit signs of Sundowning and is experiencing anxiety about getting home. One of our Team Members can appropriately approach Mr. Smith and ask if they can help. They might talk with him about his career, his family, or maybe his favorite snack – and even arrange to prepare his favorite snack, alongside a cup of decaf coffee.
This background knowledge and compassionate approach can quickly put Mr. Smith at ease. By talking with him as an old friend and reminiscing together, our Team Member is able to help provide peace, calm, and relaxation. If Mr. Smith begins to experience anxiety or a related behavior again, we might approach him with a photo album, or ask if he would like to watch his favorite movie, or even video chat with his grandson to help him feel better.
Although not a cure-all, this dedication and continued compassion for each resident will help resolve behaviors driven from Sundowning. As behaviors and anxiety come back, so too will our resilience and commitment to providing holistic care and comfort for each resident.
Even with all of these helpful tips, it can be overwhelming for the family caregivers and loved ones who are giving of their time, patience, and compassion each day. If you, or someone you know, need a break or additional resources, please contact your local JEA Senior Living community for information on our Respite Stay programs or on how to approach Behaviors as Communication.