Sundowning and night-time wandering in dementia: what families can do at home

What is sundowning?

Sundowning, sometimes called sundown syndrome, is a pattern in which a person with dementia becomes more confused, restless, anxious, suspicious or agitated as the day goes on, typically from late afternoon into the evening. They may pace, ask to “go home” while at home, follow you around, shout, or try to leave. It is not a separate illness. It is a set of behaviours that many people with Alzheimer’s disease and other dementias show at some stage, and it can come and go.

In Singapore, about 1 in 11 people aged 60 and over had dementia in 2023, around 74,000 people, according to the Institute of Mental Health’s Well-being of the Singapore Elderly (WiSE) study. If you are caring for one of them through difficult evenings, you are far from alone.

Common triggers

• Tiredness at the end of the day, or too much activity.
• Fading light and shadows, which can be confusing or frightening.
• Hunger, thirst, pain or a full bladder that the person cannot explain.
• A disrupted body clock, from long daytime naps or too little daylight.
• Noise and busyness, such as a loud television, visitors or the evening household rush.
• Changes, such as a new helper, a hospital stay or a move.
• Caffeine or alcohol later in the day, and some medicines.

A sudden change in behaviour can also be a sign of an infection (a urinary infection is a common one), constipation, pain or a medicine side effect. Tell their doctor about any sudden worsening.

What helps in the afternoon and evening

1. Keep a steady routine. Meals, outings, baths and bedtime at roughly the same times each day.
2. Get daylight and activity earlier. A morning walk or an activity at the Active Ageing Centre, and fewer or shorter late naps.
3. Light the home before dusk. Turn lights on early, close curtains as it gets dark to reduce reflections and shadows.
4. Make the evening calm. Quiet music, a familiar task such as folding laundry, fewer visitors and less television news.
5. Check basic needs. A snack and a drink, the toilet, comfortable clothes, glasses and hearing aids in place, pain treated.
6. Respond to the feeling, not the words. If they ask to go home, reassure them and talk about home, rather than arguing that they are already there.
7. Look after yourself. Evenings are when caregivers are most tired too. Share the evening shift where you can.

Keep a simple note of when sundowning happens and what came before it. Patterns often emerge, and the note is useful for the doctor.

Night-time waking and wandering

Some people with dementia get up at night, are confused about the time, and try to go out. In an HDB flat that can mean the corridor, the lift and the road in the dark. Ways to reduce the risk:

• Night lights in the bedroom, corridor and bathroom, so getting up to the toilet does not end at the front door.
• A toilet visit before bed, and fewer drinks in the last two hours before sleep.
• Cues and locks: a sign on the bedroom door, keys kept out of sight, and a lock that is safe in a fire (never one that traps the person inside).
• An identification card or tag with a contact number, in case they are found outside. Dementia Singapore and community partners run programmes for this.
• An alert when the front door opens at night, so a family member or helper knows within minutes rather than in the morning.

What sensors can tell you, without a camera

Cameras are a common first thought, but many people with dementia find them distressing, and they record a lot more than you need. A door sensor and motion sensors answer the questions that matter at night: is Mum up, is she in the bathroom, and has the front door opened?

• Front door opened at night. Birdhouse suggests an alert when the front door opens between 23:00 and 06:00, and another when it is left open for more than 10 minutes. You can move the window to fit their routine.
• Night-time activity over weeks. The Insights tab shows night events and bathroom visits against their usual nights, so a slowly worsening pattern is visible early, and you have something concrete to show the doctor.
• Long stays in the bathroom. “Still in the bathroom after 45 minutes with no movement elsewhere” is an urgent alert by default.
• Alerts that reach the right person. The person nearest can hear everything at night, while relatives further away hear only urgent alerts.

What sensors cannot do: they cannot tell where someone has gone once they leave the flat. If wandering outside is the main risk, a GPS tracker or an identification programme may be needed as well. See GPS trackers for seniors with dementia.