When thunder and lightning strike, Mr A would become agitated, afraid and would run to hide under the bed. Although he suffered from dementia, he was normally docile and calm. His family could not understand his behaviour whenever there was a thunderstorm.
Mr A had worked onboard ships in his youth, and storms brought back painful memories of those times. When the family realised his past and the association with storms, thunder and lightning, they became aware that they needed to reassure and calm him when storms occurred. His behaviour improved.
Known as sundown syndrome, such symptoms of confusion and agitation occur mostly in people with dementia. “Sundown syndrome is a group of symptoms that occur at a specific time of the day. Some patients get anxious and agitated; others become aggressive, and shout or hit others,” said Dr Trina Arifin, Associate Consultant, Department of Geriatric Medicine, Singapore General Hospital (SGH). “This phenomenon of behavioural deterioration is seen usually in the late afternoon or evening. Basically, any unmet physical or psychological need can trigger the symptoms. Caregivers need to know what the triggers are and try to minimise them.”
In Singapore, one in 10 people above the age of 60 suffers from dementia, or about 82,000 people in 2018. The number is projected to rise to about 152,000 by 2030. Sundowning, as the syndrome is also called, is most commonly associated with dementia patients diagnosed with Alzheimer’s disease (about 60 per cent of Alzheimer patients experience sundowning), but is also found in people with other forms of dementia.
The causes of sundowning are unclear although it is known that changes to the brain — pharmacological, psychological, medical, environmental — can affect our biological clock, leading to confusion in sleep-wake cycles or the circadian rhythm.
The first choice of treatment, Dr Arifin said, is to keep patients in the comfort and familiarity of their own homes surrounded by family members. She added that it is important to set a routine so that patients know what they can expect to do for the day. Engaging them in simple activities, avoiding long afternoon naps, taking walks or going for lunch outside helps tire them out and prepare them for bed.
Dementia day care centres offer morning to afternoon cognitive involvement programmes to keep care recipients occupied with activities targeted at the stage of the dementia. Night respite care is an overnight option for care recipients who are active at night, offering their caregivers some time off from night-time duties. In cases where the caregiver is temporarily unavailable, such as when a foreign domestic worker goes on home leave, nursing respite care is available for the patient during the period.
Dos and Don'ts
- Get plenty of rest
- Set a routine for waking up, mealtime and bedtime
- Spend time outdoors in the sunlight
- Identify triggers of sundowning events
- Reduce stimulation like loud music and TV in the evening
- Eat heavier lunches and lighter dinners
- Keep the home well lit to reduce confusion
- Soothe patient's mood by listening calming music, looking at photographs, or watching a film
- Take walks to reduce restlessness
- Limit daytime naps
- Reduce or avoid alcohol, caffeine and nicotine consumption
The Agency for Integrated Care (AIC) website has comprehensive resources on understanding sundown syndrome, managing sundowning behaviour, facilities for care of patients as well as subsidies available for such services. Visit: https://www.aic.sg/body-mind/ dementia-brochures
Dementia Singapore has a hotline for caregivers who need support in caring for their charges: 6377 0700 Dementia Singapore Academy (DSA), the organisation’s training and consultancy arm, provides training programmes for professionals, family caregivers, foreign domestic workers and the general public. Visit: https://dementia.org.sg/ academy/
Read more: Lower your risk of getting Alzheimer’s disease, the most common form of dementia. Click here to find out how.
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