Restlessness or confusion, especially later in the day

Overview

It is thought that late-day confusion (sometimes called "sundowning") can be a problem for as many as 66% of people with Alzheimer’s disease or other dementias. It can occur at any stage of the disease but it tends to peak in the middle stages of dementia and lessens as the disease progresses.

This late-day confusion often affects the person’s quality of life and it can be exhausting for the caregiver. The person living with dementia may become suspicious, upset or disoriented, see or hear things that are not there and believe things that are not true.

Behaviour changes associated with late-day confusion

Some behaviour changes are typical with this type of confusion. They can include:

• Becoming demanding or aggressive
• Experiencing delusions and hallucinations. Learn more about delusions and hallucinations.
• Pacing or wandering
• Doing impulsive things
• Attempting to leave home
• Having difficulty understanding others
• Having difficulty doing tasks that were done without difficulty earlier in the day

Possible causes

A variety of events or issues can trigger late-day confusion. These can include:

• Being tired at the end of day (can lead to an inability to cope with stress)
• Low lighting and more shadows (can create confusion and hallucinations, especially with common objects that look different when it is darker)
• Disruption of the circadian cycle (sleep/wake pattern) because of the dementia (the person cannot distinguish day from night)
• Not as much or no activity in the afternoon compared to the morning (can lead to restlessness later in the day)

Tips and strategies

Finding a way to respond to late-day confusion may take some trial and error. Every person is different and may react differently. Some ways to try to head off an episode or to lessen it once it has started are:

• Discourage napping or keep naps short.
• Try to schedule calming activities when agitation usually occurs.
• Try to restrict sweets and avoid caffeine at night.
• Provide adequate lighting to help the person identify objects and people.
• Provide items of comfort like a favourite pillow or blanket.
• Plan and encourage activities during the day.
• Provide reassurance and reminisce as a distraction.

Example

After a short visit, Hannah struggles to maintain a conversation with her daughter. She becomes upset, paces in her room and says “I want to get out of here NOW.” Her daughter notes that her mom experienced similar distress yesterday and the day before around 4:30 p.m., as she arrives for a visit after work.

Don’t

• Request that Hannah is prescribed a medication to calm her, which results in her sleeping much of the day.

Do

• As late afternoon approaches, turn on bedroom lights and lamps.
• Close drapes to lessen shadows.
• Request a morning exercise program to reduce restlessness in the afternoon.
• Devise strategies that provide a sense of purpose, like setting the dining room table or putting vases out for that evening’s meal.
• Visit in the morning.