Sundowning in dementia: what the team can change in the environment

At five in the afternoon the house changes. Someone calm all day stands up, looks for the door, asks for their mother, wants to go home. The afternoon shift knows this better than anyone.

What is sundowning

Sundowning is the name for a pattern where restlessness, confusion and anxiety rise in the late afternoon and evening in people with dementia. The word comes from sundown. It is also called sundown syndrome or late-day confusion.

It is not a diagnosis and it has no single cause. What exists is a set of things that tend to contribute, and some of them are within reach of whoever is in the room.

First, what is not behaviour

Before changing the environment, rule out the physical. A good share of what reads as agitation is something else showing itself:

• pain nobody named, especially in people who no longer describe it;
• needing the toilet, constipation, urinary retention;
• hunger or thirst: dinner is still far off;
• infection, urinary in particular, which in older adults often appears as confusion before it appears as fever;
• medication effects, including recent changes.

This list comes first, always. And any decision about medication belongs to the clinical team: nothing below replaces it.

Then, the environment

Late afternoon brings three things together: the light drops, the noise rises (shifts changing, visitors leaving, a television on) and the body is tired. Teams that manage to bring agitation down almost always work on these points:

• Light. Switch it on before it gets dark, not after. The abrupt shift from light to dark is the most cited trigger.
• Noise. Fewer sources at once. A television nobody is watching is noise, not company.
• Routine. The same thing, at the same time, by the same person where possible. Predictability does more than any new activity.
• Caffeine and long naps late in the day: both show up in the guidance.
• A task with meaning. Folding towels, setting the table, tending a plant. Occupying is not entertaining.

Where a calm scenario fits

This is where what we build comes in, and it is worth being exact about what it is and is not.

A 360° video scenario (a beach at dusk, a garden, a familiar village) is one more calm-environment option, alongside music, photographs and conversation. What is different about it is that it occupies the field of view: the room with the shift-change noise stays outside for a few minutes.

Three things need saying plainly:

1. The published research on virtual reality in dementia is mostly about wellbeing, engagement and reminiscence, not about sundowning specifically. We have no trials saying it resolves sundowning, and that is not our claim.
2. It is not for everyone. Someone already very agitated will not accept anything on their head, and insisting makes it worse. The useful window is usually before the peak, not during it.
3. The session is always accompanied and stops whenever the person wants. Covering someone's eyes is not neutral when they are disoriented.

In practice, teams that use this late in the day do it early, around four, and keep it short: five to ten minutes, seated, with someone alongside.

A checklist for the afternoon shift

1. Rule out pain, toilet, hunger, thirst and infection.
2. Turn the lights on before it gets dark.
3. Cut the number of noise sources.
4. Keep the same sequence every day.
5. Offer a meaningful task, or a calm environment, before the peak.
6. Record what happened and at what time: that is what reveals the pattern.

Point 6 is the one usually missing. Without a record, every shift starts from scratch and nobody knows whether yesterday's attempt worked.

RVer is a virtual reality system for clinical use designed for healthcare settings, whose base product is registered as a Class I Medical Device in EUDAMED (Basic UDI-DI 56006195127RVERTZ) and with INFARMED (Portugal, CDM 94571546) and bears the CE mark under MDR 2017/745. The RVer Motion, RVer Neuro and RVer Exposure modules are in development and are not covered by that registration.

On use in dementia, see reminiscence, calm and moments of presence. On who can use the equipment, see accessibility in virtual reality.