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Anthea Rowan

This is the sixth instalment in a series on dementia, including the research into its causes and treatment, advice for carers, and stories of hope.
It happens at roughly the same time of day: sundowning. But this is more than the slip of day to dusk. In the case of dementia, “sundowning” is the significant personality change that can beset sufferers towards the end of the day.
The person may become angry, agitated, confused, panicked, resistant to instruction and restless. In my mother’s case, she recently had a near-psychotic episode with hallucinations and marked distress.
Pummelling her stomach with a closed fist, she refused offers of help or fluid.
My mother can be so wired by these episodes that they prohibit her sleep, and ours. The last one kept her awake for 36 hours. We were all spent at the end of it.
“Nurses talk about it like almost a light switch,” says Trey Todd, a neuroscientist at the University of Wyoming in the United States. He says conservative estimates suggest about 20 per cent of dementia patients experience sundowning at some point.
It is often the reason families seek full-time professional care for their loved ones – a sort of final straw.

Sundowning as a syndrome – and not sunsets and sauvignon, which is what I once associated the word with – was first described in medicine in 1941 by British doctor Ewen Cameron, who called the condition “nocturnal delirium”.
He described patients who experienced disorientation, agitation and panic around bedtime.
The contemporary nickname, sundowning, was coined in 1987 by Lois Evans of Penn Nursing at Pennsylvania University, who is acknowledged as one of America’s leaders in care of the elderly.
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But even though the phenomenon has been cited in medical literature for over 80 years, its underlying cause is still unknown.
Most researchers believe that sundowning reflects that something is amiss with the circadian system that choreographs our body’s natural processes – hunger, thirst, sex drive, body temperature, blood pressure and sleep.
It functions like a 24-hour clock, Todd explains.

“Down to the daily timing of the gene activity and electrical activity of its neurons, its output controls your daily rhythms,” he says.
The circadian system’s activity is synchronised to the light-dark cycle – which is why you suffer with jet lag when you change time zones, because it takes a few days for the activity of the system to adjust.
When a person suffers dementia, the pathology of the brain changes and it throws this pace-making system out of whack, creating a “phase delay”. That means the peak of a patient’s daily activity comes later in the day than that of their healthy peers, and their body temperature minimum – when the rhythm is at its lowest point – is also later.
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Sundowning typically starts in late afternoon or early evening, commonly between 4pm and 8pm, and clinical studies suggest that it occurs in middle-to-late stages of Alzheimer’s disease or dementia and gets worse with cognitive decline.
Todd’s interest in dementia was prompted by his grandmothers, both of whom experienced dementia. When he started studying neuroscience, “I focused on the circadian system because I was interested in sleep and what made people a ‘morning person’ versus a ‘night owl’”.
He began studying sundown syndrome after he noticed the connection between mood and time of day in mice. The mice, when the circadian pathway was disrupted, grew more aggressive when they would normally be getting ready to nest for the night, previously a time of less aggression.

He posits that similarly, in humans, the circadian system normally makes us less reactive when we should be getting ready to go to bed.
“But if the system becomes dysfunctional, it’s like taking a ‘brake’ off of aggression and other mood disturbances, and the result is the emotional components we see in sundowning as well as other circadian disturbances, like nocturnal wandering” – or sleep walking.
It is a distressing disorder for sufferers and their carers but there are measures that you can take to alleviate its severity, Todd says.

1. There is some evidence that melatonin supplements might help. The pineal gland in our brain produces melatonin, a protein whose production is triggered by darkness so, as darkness falls, we get more of it. As light occurs, it fades out.
It is what helps prompt us to sleep and awaken, supporting the healthy circadian rhythm. In a broken system, its production is disrupted. Age also interferes with this.
2. Keeping a good daily routine is important for dealing with any kind of circadian problem – dementia-related or not.
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3. Bright light therapy during the daytime has been shown to be effective in improving rhythms and mood for dementia patients.
4. Getting out into the daylight early in the day is good for our sleep patterns, whether we have dementia or not.
5. Minimising the amount of light at night is important, as light may cause a worse phase delay, keeping the sufferer awake, Todd says.

This has been a challenge for me: I keep a night light on in my mother’s room to minimise the risk of falls if she gets up. I have altered this now to shed a muted glow rather than a bright light.
I watch her behaviour closely in the late afternoon and if I think she is beginning to exhibit distress, I get her to bed earlier. That seems to have helped.
Finally, says Todd, “There is some interesting work that suggests taking a patient with sundowning for a walk at a consistent time each day, morning or evening, helps alleviate symptoms.”
I have definitely noticed that my mother is more agitated on the days when she has not walked.

With all of these measures, Todd says, “You are essentially giving the patient additional cues to help stabilise their timing and daily rhythms.”
In especially resistant patients, though, when episodes can be distressing for both sufferer and carers, doctors may prescribe medications which can include antipsychotics to help sufferers calm down and sleep.
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Wellness

‘Like a light switch’: how sundowning syndrome affects dementia sufferers – and their carers; what it is and tips for how to cope

A person with dementia may experience “sundowning” syndrome - towards the end of the day they become more agitated, confused, panicked, resistant to instruction and restless. This affects their carers, too. Photo: Shutterstock

A person in bed, unable to sleep. Conservative estimates suggest about 20 per cent of dementia patients experience sundowning at some point.

Trey Todd is a neuroscientist at the University of Wyoming. Photo: Trey Todd

Sundowning was coined in 1987 by Lois Evans of Penn Nursing at Pennsylvania University. Photo: University of Pennsylvania

The pineal gland in our brain produces melatonin, which is what helps prompt us to sleep and awaken. In a broken system it is disrupted. Melatonin supplements might help fight sundowning. Photo: Shutterstock

Taking a patient with sundowning syndrome for a walk at a consistent time each day, morning or evening, may alleviate symptoms. Photo: Shutterstock

Getting out into the daylight early in the day is good for our sleep patterns, whether we have dementia or not. Photo: Shutterstock

How caring for a parent with dementia taught me about symptoms, prevention and why seeking out the latest research is so important

Author Anthea Rowan (right) with her mother.

Author Anthea Rowan (right) with her mother, who has Alzheimer’s disease, the most common type of dementia. Photo: Anthea Rowan

Anthea with her mother. Photo: Anthea Rowan

Studies suggest that regular exercise lowers the risk of cognitive decline by 35 per cent. Photo: Getty Images

Staying active can help prevent or delay the onset of dementia, studies suggest. Photo: Shutterstock

What cures dementia? Nothing, but you can delay or prevent its onset with exercise, an active social life and by not smoking

Understanding dementia and its links to depression may help caregivers take steps to prevent it in themselves. Image: Shutterstock

Anthea Rowan with her mum. Photo: courtesy of Anthea Rowan

Calvin Cheng Pak-wing is a clinical assistant professor of psychiatry at the University of Hong Kong.

Jessica Gong is the lead author of a study by The George Institute for Global Health in Australia that suggests a link between reproductive factors and the risk of dementia.

Exercise is an important part of a healthy lifestyle, which can delay the onset of dementia. Photo: Getty Images

Paddy Dempsey is the lead author of a recent study conducted by the UK’s University of Leicester on the effects of brisk walking on ageing.

A lifetime of brisk walking could lead to the equivalent of 16 years’ younger biological age by midlife. Photo: Shutterstock

‘Disabling’ hearing loss is a growing problem worldwide; how to protect your hearing – experts’ tips include not playing music too loud

Using headphones that go over your ears rather than earbuds that are inserted in the ears may help safeguard your hearing. Above all, don’t play your music too loud, says an expert on hearing loss, a growing global problem that can have other health impacts. Photo: Shutterstock

People, such as construction workers, with ongoing exposure to loud noise are most at risk of losing their hearing. Photo: Shutterstock

Hearing loss because of ageing can happen suddenly or gradually, and one or both ears can be affected, says Dr Jacky Wong, a specialist in otorhinolaryngology at Heal Medical in Hong Kong. Photo: Dr Jacky Wong

The most common type of hearing loss (sensorineural) is a progressive disorder, and the change can be permanent, says Monica Xu, a naturopathic doctor. Photo: Dr Monica Xu

Many studies have linked smoking to acquired hearing loss, because of the toxic chemicals such as carbon monoxide in cigarette smoke. Photo: Shutterstock

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Lifestyle

Health & Wellness

Health

Decoding dementia

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Timothy Rittman, the neurologist who led the dementia research at Cambridge University. Photo: Cambridge University

A brain scan showing signs of dementia. Photo: Getty Images

Lizzie Perry, founder of This is Dementia, with her father, who was diagnosed with the disease at 58. Photo: This is Dementia

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Why women are more likely to have dementia than men as they age, and how exercise and engagement can help lower your risk

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An optimal blood pressure reading, easily measured with a home device, is around 120/80. Photo: Shutterstock

Dr Ruth Peters was lead author of a study looking at the links between blood pressure and dementia. Photo: Dr Ruth Peters

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6 dementia fighting tips from Dr Sanjay Gupta and Marc Milstein, experts on brain health – walk, talk, read, learn, relax, and eat and drink properly

We can protect ourselves against the risk of dementia with some simple lifestyle practices. Exercising (above), eating a good diet, drinking less alcohol, socialising, reading more and trying new things all help keep the brain sharp, say brain experts including Dr Sanjay Gupta. Photo: Shutterstock 

The cover of one of Dr Sanjay Gupta’s book. Photo: Simon & Schuster

The cover of Marc Milstein’s book. Photo: Marc Milstein

Drink alcohol mindfully and ask yourself why you are having that drink. Photo: Shutterstock

Learning new things creates new brain cell connections and helps keep your mind sharp. Photo: Shutterstock

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Relationships keep us engaged, interested and interesting, and may help prevent dementia. Photo: Shutterstock

Healthy marriage, healthy mind? Dementia risk lower for people married a long time, studies show; expert suggests why

Research suggests that people who have stayed married for a long time have a lower risk for dementia because they feel less lonely, are more likely to eat well and exercise more, and are more cognitively engaged. Photo: Shutterstock

Vegard Skirbekk is a researcher at the Norwegian Institute of Public Health. Photo: Norwegian Institute of Public Health

Anthea Rowan’s parents on their wedding day. Photo: courtesy of Anthea Rowan

A long-time married partner represents a security that provides a buffer against stressors. Photo: Shutterstock

Anthea Rowan and her husband on their wedding day. Photo: courtesy of Anthea Rowan

If you live with a partner long term, you are more likely to develop healthy daily patterns, to eat well and exercise more. Photo: Shutterstock

‘Dementia village’ that’s the first of its kind helps residents live normal lives, has a restaurant, theatre and supermarket – and no one wears a white coat

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The Hogeweyk, a “dementia villlage” in the Netherlands, provides care and a familiar and safe environment in which people with dementia live while retaining their own identity and autonomy as much as possible. Photo: The Hogeweyk

Jannette Spiering is the senior managing adviser and co-founder at The Hogeweyk in the Netherlands, which offers “humanising care for people with dementia”. Photo: The Hogeweyk

Residents relax around the fountain in the theatre square at The Hogeweyk. Photo: The Hogeweyk 

Residents of The Hogeweyk respond positively to their increased autonomy. Photo: The Hogeweyk

Residents at the healthcare facility take part in a painting class. Photo: The Hogeweyk

Hearing loss dramatically raises the risk of dementia, so why are so many people in midlife doing nothing to prevent it? A test is easy to arrange

Hearing loss has been linked to a higher risk of dementia and cognitive decline,  say experts, who recommend testing for preventable hearing problems (above).  Photo: Getty Images

Alison Huang, a senior research associate at the Cochlear Centre at Johns Hopkins, in the US, says hearing loss makes the brain work harder to process sounds. Photo: Johns Hopkins

Jiang Fan from the School of Public Health at China’s Shandong University. Photo: Shandong University

Checking your hearing in midlife is crucial, and can help you stave off cognitive deterioration. Photo: Shutterstock

Can HRT reduce dementia risk? New hormone replacement therapy studies say yes, upending 2002 reports

HRT use has been linked to better cognition, blood flow and brain size and a reduction in all neurodegenerative disease in recent studies. Photo: Shutterstock

HRT (hormone replacement therapy) use has been linked to better cognition, blood flow and brain size and a reduction in dementia and other neurodegenerative disease in recent studies. Photo: Shutterstock

If HRT is started after the age of 65, brain cells will have already been deprived of oestrogen for many years. This could mean there is a decline in neuronal connections – the brain’s messaging system. Photo: Shutterstock

HRT was found to be most effective when introduced early in menopause, says Anne Marie Minihane, director of the UK’s Norwich Institute of Healthy Ageing at the University of East Anglia. Photo: University of East Anglia

Dr Andrea Kwakowsky from at the University of Galway in Ireland believes the “critical period” for starting HRT is within five years of menopause. Photo: University of Galway

How can you prevent dementia? Free brain health online tool teaches the risks and gives essential tips on avoiding it

The new free “Think Brain Health Check-in” online tool from Alzheimer’s Research UK doesn’t test your memory but checks how well you’re looking after your brain and gives tips to help prevent dementia. Photo: Shutterstock

Dr Susan Mitchell is head of policy at Alzheimer’s Research UK. Photo: Dr Susan Mitchell

The Think Brain Health Check-in asks how often you challenge your brain - and then highlights why challenging your brain is key to staving off dementia. Photo: Shutterstock

Getting a good night’s sleep every night is one way to lower the risk of developing dementia. Photo: Shutterstock

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Can lack of sleep raise dementia risk? Yes, studies say – but with one exception

Having only five hours of sleep a night can increase dementia risk by 30 per cent for adults over 50, one study says. Photo: Shutterstock

One tip to overcome insomnia is to avoid clock-watching. Photo: Shutterstock

Taking a warm shower or bath in the hour or so before bed may help you fall asleep – and stay asleep. Photo: Shutterstock

Professor Roger Wong of the department of public health and preventive medicine at the State University of New York’s Upstate Medical University. Photo: Roger Wong

Sleep aids can heighten dementia risk, Wong says. Photo: Shutterstock

Can’t sleep? Try getting up and engaging in cognitively stimulating activities, like reading or making jam. Photo: Shutterstock

Dementia and ACB scores: how common prescription and over-the-counter drugs raise the risk of memory loss and cognitive decline

Certain common drugs, including antihistamines, antacids, antidepressants and anti-anxiety medicines, can disrupt the neurotransmitter acetylcholine, dubbed the “memory molecule” increasing the risk of dementia. Photo: Shutterstock

The writer, Anthea Rowan, with her mother. Photo: Anthea Rowan

Taking medications that block the action of acetylcholine can lead to memory loss, problems with spatial awareness, and cognitive decline. Photo: Shutterstock

Studies have found that anticholinergic drugs carried “significant’ dementia risk” for the over-65s. Photo: Shutterstock

Doctors need to be mindful of the risks posed by anticholinergic drugs, especially to an already at-risk population: the over 65s. Photo: Shutterstock

How to safeguard your ageing brain: build ‘cognitive reserve’ with mental and physical exercise, and stay active and socially engaged

The phrase ‘use it or lose it’ is not just a hypothesis, it’s a basic biological fact that holds as true for our brains as our muscles or bones. Photo:
Shutterstock

Our brains, like our muscles need regular use to stay healthy and flexible, say experts, and keeping our brains active builds our ‘cognitive reserve’, helping us to stave off dementia. Photo: Shutterstock

Geriatric psychiatrist Dr David Merrill recommends the active pursuit of activities that keep the brain sharp to stave off dementia. Photo: Dr David Merrill

Dorina Cadar says cultural and social engagement, reading, doing crossword puzzles, visiting art galleries, clubs and cinemas, and volunteering all increase our cognitive reserve. Photo: Dorina Cadar

Visiting an art gallery or doing something new and different are good ways to build up cognitive reserve. Photo: Shutterstock 

How yoga benefits dementia patients: new study uncovers brain-health boosts, supporting earlier research

Yoga has health benefits including better brain neuroplasticity, improved sleep quality, and more robust cardiorespiratory fitness, all of which help people experiencing cognitive decline or dementia. Photo: Shutterstock

Dr Diana Karamacoska is a research support programme fellow in healthy ageing and dementia at the NICM Health Research Institute at Western Sydney University. Photo: Courtesy of Diana Karamacoska

Yoga could be helpful in managing brain inflammation, particularly with its mindfulness component. Photo: Shutterstock

Wendy Du is the founder of Shan Studios in Hong Kong. Photo: Wendy Du/Shan Studios

Du has maintained a daily yoga practice for 10 years. Photo: Courtesy of Shan Studios

5 nutrients good for brain health that can delay dementia, or prevent it, and foods to eat with a high concentration of them

Research has identified some key nutrients we need in our diets to maintain good cognitive function and delay or prevent the onset of dementia. Photo: Shutterstock

Eating healthy isn’t just good for our bodies, it’s good for our brains, too. Photo: Shutterstock

Zahinoor Ismail, of the O’Brien Institute for Public Health at the University of Calgary. Photo: University of Calgary

Kale with pine nuts is a dish high in magnesium, and so good for brain function. Photo: Shutterstock

Oatmeal, and other wholegrain foods such as brown rice and quinoa, are rich in magnesium. Photo: Shutterstock

Mackerel is a fish that is especially high in magnesium. Photo: Shutterstock

Why you have to keep smiling at a dementia patient – you’ll feel better and it could evoke a positive response

A smile can bring a smile in return from a dementia patient, and may make them more amenable to your requests. Photo: Shutterstock

Author Anthea Rowan with her mother, who suffered from dementia. As a carer you’ve got to keep smiling, an expert on the condition tells her - and it’s not for the reason you might think. Photo: Anthea Rowan

Timothy Kwok, professor of geriatric medicine at the Chinese University of Hong Kong and Director of the Jockey Club Centre for Positive Ageing. Photo: Timothy Kwok

Dementia sufferers cannot be reasoned with, and their emotions can run the gamut from highly positive to negative in the course of a day. Photo: Shutterstock

Many dementia sufferers end up in residential care homes because caring for them is difficult and time-consuming – especially for family members with jobs. Photo: Shutterstock

The living room at Jockey Club Centre for Positive Ageing, in Hong Kong. Photo: Jockey Club Centre for Positive Ageing

‘An attack by aliens’: how to deal with a dementia patient’s delusions – experts’ tips for carers

Carers often find it challenging to calm a dementia patient down when they suffer from paranoia, hallucinations and delusions. Experts offer advice on what to do. Photo: Shutterstock

It can be heartbreaking for a carer, especially if they are a family member, when a dementia patient cannot recognise them. Photo: Shutterstock

Disinhibition, poor control or restraint over emotions or actions, is common in patients with advanced dementia. Photo: Shutterstock

Professor Fiona Kumfor is a neuropsychologist at the University of Sydney in Australia. Photo: Fiona Kumfor

When a dementia patient cannot remember where they put something, they might jump to the conclusion that it has been stolen. Photo: Shutterstock

Dementia begins in the memory centres, the hippocampus and the medial temporal lobe, then moves to other parts of the brain like the temporal lobes and then into the frontal lobe and the parietal lobes. Photo: Shutterstock

Sometimes dementia patients lose the ability to recognise loved ones’ faces, and so they may say they have never met them before. Photo: Shutterstock

Timothy Kwok is a professor of geriatric medicine at Chinese University of Hong Kong. Photo: Timothy Kwok

Unravelling 2 Alzheimer’s markers: what are amyloid plaques and tau tangles, how do they form and what do they do to the brain?

“Sepia galactic storms”: the rust coloured clumps are the stained amyloid plaques, the little black squiggles are the tau tangles. Photo: Andrew Lee

Amyloid plaques and tau tangles found in Alzheimer’s sufferers’ brains are caused by build-ups of proteins that block electrical messages. 
Photo: Shutterstock

Dr Andrew Lees, author of “The Silent Plague”, is a professor of neurology at the National Hospital in London and University College London. Photo: Dr Andrew Lees

Lee’s image of “sepia galactic storms”: the rust-coloured clumps are stained amyloid plaques, the little black squiggles are tau tangles. Photo: Andrew Lee

Two neurons: a healthy one and one with Alzheimer’s disease – with tangles and disintegration of the microtubules. Photo: Shutterstock

Daniele Vigolo and his team were able to monitor the change from liquid to solid in “fused in sarcoma” proteins, and study their internal structure. Photo: Daniele Vigolo

5 Alzheimer’s experts’ lifestyle advice on avoiding and delaying the onset of the most common form of dementia

Lifestyle tips for avoiding or delaying the onset of Alzheimer’s disease, the most common form of dementia, include staying active and socially engaged. Photo: Shutterstock

Keep your brain active throughout your lifetime – particularly by learning new skills as you age. Photo: Shutterstock 

Regular physical activity – even having a daily walk – can help delay the onset of dementia. Photo: Shutterstock

Dr Andrew Lees is professor of neurology at the National Hospital in London, and University College London. Photo: Dr Andrew Lees

Professor Timothy Kwok is professor of geriatric medicine at the Chinese University of Hong Kong. 

Professor Craig Ritchie is professor of the psychiatry of ageing at the University of Edinburgh. Photo: Professor Craig Ritchie

Dr David Merrill is an adult and geriatric psychiatrist and director of the Brain Health Centre at the Pacific Neuroscience Institute in California. Photo: courtesy of David Merrill

David Robinson is a consultant geriatrician at St James’s Hospital in Dublin. Photo: David Robinson

At risk for Alzheimer’s disease? 2 new blood tests could detect it early – here’s how they do it

New blood tests developed in Hong Kong and the US deliver an easier, less invasive and more cost-effective way to detect Alzheimer’s disease early. Photo: Shutterstock

Professor Amy Fu is on the Cognitact team at The Hong Kong University of Science and Technology. Photo: Professor Amy Fu

Previously, Alzheimer’s disease diagnosis relied on costly MRI scans. Photo: Shutterstock

Simulated results of Quest’s AD Detect Test for Alzheimer’s Disease. Photo: Quest

The author, Anthea Rowan, pictured with her late mother, who suffered from Alzheimer’s disease. Photo: Courtesy of Anthea Rowan

Excess belly fat linked to higher dementia risk, research shows. Experts explain, and advise how to shrink your waist to protect your brain

Having excess belly fat increases the risk of suffering from dementia, especially for women, according to recent research. Experts explain the link and give tips on how to shrink your waist to prevent your brain shrinking. Photo: Shutterstock

A waist size of more than 88cm for women and more than 102cm for men may put brain health at risk. Photo: Shutterstock

Dr Cyrus Raji, assistant professor of radiology and neurology at Washington University School of Medicine. Photo: Washington University School of Medicine 

David Merrill, director of the Pacific Brain Health Centre. Photo: Pacific Brain Health Centre

Amanda Corse, nutrition and wellness coach at Fizz Fitness in Tanzania. Photo: Instagram/@fizz.fitness

A Buddha bowl containing vegetables and other healthy ingredients, recommended by Corse of Fizz Fitness in Tanzania. Photo: Instagram/@fizz.fitness

These MRI images of two 61-year-old women’s bodies and brains show how one with a high level of abdominal fat (red border) has a higher level of brain atrophy than the other with a normal amount of abdominal fat. Photo: Cyrus Raji

Is your distance vision bad? Your risk of getting dementia could be higher, study suggests

Your eyesight could affect your mental health, according to a recent study, which found a link between vision problems and a higher risk of dementia. Experts advise getting your vision checked regularly. Photo: Shutterstock

Hemianopia is a condition in which half the field of vision is lost because of damage to the optic nerve in the brain. It is usually caused by stroke or tumour. Photo: Shutterstock

Joshua Ehrlich led a study that found that the risk of dementia was much higher among those with eyesight problems. Photo: Scott C. Soderberg, Michigan Photography

Dr Orlando Chan, a Hong Kong-based specialist in ophthalmology, says cataracts are still the number one cause of blindness worldwide, but they are reversible. Photo: Dr Orlando Chan

How intermittent fasting may protect brain health and help extend longevity – expert tips on how to begin and how long to fast for

Intermittent fasting might promote brain health and help protect against diseases such as Alzheimer’s and Parkinson’s, according to neuroscientist Mark Mattson. Photo: Getty Images

Mark Mattson is a professor of neuroscience at Johns Hopkins University.