Sundowning — also called sundown syndrome — is a pattern of increased confusion, agitation, and behavioral changes that occurs in the late afternoon and evening hours in some people with Alzheimer’s disease or other forms of dementia. It is one of the most challenging aspects of dementia caregiving and affects a significant number of people with cognitive impairment.
Understanding what sundowning is, why it happens, and how to manage it can make a significant difference for both people with dementia and their caregivers.
What sundowning looks like
Sundowning is not a disease itself but rather a collection of symptoms that tend to worsen as the day progresses into evening. Common symptoms include:
- Increased confusion and disorientation
- Agitation and restlessness
- Anxiety and fearfulness
- Mood swings and irritability
- Pacing or wandering
- Suspiciousness or paranoia
- Hallucinations or seeing things that are not there
- Yelling, calling out, or making repetitive noises
- Resistance to care or redirection
- Difficulty sleeping at night
These symptoms typically begin in the late afternoon — around the time the sun goes down hence the name — and may continue into the evening and nighttime hours. They often improve in the morning.
Who experiences sundowning
Sundowning is most commonly associated with Alzheimer’s disease but can occur in people with other types of dementia including vascular dementia, Lewy body dementia, and frontotemporal dementia. It is estimated that up to 20 percent of people with Alzheimer’s disease experience sundowning at some point during their illness.
Sundowning tends to be more common and more severe in the middle and later stages of dementia. It can occur in people living at home as well as those living in care facilities.
Why sundowning happens
The exact cause of sundowning is not fully understood but researchers believe several factors may contribute:
- Disruption of the internal body clock — dementia can damage the part of the brain that regulates the sleep-wake cycle leading to confusion about time of day
- Fatigue — people with dementia may become increasingly tired and overwhelmed as the day progresses making it harder to manage confusion and anxiety
- Reduced light — as natural light decreases in the evening it may become harder for people with dementia to distinguish reality from confusion
- Hunger or thirst — unmet physical needs can contribute to agitation
- Pain or discomfort — physical discomfort that the person cannot communicate verbally may manifest as behavioral symptoms
- Medication effects — some medications may contribute to confusion or behavioral changes at certain times of day
- Overstimulation or understimulation — too much or too little activity and stimulation during the day can affect evening behavior
How to manage sundowning
While there is no cure for sundowning there are many strategies that can help reduce its frequency and severity:
Maintain a consistent daily routine People with dementia do better with predictable routines. Try to schedule meals, activities, and bedtime at the same times each day. Consistency reduces confusion and anxiety.
Increase light exposure during the day Bright light therapy — exposure to natural or artificial bright light during the day — can help regulate the sleep-wake cycle and reduce sundowning symptoms. Open curtains during the day and consider a light therapy lamp.
Limit napping While rest is important excessive daytime napping can disrupt nighttime sleep and contribute to sundowning. Try to keep naps short and early in the day.
Plan activities strategically Schedule more stimulating activities in the morning and early afternoon when the person with dementia is typically more alert and capable. Keep the late afternoon and evening calm and low-key.
Create a calm evening environment As the afternoon progresses reduce noise and stimulation. Turn off the television, lower lights gradually rather than suddenly, and create a peaceful atmosphere.
Address physical needs Make sure the person with dementia is not hungry, thirsty, in pain, or uncomfortable. Sometimes agitation in the evening is a response to unmet physical needs that the person cannot communicate verbally.
Redirect and reassure When sundowning symptoms occur try to redirect the person’s attention to a calming activity such as listening to familiar music, looking at photo albums, or gentle hand massage. Reassure them calmly and avoid arguing or trying to correct their confusion.
Consider music therapy Familiar music from the person’s past can have a calming effect during sundowning episodes. Creating a playlist of favorite songs from their youth or young adulthood can be a helpful tool.
When to seek medical help
If sundowning symptoms are severe, sudden in onset, or represent a significant change from the person’s baseline consult with their physician. Sudden worsening of confusion or behavioral symptoms can sometimes indicate an underlying medical issue such as a urinary tract infection, medication side effect, or other treatable condition.
A physician may also be able to recommend medications that can help manage severe sundowning symptoms when non-pharmacological strategies are not sufficient. However medication is generally considered a last resort because of the risks associated with sedating medications in older adults with dementia.
Supporting caregivers
Sundowning can be exhausting and emotionally draining for caregivers. The late afternoon and evening hours when sundowning typically occurs can feel like the most difficult part of the day. Caregiver support strategies include:
- Asking family members or friends to take over caregiving duties during the most difficult hours
- Using adult day care programs to provide structured activities and respite during daytime hours
- Contacting the Alzheimer’s Association at alz.org for resources, support groups, and a 24-hour helpline
- Working with a geriatric care manager to develop strategies and coordinate support services
- Considering respite care or short term residential care to give primary caregivers a break
Key terms to know
- Sundowning — a pattern of increased confusion and behavioral changes in the late afternoon and evening in people with dementia
- Dementia — a group of conditions characterized by a decline in cognitive function severe enough to interfere with daily life
- Alzheimer’s disease — the most common form of dementia
- Sleep-wake cycle — the internal body clock that regulates periods of sleep and wakefulness
- Light therapy — exposure to bright light to regulate the sleep-wake cycle
- Redirection — a caregiving technique that involves shifting a person’s attention from a distressing situation to a calming activity
- Respite care — temporary relief for family caregivers
Sources
- Alzheimer’s Association — alz.org
- National Institute on Aging — Alzheimer’s Disease and Related Dementias
- Centers for Disease Control and Prevention — CDC
- Mayo Clinic — Sundowning
This article is for general informational purposes only and does not constitute legal or medical advice. Consult a licensed healthcare provider for guidance specific to your situation.