How To Handle Sundowning: A Guide To Evening Agitation

If you care for someone who has Alzheimer’s or another form of dementia, you may experience a phenomenon known as sundowning. Sundowning syndrome refers to a group of behavioral disturbances and symptoms that change an individual’s thinking, actions, and mood as evening approaches.

It occurs in the late afternoon and into the evening. Sundowning occurs in as many as 20% of people with Alzheimer’s Disease¹. It’s essential for caregivers to understand sundowning for what it is and have the tools to help manage it to keep their care recipient calm and comfortable.

Are you interested in learning more about dementia, its symptoms, and caregiving? Check if you have free access to Trualta’s learning library.

Symptoms Of Sundowning

Sundowning behavior can look different depending on the person. It affects how individuals perceive the world, can change their overall mood, and may lead them to present with agitated or strange behaviors. These symptoms can start as soon as the early afternoon and progress into the early evening and nighttime.

Some examples of sundowning behaviors and feelings include: 

• Confusion 
• Paranoia and suspicion 
• Agitation 
• Frustration and anger
• Hallucinations and delusions (auditory or visual)
• Pacing or wandering 
• Restlessness
• Anxiety or fear

Some people with dementia experience mild symptoms, while others experience significant symptoms with complete hallucinations that seem very real to them. Regardless of the severity, it’s important to approach the care recipient with patience, kindness, and understanding to keep them calm. 

Sundowning Triggers

Sundowning symptoms can be affected by the environment, psychological stressors, and even the care recipient’s medical conditions. Understanding these triggers is key in formulating a plan to minimize the occurrence of this phenomenon. 

Disruption Of Sleep Cycle & Routine

Older individuals and people with dementia thrive with consistent routines, both during the day and at night. When these routines are disrupted, their internal rhythm is upset, which can lead to sundowning. 

When an individual’s circadian rhythm is disrupted, they may become confused and don’t know what time of day it is. They may sleep more during the day and be up at night, further perpetuating their confusion and anxiety.  

Fatigue & Overstimulation 

Someone with dementia may be triggered by feeling exhausted or overstimulated. Here are some examples of situations where sundowning may be triggered: 

• Having a long busy day full of many activities
• Being in a new, unfamiliar environment
• Poor sleep from the night before leading to significant fatigue during the day
• Overstimulation from crowded places or loud, busy environments

Psychological Factors

An individual’s inner state can have a large impact on their overall mood, behaviors, and actions. If your loved one is feeling stressed, anxious, or experiencing depression, sundowning symptoms may be triggered. 

Difficulty Communicating Unmet Needs

Sometimes symptoms of sundowning occur because an individual is uncomfortable or trying to communicate something with their caregiver. 

Examples of this include: 

• The care recipient is feeling hungry or thirsty
• They’re having significant pain 
• They need to void and use the bathroom 
• They’re exhausted and need to take a nap

Medical Issues 

The person’s medical status can put them more at risk of experiencing confusion, agitation, and anxiety that comes along with sundowning. Having an infection, like a urinary tract infection, can exacerbate confusion and make sundowning behaviors worse. Additionally, certain medications may lead to hallucinations and confusion which can also trigger increased sundowning. 

Tips For Managing Sundowning Symptoms

The most important way to manage sundowning behaviors, moods, and patterns is to address the trigger or prevent the trigger from happening. Here are some general tips that may help mitigate sundowning for the person you care for: 

Maintain A Routine 

One of the best ways to manage and avoid sundowning is to keep a consistent routine in the care recipient’s life. This provides them with consistency and predictability which helps to manage any confusion and provides structure during their day. Here are some tips:

• Consistent meal times. Choose to have meals at the same time each day. This ensures the care recipient won’t be hungry later in the day and provides them with a sense of comfort. Offering a heavier lunch and a lighter dinner can help the care recipient easily go to sleep. 
• Regular bathing routine. This ensures the care recipient’s hygiene and if it’s occurring at night, provides a signal that it’s time to wind down for the day.
• Similar wake and bedtime steps each night. Maintaining a consistent sleep and wake cycle gives the care recipient the best chance of having a good night’s sleep. It also prevents the care recipient from sleeping all day, which can minimize confusion.
• Balance of activity and rest. It may be a good idea to have just one bigger activity planned for the day, whether it’s physical activity or seeing a friend. Be sure to mix in a calming activity, too, like listening to music or reading a book with them. 
• Schedule appointments for earlier in the day. This is when the care recipient is likely clearest and most awake. 

Manage The Environment

A care recipient’s environment can be a large trigger for sundown symptoms. Here are some suggestions that can help optimize their surroundings to keep them calm and at peace: 

• Keep the environment quiet and calm, especially in the evening, to minimize stress.
• Help them get natural light during the day by a window or by taking a walk outside.
• Don’t use a bright light that can cause shadows, as this can confuse them.
• Use familiar items such as the care recipient’s favorite book, photos of family, or music to put them at ease. 

Facilitate Sleep 

Ensuring that the care recipient gets a restful night of sleep and maintains a balanced sleep wake cycle are key factors in managing sundowning symptoms. Some tips to avoid increased confusion and other sundowning behaviors include:

• Avoid caffeine late in the day
• Minimize alcohol intake
• Set up the environment to help them wind down
• If a nap is needed during the day, ensure it’s a short one

Monitor Their Health

Keeping tabs on the care recipient’s health can help you identify if any medical factors are playing a role in their sundowning symptoms. It’s wise to keep a log of important vitals and to check their skin often for areas of redness or wounds. If they begin acting out of their normal, consider following up with their doctor. 

To learn more about sundowning and how to manage it, check out if you have access to Trualta’s learning library here. 

References: 

1. Canevelli M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, Bruno G. Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches. Front Med (Lausanne). 2016 Dec 27;3:73. doi: 10.3389/fmed.2016.00073. PMID: 28083535; PMCID: PMC5187352.
2. National Institute on Aging. (n.d.). Coping with agitation, aggression, and sundowning. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/alzheimers-changes-behavior-and-communication/coping-agitation-aggression-and-sundowning
3. Mayo Clinic. (2021, October 12). Sundowning in Alzheimer’s disease: What you need to know. Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511
4. Alzheimer’s Society. (2021, September 30). Sundowning: Understanding this common behavior in dementia. Alzheimer’s Society. https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/sundowning
5. Cleveland Clinic. (2023, February 27). Sundown syndrome: Causes and treatment for sundowning. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/22840-sundown-syndrome