When caring for people with dementia, a sudden change in behavior can be worrying. One possible cause for these changes is something called sundowning. If you notice increased confusion, restlessness, or other difficult behaviors, especially in the late afternoon or early evening, sundowning could be the cause.

In this article, we will review:

• What Is sundowning?
• What causes sundowning?
• Strategies to prevent sundowning
• Managing sundowning
• The effect of sundowning on caregivers

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

What Is Sundowning?

Sundowning is a common challenge for caregivers of people with dementia, including conditions like Alzheimer’s disease. It’s not a disease itself, but a set of symptoms that occurs later in the day. Recognizing sundowning can help you understand how to respond. Some signs of sundowning include:

• Restlessness: Your loved one might pace, wander around, or keep getting up and sitting down.
• Agitation: They may become more irritable, frustrated, or have emotional outbursts. Sometimes, they might even act aggressively.
• Confusion: They may have trouble remembering the time of day, where they are, or who is with them. They might refuse to cooperate or act difficult.
• Wandering: They may try to leave the house or walk around, even in places they don’t know well.
• Increased anxiety or fear: Your loved one might become more anxious or scared, especially in low light or unfamiliar surroundings.

Around 1 in 5 people with dementia will experience some form of sundowning. The timing, duration, and intensity of sundowning can be different for each person. It often starts in the late afternoon or early evening (around sundown) and can last anywhere from a few minutes to all night. The symptoms can stay consistent or change from day to day. Sundowning can happen at any stage of dementia, but it’s usually worse in the middle stages. Sundowning is not permanent and will generally resolve by the morning.

Sundowning vs. Delirium

It’s important to tell the difference between sundowning and delirium because they can look similar. An important difference is that sundowning happens at a certain time of day (usually in the late afternoon or evening), while delirium can happen at any time. 

Delirium is characterized by a sudden onset of a cognitive change, such as:

• Changes in personality or mood
• Forgetfulness or confusion
• Behavior changes like agitation or quietness
• Trouble focusing or speaking
• Delusions
• Less awareness of surroundings, time, and place
• Slowed movements, restlessness, or falls 

Delirium is a medical emergency and could also be the first sign of a serious medical problem. Seek urgent medical attention if you notice signs of delirium.

Knowing what’s causing the symptoms is important. Delirium usually only gets better when the problem is treated, while sundowning is often reversed by morning and is managed through changes in behavior and routines.

What Causes Sundowning?

The exact cause of sundowning isn’t fully understood, but several things are believed to contribute. One key factor is that the internal “body clock” or circadian rhythm (which helps regulate the sleep-wake cycle) can get out of sync in people with dementia. When this happens, it becomes harder to tell the difference between day and night.

Other factors that can make sundowning syndrome worse include:

• Lack of routine: A regular schedule can help reduce late-day confusion and anxiety.
• Poor management of pain, stress, or mental health: When these things aren’t well managed, they can worsen sundowning.
• Over-stimulation: As evening approaches, environments that are too noisy or busy can overwhelm the person with dementia, making them more agitated and confused.
• Changes in lighting: Older individuals have more trouble seeing in low light, which can cause confusion or fear. Shadows, in particular, can seem threatening. If your loved one has vision problems, it’s important to have their eyes checked and to adjust lighting in the evenings.
• Lack of sunlight during the day: Sunlight helps to keep the body’s internal clock on track. If a person doesn’t get enough natural light during the day, it can mess up their sleep wake cycle and trigger sundowning.
• Fatigue: Being overly tired or having sleep disturbance can make sundowning worse.
• Certain medications, like narcotics, can make sundowning worse. Pay attention to any changes in behavior and talk to a doctor about whether medications could be affecting sundowning symptoms.

Strategies To Prevent Sundowning

Here are some practical strategies you can use to help manage sundowning and reduce its impact on both you and your loved one:

• Stick to a routine: Create a consistent daily schedule for meals, activities, and bedtime. A routine can help reduce anxiety and confusion. Make appointments earlier in the day and avoid making big changes in the evening.
• Create a calm, soothing environment:
  • Lighting: Bright light in the late afternoon and evening can help reduce confusion and shadows. If your loved one has trouble seeing in low light, try using nightlights or brighter bulbs. 
  • Reduce noise: Too much noise can overwhelm someone with dementia, so keep the environment as calm as possible. Turn down the TV or radio if they become too loud or distracting.
  • Comfortable temperature: The room should be neither too hot nor too cold, as discomfort can add to agitation.
• Encourage daytime activity: More mental and physical activity during the day can help reduce sundowning. Encourage outdoor walks, light exercise, or mentally stimulating activities like puzzles or reading.
• Monitor sleep patterns: Reduce any sleep disturbances by having your loved one stick to a regular sleep schedule. Limit naps during the day, especially in the late afternoon, and encourage them to go to bed at the same time each night. 
• Limit sugar, alcohol, and caffeine in the evening: These can interfere with sleep and make sundowning worse. Reducing these at night can help the brain “wind down” and improve sleep quality.

Managing Sundowning 

If you’re caring for someone experiencing sundowning, here are some steps you can take to manage the situation:

Address physical needs: Sundowning behaviors may be caused by unmet physical needs. First, check if your loved one is hungry or thirsty, needs to use the bathroom, or is in pain or discomfort.

Provide reassurance: Sundowning can be a scary experience for both the caregiver and the person with dementia. Reassure them by speaking in a calm and soothing voice. Use simple, clear sentences, and avoid arguing. Try to keep them close and offer reassurance, as isolation can make sundowning worse. If your loved one becomes aggressive, maintain a safe distance until the behavior subsides.

Validate and distract: Trying to reason with someone during sundowning often doesn’t work. Instead, validate their feelings, even if they don’t make sense. For example, you could say, “I understand that you’re frustrated.” You can also try distracting them with something they enjoy, like going for a walk, playing a game, watching a favorite TV show, or listening to music.

Sundowning Effect On Caregivers

Sundowning can be very hard on caregivers. It often happens in the late afternoon or evening, when caregivers are already tired. The confusion, restlessness, and anger that come with sundowning can be upsetting and stressful. This makes it harder for caregivers to relax or enjoy their evening. Over time, caring for someone with sundowning can lead to frustration, anxiety, and exhaustion. To avoid burnout, caregivers need to ask for help, take breaks, and make time for themselves.

When To Seek Professional Help

While the strategies mentioned above can help, there may be times when sundowning becomes too difficult to manage alone. If you notice these sudden behavior changes are getting worse, it’s important to speak with a healthcare professional. They can help rule out other medical conditions and suggest additional treatments or strategies.

Conclusion

Sundowning is a set of symptoms experienced by about 1 in 5 people with dementia experience sundowning, including increased anxiety, agitation, and confusion. It typically occurs in the late afternoon or evening hours and resolves by morning. Caregivers can help reduce the risk of sundown syndrome by maintaining a consistent routine, encouraging healthy sleep habits, and ensuring adequate lighting in the evening. When caring for someone experiencing sundowning, it’s important to stay calm, offer reassurance, and provide support. Managing sundowning can be taxing on caregivers. If sundowning becomes too difficult to manage, seeking professional help may be necessary.

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

References

1. Alzheimer’s Caregiving Tips. (n.d.). https://www.bu.edu/alzresearch/files/2010/03/alzheimers_caregiving_tips_sundowning.pdf
2. Cleveland Clinic. (2022, April 26). Sundown Syndrome: Causes, Treatment & Symptoms. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/22840-sundown-syndrome
3. NIH. (2024, July 17). Coping with Agitation, Aggression, and Sundowning in Alzheimer’s Disease. National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-changes-behavior-and-communication/coping-agitation-aggression-and-sundowning
4. Roland, J. (2022, April 25). What Is Sundowning and How Can You Manage It? Healthline; Healthline Media. https://www.healthline.com/health/sundowning#how-to-help
5. Sasser, J. (2010). Sundowning. JAMA, 303(14), 1345. https://doi.org/10.1001/jama.2010.304 
6. https://www.webmd.com/alzheimers/manage-sundowning