Sundowning in Dementia: Causes, Symptoms, and Solutions

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Five step diagram of an afternoon routine for sundowning: morning daylight and activity, limit afternoon naps and caffeine, turn on lights before dusk, quiet evening activity, calm bedtime routine.
An afternoon routine to ease sundowning

Sundowning in Dementia: Causes, Symptoms, and Solutions

Many people with dementia experience increased confusion, agitation, and behavioral changes as afternoon fades into evening. This pattern, known as sundowning, affects an estimated 20-45% of people with Alzheimer's disease and related dementias.

What Is Sundowning?

Sundowning (also called sundown syndrome) is a pattern of increased behavioral and psychological symptoms in the late afternoon, evening, or nighttime. Despite its name, sundowning doesn't always coincide with sunset.

Common Symptoms

What Causes Sundowning?

Researchers believe sundowning results from a combination of factors:

#### Biological Factors

#### Environmental Factors

Strategies That Help

#### Adjust the Environment

#### Modify the Daily Routine

#### Manage Evening Time

#### Address Unmet Needs

When to Call the Doctor

Caregivers should contact their loved one's physician if:

#### Medical Treatments

Doctors may recommend the following treatments in some cases:

For Caregivers: Protecting Yourself

Sundowning is exhausting for caregivers. Protect your own well-being:

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Why does sundowning happen at all?

Sundowning is late-day confusion, restlessness or agitation in someone with dementia. Sundowning usually begins in the late afternoon and can last into the night.

Several factors build up at that hour. Dementia damages the internal body clock, weakening the light cue that separates day from evening. Fatigue has built up all day, and a tired brain with dementia has less capacity to cope. Household activity often peaks around dinner, adding noise and movement. Fading light creates shadows that people misread. Unmet needs such as hunger, thirst, pain, constipation or a full bladder arrive at the same time.

What should be ruled out medically first?

Sudden agitation is not always sundowning. A urinary tract infection is a common cause of an abrupt change in someone with dementia, often with no fever. Constipation, uncontrolled pain, dehydration and a new or changed medication are the next possible causes.

Caregivers should call the doctor when agitation appears suddenly or worsens sharply over a day or two. Also call when agitation comes with fever, new incontinence, new falls or hallucinations. A rapid change is a medical event, not a behaviour problem.

Which practical changes reduce it?

How should you respond in the moment?

Caregivers should not argue about what the person with dementia says. Arguing increases tension and never wins. Agree with the feeling instead, then redirect.

Caregivers should lower their voice and slow down. Approach from the front, at eye level. Offer one simple choice rather than an open question. Give a job to do, such as folding towels or sorting mail. Purposeful movement settles agitation better than being told to sit down.

A person with dementia may want to go home despite standing in their own home. Ask what the person misses about home. That question usually leads to a gentler conversation than a correction.

When are medications appropriate?

Medication is a last step, not a first one, and antipsychotics carry real risks for older adults with dementia. Before agreeing to an antipsychotic, ask the prescriber what specific behaviour the medication targets and what will be tried first. Ask how long the trial lasts and when the medication will be reviewed for stopping. Treat any new prescription as a trial with an end date.

Caregivers should keep a simple log for two weeks: the time, what happened just before, what you tried and what worked. Patterns show up quickly, and the log helps make the doctor's visit useful.

Sources

How this guide was written and reviewed

CareBridge Navigator guides are drafted with writing software and research tools, then checked line by line by Shanda Browning Vaughn, RN, a registered nurse since 2000. Shanda confirms every figure against the official sources listed on the page before a guide is published, and updates the guide when Medicare, Medicaid or VA rules change.

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