A Caregiver’s Guide to Sundowning and Dementia

Caring for an older adult is never easy, but it’s even more of a challenge when that person has dementia. In addition to running errands and providing daily supervision, you need to watch for behavioral changes and signs of worsening memory loss. You may also have to provide assistance with bathing, toileting and other activities of daily living, increasing the physical stress on your body.

Some seniors with dementia experience sundowning, a phenomenon that causes concerning symptoms. Fortunately, there are several things you can do to reduce the risk of sundown syndrome or shorten the length of an episode. This guide defines sundowning, explains what causes it and provides tips to help you cope. It also includes a list of resources for families who need support caring for someone with dementia. 

Sundowning is a term used to describe the agitation, restlessness and confusion that sometimes occurs in the late afternoon and early evening — just when the sun starts going down for the day. It often persists into the night, making it difficult for someone with dementia to fall asleep or stay asleep. According to the Cleveland Clinic, sundowning affects up to 20% of seniors with Alzheimer’s disease.

Sundowning takes a toll on caregivers, as it’s difficult to see someone you love struggling with their symptoms. Since the phenomenon occurs late in the day, it can also make it more difficult to juggle your caregiving duties with parenting, meal preparation, household chores and other activities that usually occur in the late afternoon or early evening. 

Sundowning typically occurs in the middle and late stages of dementia, but it can occur at any time. Alzheimer’s disease progresses through seven stages, and sundowning doesn’t usually appear until the third or fourth stage, which is when an older adult has noticeable memory loss.

It’s possible for an older adult to experience sundowning even if they don’t have dementia. If you notice sundowning symptoms in a loved one without a dementia diagnosis, make sure they seek medical attention right away. Sundowning could be due to medication usage, severe infections and severe pain, all of which require professional care.

In some cases, sundowning is a symptom of hospital-induced delirium. This condition causes impaired cognition, disorientation, delusions and other problems. It’s especially common in older adults, which is why the symptoms are often blamed on dementia even when the patient has no history of memory loss or cognitive difficulties.

Long-term outlook can vary greatly based on the person’s overall health, the progression of their dementia, and the effectiveness of their symptom management strategies. With proper symptom management, you can often reduce episodes of Sundown Syndrome, and in some cases, the syndrome may even resolve over time.

Please remember that every individual’s experience with Sundown Syndrome is unique. Some people may have mild symptoms that are relatively easy to manage, while others may have severe symptoms that require more intensive interventions.

Scientists don’t know exactly what causes sundowning, but there are several factors that can trigger an episode:

• Poor lighting may produce shadows, causing a loved one with dementia to become agitated.
• Older adults may have trouble distinguishing their dreams from reality.
• Your loved one may get their days and nights mixed up.
• Older adults need less sleep than younger people, which may contribute to changes in your loved one’s internal clock.
• Doing too much during the day can cause overstimulation, putting additional stress on your loved one’s brain.
• Pain, fatigue and medication side effects may alter your loved one’s perception of reality.

If your loved one has a sundowning episode, you may notice changes in their behavior, emotions or mental state, so be on the lookout for these signs.

Sundowning can be scary, especially if your loved one has a hard time distinguishing what’s real from what isn’t. During an episode, they may display fear, agitation, anxiety, restlessness and irritability. Some adults with dementia also experience sadness while they’re sundowning.

Once a sundowning episode begins, your loved one may start shadowing you, or following you wherever you go. This behavior stems from fear and disorientation. Calendars, maps and other tools are no longer helpful, leaving an older person with dementia feeling unattached. Shadowing gives them a chance to feel safe. Sundowning may also cause pacing, wandering or rocking back and forth. In some cases, these behaviors are the result of fear or restlessness.

Sundowning also causes these behavioral changes:

• Screaming
• Crying
• Violence
• Difficulty sleeping

Many seniors experience confusion while they’re sundowning, making it more difficult to think clearly. Sundowning is also associated with delusions and hallucinations. A delusion is a sincere belief in something that isn’t true. For example, an adult with dementia may believe that you’re stealing from them, that you’re an impostor, or that where they’re living isn’t their real home.

Hallucinations are false perceptions of people, places, things and events. These perceptions may involve any of the five senses. For example, it’s common for people with dementia to see things that aren’t there or hear noises that no one else can hear.

In general, the first step to diagnosing Sundown Syndrome is a detailed medical evaluation. The doctor will want to know about your loved one’s symptoms, how often they happen, and when. They might ask about their sleep habits, daily routine, and any changes in their surroundings.

Besides the medical evaluation, the doctor might also perform cognitive tests on the patient. These tests can evaluate memory, attention, language skills, and other mental functions. The results can help the physician determine the severity of the person’s cognitive impairment and whether their symptoms match those of Sundown Syndrome.

Keep in mind there’s no single lab test or imaging study that can tell if someone has Sundowners Syndrome. Instead, the healthcare professional will examine all the symptoms and rule out other possible causes.

It’s not possible to prevent sundowning 100% of the time, but there are things you can do to reduce the risk of an episode:

• Make sure your loved one gets as much physical activity as possible. 
• Seat your loved one near a window. Exposure to bright light may prevent them from getting their days and nights mixed up.
• Create an environment that promotes restful sleep. Your loved one’s bedroom should be dark and quiet near bedtime.
• Turn on lights in the afternoon so that the house doesn’t get too dark when the sun starts going down.
• Serve light meals later in the day.
• Establish a daily routine and stick to it.

If you’re concerned about sundowning, there are also a few things to avoid when caring for a loved one with dementia:

• Don’t serve coffee and other caffeinated beverages after 3:00 p.m.
• Avoid scheduling several activities on the same day. Although it’s more convenient for you, it can be stressful for a loved one with dementia.
• Avoid serving alcohol, as it can contribute to confusion.

Treatment for Sundown Syndrome is typically multifaceted, involving pharmacological and non-pharmacological approaches. The primary goal of treatment is to manage symptoms, improve quality of life, and reduce the burden on caregivers.

Doctors might consider a few options when it comes to using medicine to help manage Sundowning. These can include sedatives, antipsychotics, or mood stabilizers.

Sedatives can help to calm your loved one and promote better sleep. Antipsychotics can help manage symptoms like agitation, aggression, or hallucinations. Mood stabilizers can help to even out their mood swings and reduce irritability.

However, it’s vital to exercise caution when using these medicines. They can have side effects, and there’s also a risk of making the patient too sleepy or sedated. Side effects can vary depending on the medication, but they can include dizziness, confusion, loss of balance, and falls. As such, some medicines may have more serious side effects, like an increased risk of stroke or other health problems.

Non-medical approaches to treating Sundowners Syndrome focus on managing the environment and behaviors to reduce symptoms. Below are some strategies that can help:

• Maintain a consistent routine: Keeping a regular schedule for meals, medication, activities, and bedtime can provide a sense of security and predictability for loved ones with Sundowners Syndrome.
• Try light therapy: Exposure to natural light during the day can help regulate the body’s internal clock and potentially reduce symptoms of Sundown Syndrome. Some studies suggest that bright light therapy may be beneficial in treating Sundowning and related symptoms, including agitation.
• Create a calm environment: Reducing noise and activity in the evening hours can help create a more peaceful environment. This involves turning off the television, dimming lights, and avoiding activities that cause agitation or excitement.
• Exercise: Regular physical activity during the day can promote better sleep at night and potentially reduce symptoms of Sundowners Syndrome. Think of light exercises like walking, gardening, etc.
• Eat a healthy diet: Certain foods and drinks, especially those containing caffeine or large amounts of sugar, can contribute to restlessness and sleep disturbances. A balanced diet is beneficial in improving your loved one’s overall health and sleep quality.
• Engage in comforting activities: Engaging in calming activities in the evening can help soothe agitation. Let your loved ones listen to soft music, read, or do puzzles.
• Use reorientation techniques: If your loved one becomes confused or disoriented, gently remind them of the time, place, and people around them.

While these strategies may help alleviate symptoms, it’s always best to work with a healthcare professional to develop a care plan tailored to your loved one’s needs and symptoms.

It’s not easy to watch a loved one go through a sundowning episode, but it’s important to remember that the situation isn’t hopeless. There are many things you can do to ease their anxiety, reduce confusion and manage other symptoms. 

It’s easier said than done, but staying calm is one of the best ways to respond to sundowning behavior. Instead of using restraints or speaking loudly, talk to your loved one in a quiet tone of voice. Reassure them and let them know that you’re there to help.

If your loved one experiences hallucinations or delusions, they might say something that doesn’t make sense to you. Your instinct may be to correct them, but it’s better to listen carefully and avoid arguing. Trying to correct them may only lead to increased agitation and irritability.

Distracting someone who’s going through a sundowning episode is a good way to prevent them from getting even more upset. If you notice that your loved one is anxious or agitated, suggest that you work on a puzzle or do another favorite activity together. Some people benefit from counting coins or folding laundry — two simple activities that keep the hands busy and don’t require much thought.

Some people with dementia experience sundowning because they’re stressed and overstimulated. As soon as you notice the symptoms, try adjusting your loved one’s environment. Depending on your circumstances, you may need to turn off the TV, turn down the stereo or ask other family members to leave the room.

If you’re not making any progress after implementing the tips above, contact your loved one’s physician. A trained professional can conduct a thorough assessment and medication review to determine if the episodes are linked to physical problems or medication side effects. They may also recommend medications to treat the symptoms of sundowning, such as melatonin, antidepressants, antipsychotics or antianxiety drugs.

The table below includes resources that can help you provide the best possible care to a loved one who has dementia.