Sundowning and Dementia: A Guide

Reviewed By: Dr. Brindusa Vanta, MD

When a loved one is diagnosed with dementia, it can be difficult to know how to help them. They may become forgetful and confused or experience unfamiliar personality and behavior changes that can worsen over time, resulting in needing assistance with everyday tasks. If you notice that your loved one's confusion or restlessness seems to increase around nightfall, this may indicate they're affected by sundowning. 

According to the Alzheimer's Association, as many as 20% of individuals diagnosed with Alzheimer's or dementia are impacted by sundowning. This behavior change isn't a disease, but a set of symptoms that occur at a specific time of day. Watching your loved one undergo these changes can be stressful, but understanding how to spot signs of sundowning can help you keep them safe. 

This guide provides a comprehensive overview of what sundowning is as well as its symptoms and potential causes. You can also explore tips and resources that offer guidance on how to care for someone struggling with sundowning and dementia. 

Sundowning refers to a state of confusion that may begin in the late afternoon and last through the night. During this time, your loved one may become increasingly agitated, distressed, confused or disoriented and start pacing or wandering. They also may experience sleeping issues due to their restless behavior.

Sundowning can occur in people with Alzheimer's or forms of dementia. Episodes usually start around the same time of day and last for a few hours. Most people revert back to their normal selves once the episode is over. 

Although sundowning can happen at any stage of dementia, it's most common during the middle or later stages. The middle stage of Alzheimer's can last for many years and cause brain changes that make it difficult for people to perform routine tasks or express their thoughts. Disorientation can also become more severe, causing confusion about the time of day. 

During the later stages of dementia, your loved one may require intensive, 24-hour care. They will most likely need full-time assistance with personal care tasks and have a hard time expressing their needs. Their anxiety, depression or fear may worsen, which can cause symptoms of sundowning. 

As people age, the brain can shrink in volume, particularly in the frontal cortex, impacting memory. A shrunken brain can also affect intellect and judgment, making it difficult to cope with the stress of performing daily activities. Some seniors may exhibit symptoms of sundowning from these brain changes, even if they don't show signs of Alzheimer's or dementia. 

The exact cause of sundowning isn't fully known. One theory suggests that it's triggered by a disruption in a person's circadian rhythm. Circadian rhythms are responsible for the sleep-wake cycle. When this process is disrupted, a person may become confused or frustrated, resulting in sundowning behaviors. 

There are several other factors that may contribute to sundowning, including:

• Reduced lighting and increased shadows that may cause fear or confusion
• Mental or physical exhaustion from being in an unfamiliar or confusing environment
• Overstimulation from a noisy or busy environment
• Sensory deprivation, such as not having enough exposure to sunlight
• Mood disorders, including depression or anxiety
• Decreased sense of safety or security
• Hunger or dehydration
• Underlying health issues, including pain, discomfort or infection
• Increased stress levels or boredom

Also referred to as late-day confusion, sundowning can cause delirium that worsens as the sun sets. Your loved one may begin to experience trouble with several cognitive functions including memory, thinking, reasoning and mood that affect their thoughts, feelings or behaviors. These changes will typically occur around the same time each day. 

Sundowning symptoms typically begin in the late afternoon and can last into the night. Although each person will be affected by sundown syndrome differently, common symptoms include:

• Anxiety
• Anger
• Depression
• Extreme agitation
• Delusions or hallucinations
• Paranoia and fear
• Confusion
• Emotional or physical outbursts
• Pacing or wandering
• Crying
• Trouble sleeping
• Hiding objects
• Inability to follow directions

Helping your loved one navigate sundowning symptoms may take some trial and error, but it's important to remain patient and determine what factors are aggravating symptoms the most. The following tips can help you identify what may be affecting your loved one's symptoms and deal with them in an effective manner. 

Maintaining a regular routine can help your loved one stay oriented and feel less anxious or confused. You can do this by establishing a time for waking up, eating meals and going to bed. Your loved one may find comfort in knowing what to expect throughout the day, and the routine may stabilize their sleep-wake cycle, which can prevent sundowning symptoms. 

Too much stimulation at night may overwhelm or confuse your loved one. Try to avoid loud noises or too much activity at the end of the day, such as playing music or doing household chores. These can make it harder for your loved one to wind down, resulting in pacing, wandering or trouble sleeping. Schedule these activities in the morning or early afternoon instead. 

Since agitation and frustration are common sundowning symptoms, engaging your loved one in calming activities during the late afternoon or early evening may ease these negative emotions. Calming activities can include watching a movie, playing a card game, doing arts and crafts or looking at photographs that evoke happy memories. 

Adjust the lighting in your loved one's home to mimic the time of day. For example, let natural light into the home during the day and use softer room lighting in the evening when your relative is getting ready for bed. 

You may want to talk to your loved one's doctor if sundowning symptoms begin suddenly or increase in intensity. While there isn't a known cure for sundowning, there are certain medications, such as antianxiety, antidepressant and antipsychotic drugs, that can be used to reduce symptoms. Melatonin can also help with sleep. A doctor can let you know the best time of day for medications to be taken.