Sundowning—a pattern of increased confusion, anxiety, and agitation that occurs in the late afternoon and evening—affects an estimated 20% to 45% of people living with Alzheimer’s disease or other forms of dementia. For families and caregivers, watching a loved one become increasingly distressed as the day goes on can be frightening and exhausting. Understanding what sundowning is, what causes it, and how to manage it can make a meaningful difference for everyone involved.
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In this comprehensive guide, we explore the causes, symptoms, and practical coping strategies for sundowning in elderly adults. Whether you are a family caregiver, healthcare professional, or senior navigating these challenges yourself, this resource provides the information you need to manage sundowning with confidence and compassion.
What Is Sundowning?
Sundowning, also called “sundowner’s syndrome” or “sundown syndrome,” refers to a cluster of behavioral and psychological symptoms that typically worsen during the late afternoon, evening, or nighttime hours. It is not a standalone disease or diagnosis. Instead, sundowning describes a recurring pattern of symptoms most commonly associated with Alzheimer’s disease and other types of dementia.
The term “sundowning” comes from the observation that symptoms tend to emerge or intensify around sunset. However, the behaviors can begin as early as mid-afternoon and may persist well into the night. Sundowning can affect people at any stage of dementia, though it tends to be more common in the middle to later stages.
Who Is Affected by Sundowning?
While sundowning is most closely associated with dementia, it can also occur in older adults who are:
- Recovering from surgery or hospitalization (known as hospital-related delirium)
- Experiencing urinary tract infections or other acute illnesses
- Adjusting to new living environments, such as moving to assisted living
- Dealing with significant life changes, stress, or grief and loss
Research published in the Journal of the American Medical Directors Association suggests that sundowning symptoms affect between 20% and 45% of individuals with Alzheimer’s disease, making it one of the most common behavioral challenges associated with the condition.
Common Symptoms of Sundowning in Elderly Adults
Sundowning can manifest in many ways, and symptoms may vary from person to person or even from day to day. Recognizing these symptoms early can help caregivers respond with appropriate strategies before behaviors escalate.
Cognitive and Emotional Symptoms
- Increased confusion: Difficulty recognizing familiar people, places, or routines
- Anxiety and fearfulness: Heightened nervousness, worry, or panic as daylight fades
- Agitation and irritability: Sudden mood shifts, verbal outbursts, or resistance to help
- Paranoia or suspicion: Unfounded beliefs that someone is stealing from them or intending harm
- Hallucinations: Seeing or hearing things that are not present, particularly in dimly lit rooms
- Crying or emotional distress: Unexplained sadness or tearfulness
Behavioral Symptoms
- Pacing and restlessness: An inability to sit still, wandering through the home
- Shadowing: Following a caregiver from room to room, seeking constant reassurance
- Sundown wandering: Attempting to leave the house, particularly dangerous in the evening
- Repetitive behaviors: Asking the same question repeatedly or performing the same action over and over
- Resistance to care: Refusing to eat, bathe, take medications, or go to bed
- Sleep disturbances: Difficulty falling asleep, frequent waking, or reversal of the sleep-wake cycle
Physical Symptoms
- Increased heart rate or blood pressure
- Muscle tension and restlessness
- Changes in appetite (often decreased in the evening)
- Fatigue combined with inability to rest
If you or a loved one are experiencing persistent anxiety or emotional distress related to sundowning or caregiving, professional support can help.
What Causes Sundowning?
The exact cause of sundowning is not fully understood, but researchers have identified several contributing factors. In most cases, sundowning results from a combination of biological, environmental, and psychological triggers.
Biological Factors
Disrupted circadian rhythm: Dementia can damage the suprachiasmatic nucleus (SCN) in the brain—the “master clock” that regulates the sleep-wake cycle. When this internal clock malfunctions, the body loses its ability to distinguish between day and night, leading to increased confusion and restlessness in the evening hours.
Neurotransmitter changes: As dementia progresses, levels of key brain chemicals like melatonin and serotonin decline. Melatonin, which helps regulate sleep, naturally decreases with age and drops even further in people with Alzheimer’s disease. Lower serotonin levels may contribute to mood instability and increased agitation.
Physical fatigue: By the end of the day, the cumulative mental and physical effort of processing information, navigating surroundings, and managing daily activities can overwhelm a brain already compromised by dementia. This “cognitive exhaustion” may lower the threshold for confusion and emotional dysregulation.
Unmet physical needs: Pain, hunger, thirst, constipation, or urinary tract infections can trigger or worsen sundowning symptoms. Seniors may not be able to communicate these needs clearly, expressing discomfort through agitation instead.
Environmental Factors
Reduced lighting: As natural light fades, shadows lengthen and visual contrast decreases. For someone with dementia, this can create visual misperceptions—interpreting shadows as threatening figures or struggling to recognize familiar spaces.
Increased noise and activity: In care facilities, shift changes, dinner preparations, and visitor departures often coincide with the late afternoon hours, creating an overstimulating environment that can trigger sundowning.
Unfamiliar surroundings: Transitions to new environments—whether a hospital stay, move to assisted living, or even rearranged furniture at home—can intensify disorientation during vulnerable evening hours.
Psychological Factors
Emotional exhaustion: A full day of trying to make sense of a confusing world takes an emotional toll. By evening, coping reserves may be depleted, leaving the person more vulnerable to distress.
Caregiver stress: Seniors with dementia are remarkably sensitive to the emotions of those around them. When caregivers are tired, frustrated, or anxious at the end of a long day, those feelings can transfer to the person they are caring for. Caregiver burnout is a real and serious concern.
Fear and insecurity: Nighttime can feel threatening to someone whose cognitive abilities are declining. The quiet, dark hours may amplify feelings of vulnerability, isolation, and loneliness.
Medication Side Effects
Certain medications—particularly those with sedating or stimulating properties—can contribute to sundowning when their effects wear off or peak at the wrong time of day. Common culprits include:
- Sleep medications that cause daytime drowsiness and nighttime wakefulness
- Pain medications that wear off by evening, leaving discomfort unmanaged
- Anticholinergic drugs that can worsen confusion in elderly patients
- Some antidepressants or anti-anxiety medications with activating effects
Always discuss medication timing and side effects with a healthcare provider if sundowning symptoms appear to coincide with medication schedules.
Stages of Sundowning: What to Expect
Understanding how sundowning may change over time can help caregivers prepare and adapt their approach. While every person’s experience is different, sundowning generally follows patterns related to the progression of the underlying condition.
Early Stage
In the early stages, sundowning may be subtle and easy to overlook. A senior might become slightly more restless or irritable in the late afternoon, have occasional difficulty sleeping, or seem mildly confused about evening routines. At this stage, simple environmental adjustments, such as increasing lighting and maintaining a consistent schedule, are often enough to manage symptoms effectively.
Middle Stage
As dementia progresses, sundowning behaviors tend to become more pronounced. Agitation may escalate more quickly, hallucinations or paranoia may emerge, and the person may become more resistant to redirection. Wandering becomes a greater safety concern during this stage, and caregivers often need to implement more structured interventions including secured doors, monitoring systems, and professional guidance.
Late Stage
In later stages of dementia, sundowning may paradoxically decrease for some individuals as overall activity levels decline. However, for others, sleep-wake cycle disruption becomes severe, with the person sleeping much of the day and remaining awake and distressed at night. At this stage, professional caregiving support and potentially specialized memory care may become necessary.
Tracking Sundowning Patterns
Keeping a simple journal or log of sundowning episodes can be extremely valuable. Record the time symptoms began, what was happening beforehand (meals, activities, visitors), how long the episode lasted, and what helped calm the person. Over time, patterns often emerge that reveal specific triggers you can work to avoid.
How Sundowning Differs from Other Conditions
It is important to distinguish sundowning from other conditions that may cause similar symptoms in elderly adults, as the management approaches differ significantly.
Sundowning vs. Delirium
Delirium is an acute, sudden change in mental status that can occur at any time of day. Unlike sundowning, which follows a predictable late-day pattern, delirium often has a rapid onset and is usually caused by an underlying medical condition such as infection, dehydration, or medication toxicity. Delirium requires immediate medical evaluation.
Key differences to watch for:
- Onset: Sundowning develops gradually over weeks or months. Delirium appears suddenly, often within hours.
- Pattern: Sundowning follows a predictable late-day cycle. Delirium can occur at any time and often fluctuates throughout the day.
- Cause: Sundowning is linked to dementia and circadian disruption. Delirium usually has an identifiable medical trigger.
- Reversibility: Delirium is often reversible when the underlying cause is treated. Sundowning is typically an ongoing management challenge.
Sundowning vs. Depression
Late-life depression can cause agitation, sleep disruption, and withdrawal, symptoms that may overlap with sundowning. However, depression typically does not follow a specific time-of-day pattern. If mood changes occur consistently throughout the day rather than worsening in the evening, depression may be the primary concern.
It is also important to note that depression and sundowning can coexist. Seniors with dementia have higher rates of depression, and the combination of both conditions can intensify evening distress. If you suspect your loved one is experiencing both, a comprehensive evaluation by a healthcare provider experienced in geriatric mental health can help guide treatment.
Sundowning vs. Sleep Disorders
Sleep apnea, restless leg syndrome, and other sleep disorders are common in older adults and can cause nighttime agitation and daytime fatigue. These conditions can coexist with sundowning and should be evaluated separately. A sleep study may be recommended if there are signs such as loud snoring, gasping during sleep, or excessive leg movements at night.
When Sundowning Occurs Without Dementia
While sundowning is most commonly associated with dementia, some older adults experience milder forms of late-day confusion or agitation without a dementia diagnosis. Contributing factors may include:
- Chronic pain that worsens with fatigue
- Vision or hearing impairment that becomes more challenging in low light
- Social isolation and reduced stimulation during evening hours
- Adjustment disorders following major life transitions
- Side effects from medications that peak or wear off in the afternoon
- Undiagnosed early-stage cognitive decline that has not yet been formally evaluated
If a senior without a dementia diagnosis is experiencing recurring late-day agitation or confusion, it is important to bring this to the attention of their primary care physician. Early evaluation can identify treatable causes and, when necessary, facilitate early intervention for cognitive decline.
Struggling with sundowning or caregiving stress? Connect with a licensed geriatric therapist today — covered by Medicare Part B.
How Sundowning Progresses Over Time
Understanding how sundowning tends to evolve at different stages of dementia helps caregivers plan ahead and adapt their approach.
Early stages of dementia: Sundowning episodes tend to be mild, infrequent, and may be dismissed as tiredness or a “bad day.” The person may seem slightly more confused or irritable in the evening but can often be redirected with minimal effort. At this stage, establishing routines and environmental adjustments can be highly effective at preventing episodes from escalating.
Moderate stages of dementia: This is when sundowning typically becomes most challenging. Episodes may occur daily, last longer, and involve more pronounced agitation, wandering, or emotional distress. Caregivers often report that the moderate stage is when they first seek outside help. It is also the stage where consistent coping strategies can make the most significant difference in quality of life.
Advanced stages of dementia: Sundowning may evolve or change character as overall communication and mobility decline. Some individuals experience fewer specific behavioral episodes but develop more severe sleep-wake cycle disruptions. The care focus often shifts from managing specific sundowning behaviors to ensuring overall safety and comfort.
Important: Sundowning does not follow a single, predictable trajectory. Some people experience a reduction in symptoms over time, while others see fluctuations tied to illness, medication changes, or environmental shifts. Regular communication with healthcare providers helps ensure the care plan remains appropriate as the condition evolves.
Practical Coping Strategies for Managing Sundowning
While there is no cure for sundowning, many strategies can significantly reduce the frequency and severity of episodes. A proactive, structured approach works best.
Create a Consistent Daily Routine
Predictability is one of the most effective tools for managing sundowning. Establish regular times for:
- Waking up and going to bed
- Meals and snacks
- Physical activity and exercise
- Social interactions and quiet time
- Personal care activities like bathing
Keep the most demanding activities—doctor appointments, shopping trips, bathing—in the morning when the person is typically most alert and calm. Reserve the late afternoon and evening for simple, calming activities.
Optimize the Environment
Maximize natural light exposure: Open curtains during the day and consider light therapy in the morning. Exposure to bright light helps regulate the circadian rhythm and may reduce sundowning severity.
Increase evening lighting: Before sunset, turn on additional lights throughout the home. Well-lit spaces reduce shadows and visual confusion. Use nightlights in hallways, bathrooms, and bedrooms to ease nighttime navigation.
Reduce evening stimulation: Turn off loud television programs, minimize household noise, and create a calm environment in the hours leading up to bedtime. Soft music, gentle conversation, or a favorite television show at low volume can provide comfort without overstimulation.
Maintain a comfortable temperature: Seniors are particularly sensitive to temperature changes. A room that is too warm or too cold can increase restlessness.
Nutrition and Hydration
- Serve a larger meal at lunch and a lighter dinner to avoid digestive discomfort in the evening
- Limit caffeine and sugar after noon
- Ensure adequate hydration throughout the day, tapering slightly in the evening to reduce nighttime bathroom trips
- Offer a small, comforting snack before bed if the person seems restless
Physical Activity
Regular physical activity, adjusted to the person’s ability level, can help reduce agitation and improve sleep quality. Walking, gentle stretching, chair exercises, or gardening earlier in the day can promote better evening rest. Avoid vigorous activity in the late afternoon, as it may increase agitation rather than reduce it.
Therapeutic and Sensory Approaches
Several non-pharmacological therapies have shown promise in reducing sundowning symptoms:
- Music therapy: Playing familiar, calming music during the late afternoon can ease the transition into evening. Research shows that music associated with positive memories is particularly effective at reducing agitation and anxiety in people with dementia.
- Aromatherapy: Lavender and chamomile essential oils, used in diffusers or applied to pillows, have been associated with reduced agitation in some studies. While results vary, these approaches carry minimal risk and can easily be incorporated into bedtime routines.
- Pet therapy: Interactions with therapy animals or even watching videos of animals can provide comfort and redirection during periods of restlessness.
- Reminiscence therapy: Looking through old photos, handling familiar objects from the past, or discussing cherished memories can provide emotional grounding and reduce confusion.
- Sensory stimulation: Weighted blankets, textured objects, or warm drinks can provide comforting physical sensations that help calm someone who is becoming agitated.
Keeping a Sundowning Journal
Tracking episodes over time can reveal patterns that inform better management. For each episode, note the date, time of onset, duration, potential triggers (visitors, outings, medication changes, illness, weather), what strategies were tried, and what helped. Over weeks, this journal becomes an invaluable resource for identifying specific triggers and refining the care plan. Share the journal with healthcare providers during appointments.
Communication Strategies During Sundowning Episodes
When a loved one is experiencing sundowning, how you respond matters. Consider these approaches:
- Stay calm and speak softly. Your tone of voice matters more than your words. A gentle, reassuring tone can de-escalate agitation.
- Validate their feelings. Instead of correcting or arguing, acknowledge their emotions: “I can see you’re feeling upset. I’m here with you.”
- Redirect, don’t confront. If the person is fixated on something distressing, gently guide their attention to a soothing activity—looking at family photos, listening to familiar music, or holding a comforting object.
- Avoid asking “why” questions. Asking “Why are you upset?” demands cognitive effort that a sundowning person may not be able to provide. Instead, offer comfort and reassurance.
- Use simple, short sentences. Complex instructions can increase confusion. Break tasks into single steps.
Aromatherapy and Sensory Comfort
Some caregivers find that gentle sensory approaches help ease sundowning agitation:
- Lavender or chamomile scents may promote relaxation (use a diffuser rather than candles for safety)
- Weighted blankets can provide a calming, grounding effect for some individuals
- Familiar tactile objects such as a soft blanket, a stuffed animal, or a piece of familiar clothing can provide comfort
- Hand massage with lotion can be soothing and provides reassuring physical contact
While research on these approaches is still evolving, many caregivers report that sensory interventions add a helpful layer to their overall management strategy.
Safety Precautions for Sundowning
Wandering and disorientation during sundowning episodes can create safety risks. Take these precautions:
- Install locks and alarms on exterior doors that alert you when they are opened
- Use motion-sensor nightlights to illuminate paths from the bedroom to the bathroom
- Remove or secure tripping hazards, especially in hallways and stairways
- Keep car keys, sharp objects, and potentially dangerous items out of reach
- Consider a medical alert bracelet or GPS tracking device for seniors who are prone to wandering
- Ensure the person carries identification at all times
When to Seek Professional Help
Consult a healthcare provider if:
- Sundowning episodes become more frequent or severe
- The person is at risk of harming themselves or others
- Sleep disruption is significantly affecting quality of life for the person or caregiver
- You suspect an underlying medical condition, medication side effect, or untreated pain
- Caregiver burnout is affecting your own physical or mental health
- The person has experienced a sudden, dramatic change in behavior (which may indicate delirium rather than sundowning)
The Role of Therapy in Managing Sundowning and Its Effects
While sundowning itself is primarily managed through environmental and behavioral strategies, the emotional impact on both the senior and their family members can be profound. Professional counseling can play an important role in several ways.
For Seniors
Individual teletherapy can help seniors who experience sundowning-related anxiety, fear, or depression. Even in earlier stages of dementia, therapeutic interventions such as cognitive behavioral therapy (CBT) adapted for older adults can help develop coping skills to manage evening anxiety and emotional distress.
For seniors without dementia who experience late-day agitation or mood changes, therapy can address underlying causes such as chronic stress, grief, adjustment difficulties, or anxiety disorders.
For Caregivers
The emotional toll of caring for someone with sundowning is significant. Caregivers frequently experience:
- Chronic sleep disruption from nighttime caregiving
- Guilt about feeling frustrated or overwhelmed
- Social isolation from the demands of caregiving
- Anxiety about their loved one’s safety
- Grief over the gradual loss of the person they knew
Professional counseling provides a safe space to process these emotions, develop sustainable coping strategies, and prevent the progression from stress to full caregiver burnout.
Telehealth Makes Therapy More Accessible
For both seniors and caregivers, telehealth removes many of the barriers that traditionally prevent people from seeking mental health support. Individual teletherapy sessions can be conducted by phone or video—no need to arrange transportation, find respite care, or navigate a new physical location. This is especially valuable for caregivers who cannot easily leave the home and for seniors who find travel stressful or difficult.
Blue Moon Senior Counseling specializes in individual teletherapy for adults 65 and older. Our Licensed Clinical Social Workers (LCSWs) are trained specifically in the emotional challenges of aging, including the anxiety, depression, and grief that often accompany conditions like dementia and sundowning. Teletherapy sessions are a Medicare Part B covered service, typically resulting in zero or low out-of-pocket costs for beneficiaries. No doctor’s referral is required to get started.
Frequently Asked Questions About Sundowning
What is the main cause of sundowning?
The main cause of sundowning is believed to be damage to the brain’s internal clock (the suprachiasmatic nucleus) caused by Alzheimer’s disease or other forms of dementia. This damage disrupts the circadian rhythm, leading to increased confusion and agitation as the day progresses. Factors such as fatigue, reduced lighting, and unmet physical needs can worsen symptoms.
Can sundowning happen without dementia?
Yes. While sundowning is most commonly associated with dementia, some older adults experience late-day confusion or agitation related to hospitalization, acute illness, medication side effects, significant life changes, or chronic conditions. However, persistent sundowning without an identified cause should be evaluated by a healthcare provider to rule out early-stage cognitive decline.
How long does sundowning last?
Sundowning episodes typically begin in the late afternoon and may last into the evening or night. Individual episodes can range from 30 minutes to several hours. The condition itself tends to persist as long as the underlying cause (such as dementia) is present, though the severity can fluctuate and may be reduced with proper management strategies.
Is sundowning a sign that dementia is getting worse?
Not necessarily. Sundowning can occur at various stages of dementia and does not always indicate disease progression. Worsening sundowning may sometimes be triggered by temporary factors such as illness, medication changes, or environmental stressors rather than advancing dementia. If you notice a sudden increase in sundowning severity, consult a healthcare provider to rule out reversible causes.
What is the best way to calm someone who is sundowning?
Stay calm, speak in a soft and reassuring tone, and validate their feelings without arguing or correcting them. Redirect their attention to a comforting activity such as listening to music, looking at photos, or holding a familiar object. Ensure the environment is well-lit and free from excessive noise. Avoid confrontation or restraint.
Does sundowning ever go away?
In cases related to temporary conditions like hospital delirium or acute illness, sundowning may resolve once the underlying cause is treated. For individuals with progressive dementia, sundowning may persist but can often be managed effectively with consistent routines, environmental modifications, and professional support. Some individuals experience a reduction in sundowning as dementia advances to later stages, though this varies.
Supporting Your Loved One Through Sundowning
Sundowning is one of the most challenging aspects of caring for a loved one with dementia or age-related cognitive changes. While it can be distressing for everyone involved, understanding its causes and having practical strategies in place can significantly improve quality of life for both the person experiencing sundowning and the people who love and care for them.
The most important things to remember are that sundowning is not the person’s fault, it is not a sign of failure on your part as a caregiver, and there are real, evidence-based strategies that can make a meaningful difference. Start with the basics: maintain a consistent routine, optimize lighting, manage nutrition and hydration, and approach your loved one with patience and compassion during difficult moments.
Remember that you do not have to navigate this alone. Whether you are a senior experiencing anxiety or emotional distress in the evening hours, or a caregiver feeling overwhelmed by the demands of supporting someone with sundowning, professional help is available. Reaching out for support is not a sign of weakness. It is one of the most important things you can do for your own well-being and for the quality of care you provide.
Blue Moon Senior Counseling provides compassionate, Medicare-covered individual teletherapy for seniors and their caregivers. Our Licensed Clinical Social Workers understand the unique emotional challenges of aging and dementia care. Sessions are available by phone or video, whatever is most comfortable for you. No doctor’s referral is required.
Get Started Today or call us at (630) 896-7160 to learn how individual teletherapy can support you or your loved one.
Written by Melanie Donohue, LCSW — a licensed clinical social worker specializing in geriatric mental health with over 15 years of experience helping seniors and their families navigate the emotional challenges of aging.
