Sundowning, also known as sundown syndrome or sundowners syndrome, is a pattern of increased confusion, agitation, and behavioral changes that typically occurs in the late afternoon and evening. It is one of the most distressing challenges faced by seniors with dementia and their caregivers. According to the Alzheimer’s Association, roughly 20 to 45 percent of people with Alzheimer’s disease experience sundowning at some point during their illness.
If you are caring for an aging parent or loved one who seems to become a different person as the day winds down, you are not alone. Understanding what sundowning is, why it happens, and how to manage it can help you provide better care and reduce distress for everyone involved.
Key Takeaway: Sundowning is not a separate medical condition. It is a recognized cluster of neuropsychiatric symptoms linked to brain changes caused by dementia. While there is no cure, practical strategies involving routine, environment, and emotional support can significantly reduce the frequency and severity of episodes.
What Is Sundowning?
Sundowning refers to the onset or worsening of neuropsychiatric symptoms during the late afternoon, evening, or nighttime hours. The term was first coined by nurse Lois K. Evans in 1987 to describe the association between behavioral changes and the setting of the sun.
This syndrome most commonly affects people in the middle and later stages of Alzheimer’s disease and other forms of dementia. However, seniors without a dementia diagnosis can also experience sundowning, particularly when they are in unfamiliar environments like hospitals or rehabilitation facilities.
Sundowning is not recognized as a formal psychiatric diagnosis in the DSM-5, but it is widely acknowledged by healthcare providers who work with older adults. It affects everyone differently. Some seniors experience mild restlessness for an hour or two, while others become severely agitated well into the night.
Common Symptoms of Sundowning
The symptoms of sundowning can vary widely from person to person, which is part of what makes it so challenging for families to identify and manage. Common symptoms include:
- Increased confusion about where they are, what time it is, or who people are
- Agitation and irritability, including yelling, arguing, or becoming combative
- Anxiety and fearfulness, sometimes accompanied by crying or repeated calling out
- Restlessness and pacing, including wandering away from the home
- Shadowing, where the person follows their caregiver from room to room
- Hallucinations, such as seeing figures in shadows or hearing voices
- Paranoia, including accusations of theft or believing strangers are in the house
- Resistance to care, such as refusing to eat, bathe, or take medication
- Sleep disturbances, including difficulty falling asleep and frequent nighttime waking
These symptoms often worsen as the evening progresses and may continue throughout the night. One day a person may be relatively calm, and the next they may become deeply distressed. This unpredictability is one of the most exhausting aspects of sundowning for caregivers.
What Causes Sundowning?
The exact cause of sundowning has not been definitively established, but research points to several factors that likely work together:
Disruption of the Internal Clock
The strongest evidence links sundowning to damage in the brain’s circadian rhythm system. The suprachiasmatic nucleus (SCN), the brain’s internal clock, degenerates as dementia progresses. This disruption affects the body’s ability to distinguish between day and night, leading to confusion and agitation during evening hours.
At sunset, the body normally reduces dopamine levels and increases melatonin production to prepare for sleep. In people with dementia, melatonin production may be significantly decreased, throwing off this natural transition and triggering behavioral changes.
Environmental Triggers
Changes in lighting play a significant role. As natural light fades, increased shadows can cause visual confusion and fear. Noisy or overstimulating environments in the late afternoon, including busy TV programs or household activity, may also contribute.
Physical Needs
Unmet physical needs are common triggers. These include:
- Fatigue from the accumulated demands of the day
- Hunger or thirst that the person cannot articulate
- Pain from conditions like arthritis or urinary tract infections
- Medication side effects or the wearing off of medications taken earlier in the day
Urinary tract infections (UTIs) deserve special mention. They are known to cause sudden mood and behavior changes in seniors, and in older adults with dementia, a UTI may be the hidden trigger behind a new or worsening sundowning episode.
Seasonal Patterns
Sundowning tends to worsen during fall and winter months when the sun sets earlier. Shorter days mean symptoms can begin earlier and escalate more before bedtime. Reduced outdoor activity during colder months may also increase restlessness.
How to Manage Sundowning: Practical Strategies
While there is no cure for sundowning, a combination of environmental adjustments, behavioral strategies, and emotional support can make a meaningful difference. Non-pharmacological approaches should always be the first line of intervention.
1. Maintain a Consistent Daily Routine
Structure and predictability help reduce confusion and anxiety. Try to keep mealtimes, activities, and bedtime on a regular schedule. Knowing what comes next provides comfort, even when memory is impaired.
Plan stimulating activities for the morning and early afternoon when your loved one is likely at their best. Gentle exercise and outdoor time during the day can promote better sleep at night.
2. Create a Calming Evening Environment
As the afternoon progresses, shift the home environment toward calm:
- Turn on lights before dusk to prevent the sudden shift from daylight to darkness
- Close curtains early to reduce visual confusion from shadows
- Lower noise levels and turn off stimulating television programs
- Minimize clutter in common areas to reduce visual distractions
- Play soft, familiar music to create a soothing atmosphere
3. Pay Attention to Physical Needs
Before assuming a behavioral change is sundowning, check the basics:
- Is your loved one hungry, thirsty, or in pain?
- Do they need to use the bathroom?
- Are they wearing uncomfortable clothing?
- Could a medication be causing side effects?
Addressing these simple needs can sometimes prevent or quickly resolve an episode.
4. Manage Food and Drink Carefully
- Limit caffeine after midday
- Offer a lighter evening meal to avoid digestive discomfort
- Ensure adequate hydration throughout the day
- Avoid alcohol, which can increase confusion
5. Use Light Therapy
Exposure to bright light during the day, particularly in the morning, can help regulate the body’s internal clock. Light therapy has shown promise in reducing sundowning symptoms by supporting natural circadian rhythms.
If getting outside is not possible, a light therapy lamp designed for circadian support may be helpful. Discuss options with your loved one’s healthcare provider.
6. Respond with Patience During an Episode
When sundowning is happening, your response matters:
- Stay calm. Your anxiety can increase theirs.
- Speak in a soothing, reassuring tone. Simple sentences work best.
- Do not argue or try to reason with someone who is confused. Validation is more effective than correction.
- Redirect their attention to a comforting activity, such as folding towels, looking at family photos, or listening to favorite music.
- Ensure their safety by removing tripping hazards and securing exits if wandering is a concern.
Remember that these behaviors are caused by brain changes, not intention. Your loved one is not being difficult on purpose.
When to Consider Professional Support
If sundowning is causing significant distress, sleep deprivation, or safety concerns, it may be time to seek professional help. Talk to your loved one’s doctor about:
- Medication review: Some medications can worsen sundowning. A careful review of all prescriptions, including timing and dosage, may reveal contributing factors.
- Medical evaluation: Rule out underlying conditions like UTIs, pain, or sleep disorders that could be triggering episodes.
- Therapeutic support: Individual teletherapy can help seniors process the anxiety, depression, and emotional distress that often accompany cognitive decline. It can also help caregivers develop coping strategies.
Medication for sundowning, including antidepressants, anti-anxiety drugs, or low-dose sleep aids, is generally considered a last resort after non-pharmacological approaches have been tried. Antipsychotics are used cautiously due to the increased risk of stroke and other serious side effects in people with dementia. Always consult a healthcare provider before starting or changing any medication.
How Sundowning Affects Caregivers
Caregiving for someone who experiences sundowning can be physically and emotionally exhausting. The timing of symptoms, occurring just when the caregiver needs rest, makes it particularly draining. Caregiver burnout is a real and serious concern.
If you are a caregiver dealing with sundowning, consider these steps:
- Ask for help. Enlist family members, friends, or respite care services so you can take breaks.
- Prioritize your own sleep. If nighttime episodes are frequent, explore options for overnight care support.
- Join a support group. Connecting with other caregivers who understand what you are going through can reduce isolation.
- Seek your own counseling. Therapy for caregivers can provide practical coping tools and emotional support during this difficult time.
You cannot care for someone else effectively if you are running on empty. Your wellbeing matters too.
Sundowning and Mental Health Support for Seniors
Living with the confusion and distress of sundowning, whether as the person experiencing it or as the caregiver witnessing it, takes a toll on mental health. Feelings of anxiety, sadness, frustration, and helplessness are natural responses.
For seniors dealing with the emotional impact of cognitive changes, individual teletherapy can provide a safe space to process these feelings. Blue Moon Senior Counseling offers individual teletherapy by phone or video for seniors across the United States. Our licensed therapists specialize in older adult mental health and understand the unique challenges that come with aging, including coping with dementia-related changes.
Teletherapy is a Medicare Part B covered benefit, and no doctor’s order is required to get started.
Frequently Asked Questions About Sundowning
What is sundowning?
Sundowning is a pattern of increased confusion, agitation, and behavioral changes that typically occurs in the late afternoon and evening. It most commonly affects people with Alzheimer’s disease and other forms of dementia, though it can also occur in seniors without dementia who are in unfamiliar environments.
What are the early signs of sundowning?
Early signs include increased restlessness, confusion about the time of day, irritability, anxiety, and difficulty settling down as the afternoon progresses. You may notice your loved one pacing, becoming argumentative, or expressing fear or sadness as evening approaches.
Does sundowning happen every day?
Not necessarily. Some seniors experience sundowning daily, while others only have episodes occasionally. Triggers like fatigue, illness, environmental changes, or disruptions to routine can increase the likelihood of an episode.
Can sundowning happen without dementia?
Yes. While sundowning is most commonly associated with dementia, it can occur in older adults without cognitive impairment, particularly when they are in unfamiliar settings like hospitals or rehabilitation facilities. Stress, sleep problems, and medication side effects can also contribute.
Is there a cure for sundowning?
There is no cure for sundowning. Management focuses on identifying triggers, maintaining consistent routines, creating calming environments, and addressing unmet physical and emotional needs. In some cases, medication may be used under medical supervision.
When should I talk to a doctor about sundowning?
Consult a healthcare provider if sundowning episodes are frequent or severe, if they create safety concerns, if they represent a sudden change in behavior (which could indicate an underlying medical issue like a UTI), or if they are significantly impacting the quality of life for either the person or the caregiver.
