Caregiver Guide to Sundowning Syndrome in Dementia

Sundowning is one of the most exhausting and distressing symptoms families face when caring for someone with dementia. Just when you're tired from the day and hoping for a calm evening, your loved one becomes increasingly confused, agitated, anxious, or aggressive as afternoon fades into evening. They may pace, demand to "go home" even though they're already there, become paranoid, have trouble sleeping, or experience a complete personality change once the sun goes down. This predictable late-day deterioration leaves caregivers drained, frustrated, and wondering what they're doing wrong.

The truth is, you're probably not doing anything wrong. Sundowning affects up to 20% of people with Alzheimer's disease and other dementias, typically appearing in middle to late stages. While the exact causes aren't fully understood, sundowning likely results from a combination of factors: disrupted internal body clock, accumulated fatigue and overstimulation from the day, reduced lighting creating shadows and visual confusion, unmet needs that have built up, and changes in the brain that affect how it processes time and environmental cues.

Here's what to do right now: (1) Track when sundowning occurs and what seems to trigger or worsen it, (2) establish a calming late-afternoon routine that begins before symptoms typically start, (3) increase lighting in your home as daylight fades to reduce shadows and confusion, (4) ensure your loved one's basic needs (hunger, thirst, pain relief, bathroom) are met before evening, and (5) simplify the environment and reduce stimulation in late afternoon and evening hours.

Key Takeaway: Sundowning can't always be eliminated, but it can be significantly reduced through environmental modifications, consistent routines, addressing underlying causes, and responding with patience rather than logic or correction. Understanding that this is a symptom of brain changes, not intentional behavior, helps you respond more effectively and with less frustration.

Sundowning is particularly common during middle-stage dementia, when cognitive impairment is significant but the person is still mobile and active. For broader context on managing behavioral symptoms throughout the dementia journey, see our comprehensive dementia care guide.

What Sundowning Is and Why It Happens

Sundowning, also called late-day confusion or sundown syndrome, refers to increased confusion, agitation, and behavioral symptoms that occur in late afternoon and evening in people with dementia.

Typical Sundowning Symptoms

Increased confusion and disorientation
Agitation, restlessness, and pacing
Anxiety or fearfulness
Aggression or angry outbursts
Paranoia or suspiciousness
Demanding to leave or "go home"
Shadowing (following caregiver constantly)
Repetitive questions or behaviors
Difficulty sleeping or reversed sleep-wake cycle
Hallucinations or delusions worsening in evening

When Sundowning Typically Occurs

Most commonly begins in late afternoon (3 to 5 PM) and continues through evening and into night. Some people experience sundowning only during the transition from day to night, while others remain agitated throughout the evening and nighttime hours.

Why Sundowning Happens

The exact mechanisms aren't fully understood, but several factors likely contribute:

Disrupted Circadian Rhythm

Dementia damages the part of the brain that regulates the internal body clock. The natural transition from day to night may trigger confusion because the brain can't properly process time cues.

Fatigue

By late afternoon, mental and physical fatigue from the day accumulates. People with dementia have less cognitive reserve to manage fatigue, so they decompensate more dramatically.

Reduced Lighting

As natural light decreases, shadows increase and visibility decreases. This creates visual confusion and can trigger paranoia or hallucinations. Objects look different in dim light, and shadows can be frightening.

Unmet Needs

Hunger, thirst, pain, need to use bathroom, or discomfort may build up over the day. By evening, these unmet needs reach a tipping point, manifesting as agitation.

Overstimulation

The day's activities, noise, interactions, and demands accumulate. By evening, the person is overstimulated and overwhelmed, leading to behavioral symptoms.

Medication Timing

Some medications wear off by evening, or evening medications cause side effects that worsen confusion.

Caregiver Fatigue

Caregivers are tired by evening and may be less patient or attentive. The person with dementia picks up on this tension and stress.

Understanding these factors helps you target interventions more effectively. For more on recognizing and tracking symptom changes, see our guide on signs dementia is getting worse.

Tracking Patterns to Identify Triggers

Not all sundowning is identical. Your loved one's specific patterns and triggers help you develop personalized strategies. For a comprehensive system for documenting behavioral changes, see our guide on how to log behavior changes in dementia.

What to Track

Timing

What time does sundowning typically begin?
How long does it last?
Is it worse on certain days of the week?

Symptoms

What specific behaviors occur (agitation, pacing, paranoia, aggression)?
How severe are symptoms?
Do symptoms vary or stay consistent?

What Happened That Day

Activity level (busier or quieter than usual?)
Visitors or changes in routine
Sleep quality the night before
Medical issues or pain
Medications taken or missed
Meals and hydration
Weather or barometric pressure changes

Environmental Factors

Light levels in the home
Noise levels or activity in the house
Temperature and comfort
Visual stimulation (TV, people, clutter)

How to Track

Keep a simple log for at least two weeks. Note the date, what time sundowning started, what symptoms appeared, and what was happening that day. After two weeks, look for patterns.

Common Patterns You Might Notice

Sundowning is worse after busy days with appointments or visitors
Symptoms start earlier when your loved one didn't sleep well the night before
Specific activities or people seem to trigger earlier or worse symptoms
Sundowning is less severe when certain routines are followed
Certain times of year (shorter days in winter) worsen symptoms

Identifying patterns allows you to modify triggers and test interventions to see what helps. For strategies on organizing care information, see our article on using technology to organize dementia care.

Environmental Strategies to Reduce Sundowning

Modifying the environment addresses several underlying causes of sundowning.

Lighting

This is one of the most effective interventions.

Increase Lighting Before Sundown

Turn on lights throughout the house starting mid-afternoon, before natural light fades
Use bright, even lighting without harsh shadows
Add lamps to dimly lit areas
Consider full-spectrum bulbs that mimic natural daylight
Ensure hallways, bathrooms, and high-traffic areas are well-lit

Manage Shadows

Close curtains or blinds as sun sets to prevent shadows from moving trees or objects outside
Avoid single bright lights that create shadows (use multiple softer lights)
Remove or reposition furniture that casts confusing shadows

Nightlights

Use nightlights in bedroom, bathroom, and hallways for nighttime safety
Choose warm-toned nightlights rather than bright white lights

Reduce Stimulation

Minimize Noise and Activity

Turn off or lower TV, especially news or programs with violence or loud noises
Reduce household activity and commotion in late afternoon
Speak more quietly and move more slowly
Limit visitors in evening hours
Avoid phone calls or video chats in evening if they're overstimulating

Simplify the Environment

Close doors to rooms not in use to reduce visual stimulation
Cover mirrors if they cause confusion (seeing reflection and not recognizing self)
Reduce clutter and visual complexity
Create a calm, uncluttered space for evening hours

Temperature and Comfort

Keep the home at a comfortable, consistent temperature
Dress your loved one in comfortable, non-restrictive clothing
Ensure they're not too hot or too cold
Address physical discomfort (pain, itchy clothing, uncomfortable seating)

Routine and Schedule Strategies

Predictable routines reduce anxiety and help prevent sundowning by providing structure. For detailed guidance on creating daily routines, see our article on early stage dementia activities and routines.

Establish a Consistent Daily Schedule

Wake at the same time each day
Meals at the same times
Activities at regular times
Bedtime routine at the same time each evening

Consistency helps the brain anticipate what comes next, reducing confusion and anxiety.

Front-Load Activities

Schedule demanding activities, appointments, outings, and stimulating events in the morning and early afternoon when your loved one is most alert. Keep late afternoon and evening calm and predictable.

Create a Calming Pre-Sundown Routine

Starting about an hour before sundowning typically begins, transition to calming activities:

Simple, repetitive tasks (folding towels, sorting objects)
Gentle music your loved one has always enjoyed
Looking at photo albums together
Sitting outside or by a window if weather permits
Gentle physical activity like a short walk
Hand massage or other calming touch
Serving an early, light dinner

The goal is to signal to their brain that it's time to wind down before agitation has a chance to build.

Bedtime Routine

Start bedtime routine at the same time every night
Follow the same sequence of activities (bathroom, pajamas, brush teeth, settle into bed)
Keep it calm and low-key
Avoid stimulating activities close to bedtime
Use soft lighting and soothing sounds or music

Addressing Physical and Medical Needs

Unmet physical needs often contribute to sundowning. Addressing them proactively can reduce symptoms.

Ensure Adequate Hydration and Nutrition

Throughout the Day

Offer fluids regularly (dehydration worsens confusion)
Provide adequate food at meals and snacks
Avoid heavy meals late in the day (can cause discomfort)
Limit caffeine and sugar in afternoon and evening

Late Afternoon Snack

Offer a light, protein-rich snack in mid-afternoon
Some people become agitated when hungry but don't recognize or communicate hunger

Manage Pain

Unmanaged pain is a common trigger for behavioral symptoms. Your loved one may not be able to report pain clearly.

Watch for Signs of Pain

Grimacing, frowning, or guarding body parts
Resisting movement or care
Increased agitation or irritability
Changes in typical patterns

Address pain proactively:

If your loved one has chronic pain (arthritis, old injuries), give pain medication on schedule rather than waiting for complaints
Talk to the doctor about appropriate pain management

Ensure Bathroom Needs Are Met

Offer bathroom breaks regularly, especially before the typical sundowning period
Needing to use the bathroom but not recognizing or communicating the need causes agitation

Address Sleep Problems

Poor nighttime sleep worsens daytime and evening symptoms.

Strategies for Better Sleep

Limit daytime napping (short naps are okay, but not sleeping all afternoon)
Increase daytime activity and sunlight exposure
Avoid caffeine after morning
Create a comfortable sleep environment (dark, quiet, comfortable temperature)
Address nighttime bathroom needs (bedside commode, frequent bathroom trips before bed)

Review Medications

Some medications worsen confusion or agitation, especially in evening
Medications that wear off by evening may contribute to sundowning
Ask the doctor to review timing and types of medications

Behavioral Response Strategies

How you respond to sundowning affects its intensity and duration. For more detailed strategies on managing challenging behaviors, see our comprehensive guide on caregiving for middle-stage dementia.

What Helps

Stay Calm

Your stress and frustration escalate the situation
Speak softly and move slowly
Take deep breaths and remind yourself this is the disease, not intentional behavior

Validate Emotions

Acknowledge feelings even if you don't understand the cause
"I can see you're upset. I'm here with you."
Don't dismiss or minimize their distress

Avoid Arguing or Correcting

Logic doesn't work with someone experiencing sundowning
Correcting ("We're at home, we're not going anywhere") increases agitation
Enter their reality rather than forcing them into yours

Distract and Redirect

Gently shift attention to something calming
"Let's have some tea while we wait"
"I need your help with something"
Offer an activity or snack

Provide Reassurance

Simple, repeated reassurances help
"You're safe. Everything is okay. I'm here with you."
Physical touch (if welcome) can be calming

Remove Yourself Briefly If Needed

If you're becoming frustrated or angry, step away for a moment
Have another caregiver take over if possible
Protecting your own emotional state helps you respond more effectively

What Doesn't Help

Arguing about reality
Getting angry or raising your voice
Forcing activities or compliance
Over-explaining or using complex reasoning
Restraining physically unless absolutely necessary for safety
Taking their behavior personally

Activity and Engagement Strategies

Appropriate activities during the danger zone of late afternoon can prevent or reduce sundowning.

Types of Activities That Help

Calming and Repetitive

Folding laundry or towels
Sorting objects (buttons, coins, cards)
Simple puzzles or matching games
Coloring or simple art projects
Listening to favorite music
Looking at family photos
Gentle rocking chair or porch swing

Physical but Not Overly Stimulating

Short, slow walks outdoors or around the house
Gentle stretching or chair exercises
Sweeping or wiping tables (purposeful movement)
Dancing slowly to favorite music

Sensory and Soothing

Hand or foot massage
Aromatherapy with calming scents (lavender, vanilla)
Petting therapy animals
Soft blankets or textured objects to hold
Warm drinks (non-caffeinated tea, warm milk)

What to Avoid in Late Afternoon and Evening

New or complex activities
Overstimulating outings or events
Loud or chaotic environments
Activities requiring concentration or learning
Confrontational or competitive activities

Match activities to your loved one's current abilities and preferences. What worked earlier in the day may not work during sundowning hours.

When to Consider Medication

Behavioral and environmental interventions should always be tried first, but sometimes medications are necessary when sundowning is severe or dangerous.

When to Talk to the Doctor About Medication

Sundowning creates danger to your loved one or others
Behavioral symptoms don't respond to environmental and routine changes
Your loved one is in significant distress
Caregiver burnout from managing evening symptoms is severe
Quality of life for your loved one or family is severely impacted

Types of Medications That Might Be Prescribed

Antidepressants or Anti-Anxiety Medications

Can reduce anxiety and agitation
May be given in late afternoon or early evening to prevent sundowning
Examples: trazodone, SSRIs, buspirone

Antipsychotics

Reserved for severe agitation, aggression, or psychotic symptoms
Carry risks (increased fall risk, stroke risk in elderly) so used cautiously
Examples: risperidone, quetiapine
Should be lowest effective dose for shortest time necessary

Melatonin

May help regulate sleep-wake cycle
Generally safe with few side effects
Given in evening to promote better nighttime sleep

Pain Medications

If pain contributes to sundowning, scheduled pain medication may help

Important Considerations

All medications have side effects and risks
Start with lowest dose and increase gradually if needed
Monitor for increased confusion, falls, or other problems
Medications don't address underlying causes of sundowning
Combine medications with behavioral and environmental strategies
Review medications regularly with the doctor to adjust or discontinue

Never give medications meant for sleeping during waking hours without doctor guidance. Sedating someone to manage behavior has serious risks.

Self-Care for Caregivers Dealing with Sundowning

Sundowning is exhausting for caregivers because it happens when you're already tired and need a break. Managing it without burning out requires intentional self-care. For comprehensive support strategies, see our respite care guide.

Why Sundowning Is So Hard on Caregivers

Happens at the end of the day when you're least resilient
Prevents evening relaxation and rest
Often disrupts sleep
Feels personal (Why are they acting this way with me?)
Creates sense of failure (Why can't I calm them?)
Isolates you from normal evening activities
Accumulates stress day after day

If you're experiencing these feelings regularly, see our guide on signs of caregiver burnout to assess whether you need additional support.

What You Need

Evening Coverage

Arrange for another caregiver to cover evening hours several times a week
Use adult day programs so your loved one is tired and calmer in evening
Hire evening caregivers specifically to cover the sundowning period
Explore respite care options specifically for evening hours
If placement is an option, memory care staff manage sundowning behaviors (see our guide on when to transition to 24-hour care)

Breaks During the Day

If evenings are consistently difficult, take breaks during the day while you can
Don't wait until evening to rest; you need reserves
Learn how to take a break from caregiving without guilt

Manage Expectations

You can reduce sundowning but probably can't eliminate it
Some days will be worse despite your best efforts
This is brain dysfunction, not something you're causing or can perfectly control

Support

Join a caregiver support group where others understand this specific challenge
Talk to people who've dealt with sundowning for practical tips
Consider counseling if the stress is overwhelming

Physical Space

If possible, create a space where you can briefly retreat when overwhelmed
Headphones with calming music can help you stay calm during difficult moments

You can't pour from an empty cup. If sundowning is destroying your health and wellbeing, it's time to increase support or consider whether current care arrangements are sustainable.

Special Considerations for Different Living Situations

Sundowning looks different and requires different strategies depending on where your loved one lives.

At Home with Family Caregiving

Most control over environment and routine
Can implement lighting and routine changes easily
Burden falls primarily on family
May need to hire evening caregivers specifically
Need backup plan for when you're overwhelmed

At Home with In-Home Caregivers

Ensure caregivers understand sundowning and strategies that work
Communicate clearly about evening routines and triggers
May need different caregivers for evening shift who have experience with behavioral symptoms
Monitor that strategies are being implemented consistently

In Memory Care or Assisted Living

Staff manage sundowning behaviors
Less control over environment and routines
Can request specific interventions (lighting, activities, evening snacks)
Visit at different times to observe how staff handle sundowning
Communicate your loved one's triggers and what helps

When Visiting Family

Maintain home routines as much as possible
Bring familiar items
Arrive early enough to establish routine before sundowning hours
Consider shorter visits if environment is triggering
Prepare hosts about what to expect and how to help

How CareThru Can Help You Manage Sundowning

Managing sundowning requires tracking patterns, maintaining routines, coordinating caregivers, and adjusting strategies based on what works. CareThru provides tools to make this easier. For more on care coordination, see our guide on how to coordinate a dementia care team.

Track sundowning episodes. Log when they occur, how severe they are, what preceded them, and what interventions helped. Over time, patterns emerge that guide your strategies.

Store your loved one's daily routine and evening protocols in CareThru so all caregivers follow the same approach. Consistency is critical for managing sundowning, and having routines documented ensures everyone is on the same page.

Set reminders for interventions that need to happen at specific times (turning on lights at 3 PM, offering afternoon snack, starting calming activities at 4 PM). These reminders help you stay ahead of sundowning rather than reacting to it.

Share updates with family members about what's working and what's not. When everyone understands the strategies and challenges, they can support better and adjust their interactions during evening visits.

Document conversations with doctors about sundowning, including medication trials and their effects. This information is valuable when adjusting treatment plans or changing providers.

Frequently Asked Questions About Sundowning Syndrome

What causes sundowning in dementia?

Sundowning likely results from multiple factors: disrupted internal body clock due to brain changes, accumulated fatigue and overstimulation from the day, reduced lighting creating shadows and confusion, unmet needs building up, medications wearing off or causing side effects, and changes in brain chemistry. The exact mechanisms aren't fully understood, but these contributing factors help explain why symptoms worsen in late afternoon and evening.

Can sundowning be cured or completely prevented?

Sundowning usually can't be completely eliminated, but it can be significantly reduced through environmental modifications (especially lighting), consistent routines, addressing underlying needs (hunger, pain, fatigue), reducing stimulation in late afternoon, and appropriate medication when needed. The goal is management and reduction of symptoms, not cure. Some people experience mild, manageable sundowning while others have severe symptoms despite interventions.

At what stage of dementia does sundowning start?

Sundowning typically appears in middle to moderate stages of dementia but can occur at any stage. It's less common in very early stages when cognitive function is relatively preserved and may improve in very late stages when the person sleeps most of the time. Sundowning is most problematic during middle stages when cognitive impairment is significant but the person is still mobile and active.

Does sundowning get worse over time?

Not always. Sundowning patterns can change throughout the disease. Some people experience worsening symptoms as dementia progresses, while others see improvement. Very late-stage dementia patients often experience less sundowning because they sleep more and have less awareness. The middle stages tend to be when sundowning is most severe and problematic. Understanding dementia staging and progression helps you anticipate changes.

Should I let my loved one nap during the day if they have sundowning?

Brief naps (30 to 60 minutes) in early afternoon are generally okay and may reduce fatigue that contributes to sundowning. However, long naps or sleeping most of the afternoon can worsen nighttime sleep problems and make sundowning worse. If your loved one is napping excessively, try increasing daytime activity and stimulation while allowing one short, scheduled rest period.

Is sundowning worse in winter when days are shorter?

Many caregivers report that sundowning worsens in winter, likely due to earlier sunset, reduced natural light throughout the day, and less outdoor time. Combat this by increasing artificial lighting earlier in the afternoon, using full-spectrum light bulbs, maximizing daylight exposure when possible, and being extra vigilant about lighting as days shorten. Some families notice seasonal patterns worth tracking.

What should I do when my loved one demands to go home during sundowning?

Don't argue or try to convince them with logic. Instead, validate their feelings ("I can hear that you want to go home") and redirect ("Let's have some tea first" or "Let's wait until morning when it's safer to travel"). Sometimes asking about home or what they miss triggers memories and calms them. If they're at home, they may mean a childhood home or the feeling of security "home" represents, not the actual physical location. For more communication strategies, see our guide on how to talk to someone about their dementia diagnosis.

Can diet or supplements help with sundowning?

There's limited scientific evidence for specific diets or supplements reducing sundowning. However, ensuring adequate hydration, avoiding caffeine and sugar in afternoon, providing balanced nutrition, and giving protein-rich afternoon snacks may help. Melatonin supplements in evening may help regulate sleep-wake cycles. Always consult the doctor before starting supplements, especially if your loved one takes other medications.

Disclaimer: This article provides general information about sundowning syndrome and is not a substitute for medical advice. Sundowning management should be individualized based on your loved one's specific symptoms and needs. Consult with their healthcare team about appropriate interventions and medications.

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