When late afternoon arrives and your loved one with dementia suddenly becomes agitated, confused, demanding, or even aggressive, you're witnessing sundowning. For hours each day, the person who was relatively calm in the morning transforms into someone who's restless, paranoid, combative, or insistent on leaving the house.
Sundowning is one of the most exhausting and demoralizing symptoms of dementia for caregivers. It happens at the end of the day when you're already tired, and it can last for hours. But sundowning isn't random, and it's not your loved one trying to make things harder. It's a real neurological phenomenon with identifiable triggers and effective interventions.
Key Takeaway: Sundowning is increased confusion, agitation, and difficult behaviors in late afternoon and evening caused by disrupted circadian rhythms, fatigue, and environmental factors. You can reduce it by maximizing morning light exposure, maintaining consistent routines, avoiding late-day stimulation, and addressing underlying discomfort.
For comprehensive guidance on dementia care, see our dementia care guide. Understanding the dementia symptom progression timeline helps you anticipate when sundowning typically emerges.
What is Sundowning and How Common Is It?
Sundowning is a pattern of increased confusion, agitation, anxiety, and behavioral problems that begins in late afternoon or early evening and improves later at night. It affects up to 20-45% of people with Alzheimer's disease and other dementias, most commonly in middle to late stages.
Common Sundowning Behaviors
- Increased confusion and disorientation: Not recognizing where they are, thinking they're in a different time period, forgetting who family members are
- Agitation and restlessness: Pacing, wringing hands, inability to sit still, trying to leave the house or go "home"
- Mood changes: Increased anxiety, irritability, anger, suspicion, or paranoia
- Demanding or repetitive behaviors: Asking the same questions over and over, following you from room to room
- Combativeness and resistance: Refusing care, pushing away helpers, verbal or physical aggression
- Perceptual disturbances: Seeing things that aren't there, hearing voices, misinterpreting what they see
Typical Timing
Sundowning usually begins between 3 p.m. and 6 p.m. and can last until 8 p.m., 10 p.m., or even midnight. Some people experience a second wave of confusion and agitation in the middle of the night. The exact timing varies by individual but remains fairly consistent for each person once the pattern is established.
Why Does Sundowning Happen?
The exact cause isn't fully understood, but sundowning likely results from disrupted circadian rhythms, accumulated fatigue throughout the day, changing light levels affecting brain function, and the brain's reduced ability to filter stimulation as the day progresses.
Neurological and Biological Causes
- Disrupted circadian rhythm: Dementia damages the brain area that regulates sleep-wake cycles, disrupting the normal transition from day to night
- Reduced light exposure: As daylight fades, shadows and changing light can be disorienting and frightening
- Accumulated fatigue: By late afternoon, cognitive reserve is depleted and the ability to cope with confusion decreases
- Hormonal changes: Melatonin and cortisol level shifts may be exaggerated or mistimed in people with dementia
- Reduced filtering capacity: The tired brain becomes overwhelmed by stimuli that could be ignored earlier in the day
Environmental and Situational Triggers
- Overstimulation during the day from too many activities, visitors, or appointments
- Hunger, thirst, or physical discomfort
- Pain or needing the bathroom
- Change in caregivers between day and evening shifts
- Medication timing effects
- Boredom and lack of meaningful engagement
Most Effective Ways to Reduce Sundowning
Top 3 Actions for the First Week
- Track when sundowning happens for at least three days. Note the exact time, what your loved one was doing before, environmental factors, and physical state.
- Increase bright light exposure in the morning by opening curtains, going outside, or using a bright light therapy lamp for 30-60 minutes after waking.
- Create a calm, predictable late afternoon routine with low stimulation: quiet activities, soft lighting, familiar tasks, and an early dinner.
Light and Circadian Rhythm Management
Maximize bright light exposure in the morning and early afternoon. Open curtains and blinds as soon as your loved one wakes up. Spend time outdoors in natural light. Consider using a 10,000-lux light therapy box for 30-60 minutes in the morning. As evening approaches, dim lights gradually rather than switching from bright to dark suddenly. Use soft, warm lighting in the evening. Keep nightlights in bedrooms and bathrooms.
Daily Structure and Routine
Maintain consistent wake-up and bedtimes. Schedule demanding activities for morning when your loved one is freshest. Plan an early dinner (4-5 p.m.) so they're not hungry during typical sundowning hours. Create a predictable late afternoon routine with calming activities. Avoid scheduling appointments, visitors, or stimulating activities after 2-3 p.m.
Frequently Asked Questions About Sundowning in Dementia
Will sundowning get worse as dementia progresses?
Not necessarily. Sundowning typically peaks in middle stages of dementia and may actually decrease in very late stages when overall activity levels decline. However, the pattern varies greatly between individuals. Some people experience worsening sundowning, others see improvement, and some maintain a consistent pattern for years.
Can medications help with sundowning?
Sometimes. If behavioral strategies don't adequately reduce sundowning, doctors may prescribe low doses of antipsychotics, anti-anxiety medications, or other drugs. However, these have risks and side effects in people with dementia. Medication should be a last resort after environmental and behavioral interventions have been tried. For more on managing behavioral symptoms, see our guide on managing aggression and agitation.
Is it okay to let them sleep during the day if they're tired?
Short naps (20-30 minutes) in early afternoon are generally fine and may help reduce fatigue-related sundowning. However, long afternoon naps or late-day sleeping can worsen nighttime sleep problems and increase evening confusion. If your loved one naps, keep it brief and before 3 p.m.
Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice. Always consult with your loved one's healthcare team for guidance tailored to their specific situation, especially regarding medication management and behavioral symptoms.