How to Effectively Manage Sundowning

Medically Reviewed by Zilpah Sheikh, MD on April 15, 2024
Written by Stephanie Watson, Brenda Goodman, MA, Kristin Mitchell
7 min read

Sundowning is a group of symptoms that many people with dementia get in the late afternoon and early evening. It includes confusion, trouble sleeping, anxiety, wandering, and hallucinations.

Up to 2 out of every 3 people with Alzheimer's disease have symptoms of sundowning. Though it can happen at any stage of the disease, it's most common in the middle and later stages. Fading light seems to be the trigger. The symptoms can get worse as the night goes on and usually get better by morning.

You may not be able to stop sundowning, but you can help manage this challenging time of day so you and your loved one both sleep better.

Someone who is sundowning may experience a range of symptoms. These are some of the most common ones.

Mood changes

You may notice a difference in your loved one's personality late in the day. Someone who was calm is suddenly anxious. A person who was passive may become aggressive and even violent. They may cry or yell. 

Confusion

Confusion is a normal part of dementia, but it can increase with sundowning. The person may not know where they are or what day it is. It might be harder for them to carry on or follow a conversation than it was earlier in the day.

It's common for people who are sundowning to wander inside or out of the home. Some shadow, or follow their caregiver everywhere they go.

Agitation

Someone with dementia may become more nervous and upset in the afternoon or evening hours. You might have trouble calming them down. Agitation can make it hard for the person to get to sleep.

Hallucinations

People with dementia sometimes see, hear, or smell things that aren't real. For example, they might claim to see a large frog on the wall or think a dead relative is in the room with them. Hallucinations happen because of damage to the brain from dementia, and they commonly occur in the evening. 

Some people with Alzheimer's disease also have delusions, or false beliefs. They might think a neighbor is stealing from them or that the government is watching their every move.

Sundowning in people without Alzheimer's

Sundowning is most likely to affect people with Alzheimer's and other forms of dementia. But older adults without dementia sometimes develop it in the hospital. The lack of sensory stimulation in a hospital room can make people disoriented.

Doctors don’t fully understand why sundowning happens. It could be related to tiredness, a lack of light, medication, or a problem with the internal body clock.

Medications that cause sundowning

Some medicines cause symptoms like confusion or agitation as a side effect or when they start to wear off. These include medicines that treat:

  • Depression 
  • Parkinson's disease
  • Bladder leakage
  • Belly cramps
  • Dizziness (vertigo)

Dementia sundowning

Some scientists think that changes in the brain of people with dementia might affect their inner “body clock.” The area of the brain that signals when you’re awake or asleep breaks down in people with Alzheimer’s. That could cause sundowning.

Other sundowning causes

Sundowning may be more likely if your loved one is:

  • Too tired
  • Hungry or thirsty
  • Depressed
  • In pain
  • Bored
  • Having sleep problems

Other causes of sundowning are:

  • A lack of sunlight from not going outside
  • Too much noise or activity during the day
  • Hormone changes
  • Vision or hearing loss
  • Mood changes like anxiety or depression

What happens around the person can also set off sundowning symptoms. Some common triggers are:

  • Less light and more shadows in the house late in the day. As it gets harder to see, the person may become more anxious and scared.
  • Trouble knowing what is real and what isn't. The person may confuse the world around them with their dreams. 
  • Being in a place that isn't familiar. Strange surroundings can be unsettling to someone with Alzheimer's disease.

If you feel tired or frustrated at the end of a day of caregiving, your loved one may notice, even if you don't say anything. This can upset them, too. It’s normal for you to feel this way. Just try to be aware of how you manage those emotions when you're around your loved one.

Look for patterns. If your loved one is more confused, anxious, or agitated during the evening, try to figure out the reasons. Then do your best to avoid or limit those triggers. For example, if you think loud TV shows or too much activity could be the cause, try to limit these activities at night. 

Keep a daily routine. Routines are comforting for people with dementia because they know what to expect. Set regular times for the person to wake up, eat meals, and go to sleep. Encourage them to walk or do other exercises like taking a walk in the early part of the day. Try to schedule their appointments, outings, visits, and bath time earlier in the day when they feel their best.

Limit or avoid things that affect sleep.

  • Don’t let your loved one smoke or drink alcohol.
  • Give them sweets and caffeine only in the morning. Offer healthy foods and drinks later in the day.
  • Make a big lunch. Keep the evening meal small and simple.
  • Avoid naps or exercise within 4 hours before bedtime. If they need to nap, try to keep it brief and early in the day.

Keep things calm in the evening.

  • Close the curtains and blinds and turn on lights. Darkness and shadows can make people with Alzheimer's more upset.
  • Keep the room at a comfortable temperature.
  • Ask other family members or visitors to leave the room or be quiet.
  • Put on relaxing music.
  • Read, play cards, or go for an early evening walk to help them wind down.
  • Make sure their sleeping area is comfortable and safe.
  • Turn down loud and distracting noises, such as the TV, phone, or stereo. Or turn them off.

Use these techniques to help your loved one calm down and relax:

  • Stay calm yourself. Getting upset could make the situation worse.
  • Ask your loved one what they need or what problem they're having. Try to find out what has made them upset.
  • Don’t argue with them. Reassure them and tell them everything is OK. You might gently hold their hand or stroke their back to calm them.
  • Try different things to solve the problem. If they see a person in the chair across from them, you might sit in the chair to show them no one is there.
  • Change the subject. Talk about something else, do a calming activity like folding the laundry together, or turn on a favorite TV show.
  • If they need to get up and move around or pace, don’t try to hold them back. Just stay close by to keep an eye on them.

Keep your loved one safe with night lights and locks on doors and windows. Use a gate to block the stairs. Put away dangerous objects like knives. You might get a baby monitor, motion detectors, or door sensors to let you know if your loved one is walking around or has left the home.

Sundowning may cause some people to get aggressive. To keep your loved one from hurting themselves or others, take away or lock up anything in the home that could be used as a weapon. If they get physically violent, stop what you’re doing and back away. Call for help if you need to.

Delirium means that a person is confused and not aware of their surroundings. It can look like sundowning. The main difference is that delirium comes and goes throughout the day. Sundowning happens in the late afternoon and evening.

It’s normal for people with Alzheimer’s disease to feel more confused as the disease progresses. But sometimes confusion gets worse very quickly, over a matter of hours or days. If this happens to your loved one, or if they have symptoms for the first time, call their doctor to make sure that it’s not delirium.

If sundowning doesn't stop, talk to the person's doctor. Also call if you think a urinary tract infection (UTI), sleep apnea, pain, or other condition might have caused sundowning or is making it worse. Also check that the medicines that help your loved one relax and sleep don’t cause more confusion the next day.

Caring for a loved one who is sundowning can make it hard for you to sleep and care for yourself. You need to be healthy and well rested to be there for your loved one. 

It’s normal to feel scared or overwhelmed when you care for someone with delirium or sundowning. Even things you do to help can upset them.

Make sure you eat a well-balanced diet, exercise, and get enough sleep.

Also set aside time to do things you enjoy. Visit with friends. Catch up on hobbies. Or just take a walk. 

Ask for help when you need it. See if family and friends will give you a break. Or look into adult day care or home care services. If you feel overwhelmed, make an appointment with a therapist, counselor, or other mental health care provider.

Sundowning is a group of symptoms like confusion, trouble sleeping, anxiety, wandering, and hallucinations. It affects some people with dementia in the late afternoon and early evening. To prevent sundowning, try to keep a consistent routine. Calmly reassure the person and don't argue with them.

What triggers sundowning? Hunger, tiredness, pain, and being in an unfamiliar place can trigger sundowning. Changes in the light are another cause, especially in people who have lost vision.

What stage of dementia is sundowning? Sundowning can happen at any stage of Alzheimer's disease, but it is most common in the middle and later stages.

How do you stop sundowning? Stay calm. Ask your loved one what they need. Try different things to calm them down. If nothing works, call their doctor for advice.