What Is Sundowning in Dementia? Causes, Symptoms, Stages, and Treatments

With dementia, confusion comes and goes. So, at first, the symptoms of sundowning may be subtle and easy to overlook. They may also be inconsistent. One evening your loved one may be a little more confused or weepy, while the next, they may seem slightly irritable. Signs may be minor and varying, so you may not notice a pattern right away.

Some of the most common symptoms of sundown syndrome may include:

• Rapid mood changes
• Anxiety or fear
• Agitation, restlessness, or pacing
• Sadness
• Anger
• Stubbornness
• Shadowing caregivers or others
• Repeating questions and interrupting ^[02]

For some, symptoms of sundowning can be more severe and may include:

• Hallucinating
• Hiding things
• Feeling paranoid
• Acting violently
• Wandering^[02]

Let our care assessment guide you

Typically around sunset, dementia symptoms like confusion and agitation increase. Those twilight hours may seem to directly aggravate symptoms, but the cause isn’t so straightforward.

While there isn’t one specific cause of sundown syndrome, researchers suggest several possible causes or triggers:

• End-of-day activity. A flurry of activity toward the end of the day — a dinner with unexpected guests and extra cleanup, for instance — may lead to anxiety and confusion.
• Fatigue. Memory is weakened when we’re tired, and a fatigue may make an evening bedtime routine seem extra complex. This could lead your loved one to lash out or become despondent.
• Low light. As the sun sets, shadows increase, making it more difficult to see. Familiar surroundings may seem strange or appear to have been altered, and this may increase confusion and agitation.
• Sensory impairment. A loss of hearing has been associated with significant risk of dementia. Not being able to hear well could cause your loved one to be startled if they are not aware of your presence. This can lead to nervousness and a heightened confusion as the day wears on and they grow more tired.
• Internal imbalance. Hormonal changes or disruptions in the internal biological clock, which regulates cognition between waking and sleeping hours, may be a factor. The introduction or stopping of a medication, for instance, may prevent your loved one from sleeping a full night.
• Winter. In some cases, winter’s shorter days may amplify or bring on sundowning, because waking up in the dark and experiencing an extended, dark evening can trigger confusion. Seasonal affective disorder, or depression associated with shorter days, may also make sundowning worse.^{[03][04][05][06]}

Sundowning without dementia

It’s important to note that seniors without a dementia diagnosis may also experience sundowning. General loss of brain mass due to aging may make an individual susceptible to confusion and disorientation. These behaviors can lead to other sundowning-like behaviors, such as agitation and wandering. Additionally, seniors experiencing delirium or sleep disturbances, or those diagnosed with Parkinson’s disease, may display sundowning behaviors.^[07]

Can medication cause sundowning?

Side effects of both prescription and over-the-counter medications may cause rapid behavioral changes in people with dementia. Medications used to treat incontinence, depression, or insomnia should all be used cautiously and may produce sundowning-like behaviors or worsen sundowning symptoms.^[08]

If your loved one is showing signs of sundowning, discuss their medications and each one’s potential side effects with a doctor.

Sundowner’s syndrome typically begins in the mid to late stages of dementia and lasts through the end-stage of dementia, but it can begin to present even earlier for some individuals.^[05] Every situation is unique, though, meaning the progression of dementia and sundowning varies from person to person.

How long can an episode of sundowning last?

Episodes of sundowning are temporary by definition because they generally occur during the late afternoon or evening. Episodes of sundowning may occur for a day or two, and then your loved one may not experience another episode for a while. It’s only when you notice a consistent pattern in behaviors at sundown over several days to weeks that sundown syndrome may be developing.

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Because sundowning is a group of symptoms and not one single type of difficult behavior, there’s no single treatment that will make all those behaviors go away. However, there are a handful of remedies that can alleviate the symptoms of sundowner’s syndrome:

• Establish a routine. Routines can help loved ones feel safe by minimizing surprises. Try not to schedule more than two major activities per day, as multiple events may feel overwhelming. Also, discourage napping, especially if your loved one has problems sleeping at night.
• Monitor diet. Watch for patterns in behavior linked to certain foods. Avoid food or drinks containing caffeine or large amounts of sugar, especially late in the day. Avoid alcohol as much as possible.
• Control noise. It can be helpful to reduce background noise from the TV, radio, and other entertainment devices in the late afternoon or early evening. Avoid having visitors come in the evening hours. Try playing soft, calming sounds or songs.
• Let light in.Light boxes with full-spectrum lights (light therapy) have been found to lessen the effects of dementia and sundowning, particularly depression. As the evening approaches, keep rooms well-lit. This will decrease the amount of shadows and allow your loved one to see better, which helps avoid confusion and disorientation.^[01][06]

Most experts now agree that medications should be used to treat dementia-related behaviors only after all other options have been tried. Additionally, sleep aids, antianxiety drugs, anticonvulsants, and antipsychotics should especially be used with caution. Always be sure to discuss possible drug side effects with your loved one’s doctor.^[07]

It’s important to remember that sundown syndrome isn’t something your loved one can control. They’re not purposely becoming agitated, angry, or afraid. Do your best to comfort them, but remember that you need support, too. Caregiver burnout is a real and serious risk.

If your loved one is currently experiencing an episode of sundown syndrome:

• Try to remain calm and avoid arguing. Instead, validate their feelings and let them know you’re listening.
• Offer reassurance and let them know they’re safe and everything is OK.
• Distract and redirect them to their favorite activities, such as listening to soothing music, having a snack, or going for a walk.^[07]

Don’t be afraid to ask for help. When loved ones who suffer from dementia won’t sleep at night, the caregiver also suffers. Many families suffer from a loved one’s disruption, not just the main caregiver. For example, sandwich generation caregivers—or those who care for both their aging loved ones as well as their children still living at home—have a whole household to upset. Call your loved one’s doctor if the signs become too frequent or difficult to manage. A doctor may be able to pinpoint additional triggers or offer different management techniques.

If you’d like to explore additional care options, such as memory care, for your family member or loved one, our Senior Living Advisors are available to help.

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