A Place for Mom
Assisted Living
Memory Care
Independent Living
Senior Living

Make the best senior care decision

Elderly man with his daughter looking at sunset over a skyline

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

Written by Haines Eason
9 minute readLast updated October 19, 2022

Toward the end of the day, you may notice someone with dementia becoming noticeably more irritable, anxious, angry, and irrational. This change in behavior is called sundowning, also known as sundown syndrome or sundowner’s syndrome. Because it can’t be easily attributed to a defining, treatable cause, it’s not considered a disease, but rather a set of symptoms associated with dementia. Sundowning in dementia patients is relatively common, as well: As many as 1 in 5 people with Alzheimer’s will experience sundowning, according to Cleveland Clinic.[1]

Key Takeaways

  1. Sundowning, or sundown syndrome, is common in dementia patients and refers to the onset of hard-to-manage behaviors toward the end of the day. Behaviors can include agitation or anger, sadness, confusion, paranoia, and, sometimes, physical aggression.
  2. The symptoms of sundowning may be subtle and easy to overlook. They may also be inconsistent, so you may not notice a pattern right away.
  3. Sundowning can occur at any stage of dementia but is most common in middle to late stages. Episodes of sundowning may occur, and then your loved one may not experience another episode for a while.
  4. Sundown syndrome is not something your loved one can control. Seek their physician’s guidance, and consider talking to one of our Senior Living Advisors if you need to discuss more involved support.

What are the symptoms of sundown syndrome?

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

Our free tool provides options, advice, and next steps based on your unique situation.

What are the causes or triggers of sundowning?

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.

At what stage of dementia does sundowning usually begin?

Sundowner’s syndrome typically begins in the mid to late stages of dementia and lasts through the end stages, but it can start at any stage and may improve during the late stages.[05][09]  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.

Talk with a Senior Living Advisor

Our advisors help 300,000 families each year find the right senior care for their loved ones.

How to manage sundowner’s syndrome symptoms

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]

Are medications used for sundown syndrome?

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]

Sundowning and dementia: Coping and getting help

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.

SHARE THE ARTICLE

  1. Cleveland Clinic. (2022, April 26). Sundown syndrome.

  2. Canevelli M., Valletta, M., Trebbastoni, A., Sarli, G.,  D’Antonio, F.,  Tariciotti, L., de Lena, C., & Bruno, G. (2016). Sundowning in dementia: Clinical relevance, pathophysiological determinants, and therapeutic approaches. Frontiers in Medicine.

  3. Johns Hopkins Medicine. The hidden risks of hearing loss.

  4. Torres, F. (2020, October). Seasonal affective disorder (SAD)American Psychiatric Association.

  5. Alzheimer’s Society UK. (2021, September 30). Sundowning and dementia.

  6. National Institute on Aging. (2017, May 17). Tips for coping with sundowning.

  7. National Institute on Aging. (2021, July 8). How is Alzheimer’s disease treated?

  8. Alzheimer Society of Canada. Restlessness or “sundowning”.

Meet the Author
Haines Eason

Haines Eason is managing editor at A Place for Mom and oversees its editorial team of expert senior living writers and editors. Under his leadership, his team produces hundreds of articles a year to inform and educate readers about aging, caregiving, senior living, community types and services, and providers that oversee multiple facilities. He has nearly 15 years of experience as an editor and copywriter in journalistic, agency, and institutional settings. He holds bachelor’s and master’s degrees from the University of Montana and Washington University in St. Louis, respectively.

Edited by

Danny Szlauderbach

The information contained in this article is for informational purposes only and is not intended to constitute medical, legal or financial advice or create a professional relationship between A Place for Mom and the reader.  Always seek the advice of your health care provider, attorney or financial advisor with respect to any particular matter and do not act or refrain from acting on the basis of anything you have read on this site.  Links to third-party websites are only for the convenience of the reader; A Place for Mom does not recommend or endorse the contents of the third-party sites.