Understanding Sundowning in Dementia

(Adapted from the Alzheimer’s Association, Cleveland Clinic, Family Caregiver Alliance, and other expert sources)

📖 What is Sundowning?

Sundowning (also called late-day confusion, sundown syndrome) refers to a pattern of increased confusion, agitation, disorientation etc. in people with dementia, usually during late afternoon, evening, or night. 

Behaviors may include pacing, wandering, restlessness, shadowing (following caregiver closely), yelling, crying. 

Feelings may include anxiety, fear, irritability, sadness, paranoia; may have hallucinations or delusions. 

🔍 What Causes Sundowning?

Several triggers/factors have been identified, including:

Disruption to circadian rhythms (internal body clock), less melatonin production, changes in the brain that regulate sleep-wake cycles. 

Fatigue and exhaustion after a full day.

Low light, shadows, sensory confusion. 

Unmet basic needs: hunger, thirst, pain, needing toilet, infection (e.g. UTI), dehydration. 

Medication side effects or poorly timed medications. 

Other sleep disorders (sleep apnea, restless leg syndrome, etc.). 

Overstimulation or understimulation: too much noise, activity at end of day; or too little engagement during the day (bored).

🛠️ What Caregivers Can Do

Here are strategies drawn from the Cleveland Clinic and Family Caregiver Alliance, plus others, to help manage or reduce sundowning episodes.

🕐 Structure the Day

Keep a consistent daily routine: same times for waking, meals, activity, rest, bedtime. 

Schedule more demanding or alertness-requiring tasks (doctor visits, bathing, appointments) earlier in the day when the person is more alert. Alleviate daytime boredom with enjoyable activities such as music, arts, or physical activity. 

Limit or avoid long naps, especially in the late afternoon. 

💡 Manage Light and Environment

Use exposure to bright light during the day to reinforce normal day/night cues. 

As evening approaches, reduce shadows, increase lighting before dark, close blinds/curtains to reduce confusing reflections. 

🍵 Support Health and Comfort

Monitor for underlying illnesses or conditions (pain, infection such as UTI, dehydration) that can worsen confusion. 

Avoid caffeine, alcohol, nicotine especially later in the day. 

Eat a lighter evening meal; heavier food earlier. Provide snacks if needed in late afternoon.

🎶 Encourage Calming Activities

Engage in calming, familiar activities in early evening: listening to music, looking at photos, reading, gentle hand massage.

Reduce stimulation in the evening: limit noise, bright TVs or crowded areas.

🚪 Safety First

Install night lights in hallways, bathrooms; keep environment safe for wandering. 

Consider safety measures for exits (locks, alarms), but balance with dignity and ability to exit safely in emergency. 

❤️ Communication & Caregiver Interaction Strategies

(From Family Caregiver Alliance)

Keep communication simple: one step/command at a time; reduce background distractions (e.g. turn off TV/radio). 

Use a gentle tone, reassuring words; non-verbal cues (calm posture, touch) matter a lot. 

Distraction and redirection: give something for hands to do (a soft cloth or simple task), redirect attention to familiar activity. 

🩺 When to Seek Medical Help

If behavior changes suddenly or are severe (may signal infection, pain, drug interaction). 

If sleep disturbance is causing exhaustion in caregiver or safety risk for the person with dementia. 

If medications being used are causing side effects or interacting adversely. 
 

Resources

https://www.alz.org/help-support/caregiving/stages-behaviors/sleep-issues-sundowning

https://www.caregiver.org/faq/is-there-anything-i-can-do-for-my-mothers-agitation/

https://my.clevelandclinic.org/health/articles/22840-sundown-syndrome