The long list of symptoms associated with Alzheimer’s disease and other forms of dementia often includes baffling mood and behavior changes. As the disease progresses, you may notice new patterns in the way a loved one’s symptoms fluctuate throughout the day — especially in the evenings. Known as sundowning, this increased confusion and restlessness around twilight can be distressing for both patients and caregivers alike.

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Sundowning and dementia: What it is and what to expect

Sundowning is a group of symptoms exhibited by dementia patients that may emerge or worsen as the sun goes down. The timing of the onset is what gives this group of characteristic symptoms its name. The National Institute on Aging uses the term sundowning, however literature on Alzheimer’s and dementia may also use the terms sundowners, late-day confusion, sunset dementia, and sundown syndrome.

At what stage of dementia does sundowning occur?

Sundowning in dementia patients can occur at any stage of the disease, however it most commonly starts during the middle stages. If sundowning symptoms do occur during the early stages of dementia, they’re typically mild and inconsistent. Sadly, the symptoms of sundown syndrome tend to get worse as dementia progresses and usually don’t completely go away.

Note that it’s possible for an aging loved one to experience symptoms of sundowning without a dementia diagnosis. Conversely, not everyone with Alzheimer’s or other dementias will experience sundowning.

How long does sundowning last in dementia? 

Although dementia confusion can come and go over the course of each day, sundowning typically begins later in the afternoon and can last well into the night. The exact timing and behaviors of sundowning vary greatly from patient to patient. That said, it’s important to note that Alzheimer’s disease and other types of dementia don’t present the same way in each person. For some patients, sundowning may actually occur very early in the morning. A single sundowning episode could last anywhere from a few hours to an entire night.

Unfortunately, this dementia behavior prevents many patients and their caregivers from getting adequate rest at night, and sleep deprivation can cause these symptoms to worsen. Therefore, it’s important to understand your loved one’s routines and moods as best as you can to minimize the symptoms of sundowning.

Symptoms of sundowners in dementia

Emotions that may arise during an episode of sundowning include:

  • Fear
  • Depression
  • Paranoia
  • Anger
  • Anxiety

Behaviors that may arise during an episode of sundowning include:

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What causes sundowning?

Doctors and researchers aren’t sure what causes sundowning, but the theory is that the simultaneous onset of symptoms and nightfall isn’t entirely a coincidence. Some medical professionals believe that all the sensory stimulation a patient receives over the course of the day builds up, becomes overwhelming and stressful, and causes them to act out. Other possible causes may include:

  • Hormonal imbalances that affect a patient’s natural circadian rhythm (sleep-wake cycles)
  • Feeling disoriented from seeing shadows caused by the evening’s change in lighting
  • Anxiety caused by the inability to see well in the dark
  • Fatigue
  • Boredom
  • Depression
  • Unmet needs like hunger or thirst

Sometimes, it’s caused by all of these things at once.

How can caregivers cope with sundowning?

Unfortunately, even with the best efforts at prevention, most dementia caregivers will likely need to cope with sundowning symptoms at some point. Your loved one may “shadow” you or follow you around and closely observe or mimic everything you do. They might ask questions over and over or interrupt conversations. They may temporarily lose the ability to communicate coherently, and abstract thoughts may become especially difficult for them to comprehend. In severe cases, they may wander restlessly around their environment or try to get outside to “escape.”

Because people with dementia are difficult — if not impossible — to reason with, it’s crucial for caregivers to try to stay patient throughout episodes of sundowning. Even if you don’t directly express your concern or irritation, it’s likely that your loved one will still pick up on your mood and frustration. Use the following tips to help you cope with and respond to these difficult behaviors:

  • Approach your loved one in a calm manner. Don’t yell, raise your voice, or touch them in an unexpected way. Reacting to their behaviors may unintentionally make matters worse.
  • Avoid rationalizing or arguing. Asking for explanations to statements or behaviors that don’t make sense may escalate the situation. There’s no reasoning with someone who has dementia.
  • Redirect to a non-stimulating location. Guide the person to an area away from noise, family activity, and other distractions.
  • Validate their experience. If a dementia patient is feeling paranoid or experiencing delusions or hallucinations, meet them in their version of reality. Reassure them that everything is alright and everyone is safe. This approach is called validation and is far more effective than using logic to reorient a loved one with dementia.
  • Provide comfort. Sometimes soothing or familiar music will help to calm and relax a person exhibiting anxious or restless behaviors. Provide a comfort object, such as a familiar blanket or doll, or turn on a favorite television show or movie as a distraction.

How can caregivers help prevent sundowning?

The first steps in managing these difficult symptoms are recognizing and reducing triggers by making environmental changes to alter patterns of behavior. Prevention in this way may be the best strategy for dealing with sundowning.

Develop a daily routine

Maintaining a schedule throughout the day helps orient patients and alleviates anxiety that may arise during twilight. Washing up for dinner and putting on pajamas can be helpful indicators that the day is winding down.

Plan more activities during the day such as walks, crafts, and visits to keep your loved one awake and engaged. A person who naps most of the day is likely to be more awake at night. If your loved one is tired and less lucid by the afternoon or evening, plan simple and soothing activities during those times to keep them occupied so they don’t want to nap. An upbeat movie or TV show or some pet therapy can have a calming effect while keeping them awake. If they don’t wish to participate, don’t argue with them. Instead, continue trying to appeal to their interests to find something that eventually works.

Try to prevent excessive commotion during the times they normally become more agitated. Be aware of certain times, people, places, or activities that seem to trigger difficult dementia behaviors. Notice patterns in your loved one’s sundowning to help you avoid these triggers and adapt their routine to support a peaceful environment.

Make diet adjustments

Restrict sweets and caffeine consumption to the morning hours so that they don’t keep your loved one awake at night. Consider making lunch the heaviest meal of the day or serving dinner early so that the hustle and bustle of clean up doesn’t interfere with winding down at night. Keep evening snacks light and easily digestible.

Use light strategically

Using light strategically may positively affect mood and promote healthy sleep patterns that help prevent sundowning. Consider using bright light therapy in the morning to help “reset” a dementia patient’s circadian rhythm. Studies have shown that the use of a full-spectrum light box has positive effects on sleep-wake cycle disorders, minimizes agitation and confusion, and improves sleep quality.

During the day, turn on inside lights to keep the environment well-lit, minimize shadows, and improve visibility. Then, turn down all lights a couple hours before bedtime, and use a nightlight in hallways, bathrooms, or any areas they may be walking in. 

Improve sleep hygiene

Getting a good night’s sleep is vital to prevent sundowning. If need be, change your loved one’s sleeping arrangements. Allow them to sleep in a different bedroom, in a favorite chair, or on the couch — wherever they’re most comfortable. Develop a winding down routine a couple hours before bedtime with low lights, soothing music, and anything that supports a calming ambience for them. Adding herbal chamomile tea and sleep-specific aromatherapy with lavender, bergamot, cedar wood, and clary sage to this routine may also help improve their ability to sleep.

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Improve safety and security

Help ensure the dementia patient’s safety by installing locks and safety devices as necessary. Take precautions to provide a safe space for your loved one at night so that you can get some sleep, even if they stay awake and wander. This includes removing or securing potentially dangerous items in areas that they have access to.

Seek medical advice

Sundowning syndrome can be exhausting for both you and your loved one, so don’t hesitate to ask for help. Physical ailments, such as incontinence or a urinary tract infection (UTI), can make it difficult for a dementia patient to sleep and can contribute to their confusion and agitation. Your loved one’s doctor may be able to identify and treat these conditions.

Ask the dementia patient’s doctor about the use of melatonin in dementia patients, as it may help improve sleep and suppress sundowning. This natural hormone helps regulate sleep-wake cycles and is available as a supplement at most health food stores without a prescription. Be sure to check with your loved one’s physician or pharmacist about possible drug interactions before adding any medications or supplements to their regimen.

It’s recommended to try non-pharmaceutical solutions for sundowning before turning to medications. Sleeping pills, antipsychotic drugs, and anti-anxiety medications aren’t typically recommended for dementia patients as they can potentially worsen dementia symptoms and increase the risk of death in the long term, according to the National Institute on Aging. However, such medications might be considered as a last resort for treating sundown syndrome or behavioral issues caused by dementia.

If you need help caring for your loved one, in-home care may be a good option to consider. In-home care can provide the regular respite you need as a caregiver while offering your loved one the at-home support and companionship they require.

Sources:
Tips for Coping with Sundowning (https://www.nia.nih.gov/health/tips-coping-sundowning)
Treatments for Behavior (https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior)
Treatment options for sundowning in patients with dementia (https://mhc.cpnp.org/doi/full/10.9740/mhc.n204525)
Sundown Syndrome in Persons with Dementia: An Update (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/)
A Good Night’s Sleep (https://www.nia.nih.gov/health/good-nights-sleep)
How Is Alzheimer’s Disease Treated? (https://www.nia.nih.gov/health/how-alzheimers-disease-treated)

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