Dementia and sundowning – advice for caregivers

Sundowning in dementia – sometimes called late-day confusion – describes a pattern of increased confusion, agitation or distress in the late afternoon and evening. It most commonly affects people living with mid-to-late stage Alzheimer’s disease and other types of dementia.

For families and caregivers, sundowning can be one of the most challenging dementia symptoms to manage. In this guide, we explain what sundowning is, why it happens, common symptoms, and practical ways to reduce its impact.

What is sundowning?

Sundowning in dementia is a pattern of increased confusion, agitation, anxiety or behavioural changes that typically occur in the late afternoon or evening.

It is not a separate medical condition, but a recognised group of symptoms linked to changes in the brain caused by dementia.

While symptoms often begin around sunset, they can occur at any time of day. For some people, behaviours continue throughout the night and interfere with sleep.

Sundowning is most often associated with Alzheimer’s disease but can occur in other types of dementia.

Why do dementia patients get worse at night?

There are a number of factors that experts believe may cause people with dementia to become more active or distressed at night. These include too much or too little sleep, low light levels and increased shadows or feeling hungry thirsty or in pain.

Side effects of medications or medications wearing off may also make sundowning worse too. If you think a prescribed drug is contributing to sundowning symptoms, it’s important to discuss these worries with your loved one’s GP.

How do you know if someone is sundowning?

Sundowning symptoms can vary person to person, and some symptoms are specific to the time of day.

Common symptoms associated with sundowning include:

• Rocking in chairs
• Pacing
• Violent outbursts
• Wandering
• Yelling
• Crying
• Following their caregiver very closely.

People who experience sundowning can feel many emotions and therefore suffer from anxiety, fear, restlessness, sadness, confusion and paranoia.

It’s important to remember that as dementia symptoms progress, a loved one’s behaviour and the way they communicate with you will naturally change.

When these changes happen towards the end of the day, it can be difficult to distinguish dementia-related behaviors from sundowning behaviour. Take a moment to talk to family members and carers about these changes to understand if there may be other reasons for them aside from sundowning, or to identify any patterns.

Can sundowning be treated?

There is no single cure for sundowning. Management usually focuses on identifying triggers and reducing environmental stress.

Non-drug approaches are recommended first. Strategies that may help include:

• Maintaining a consistent daily routine
• Increasing exposure to natural daylight
• Keeping rooms well-lit in the evening
• Reducing noise and background stimulation
• Ensuring regular meals and hydration
• Managing pain effectively
• Encouraging gentle daytime activity.

Some families find light therapy helpful in regulating sleep-wake cycles. Music therapy and calming evening rituals may also reduce agitation.

Are there potential medications to treat sundowning?

Medication is not usually the first option and should only be considered after medical review.

Depending on symptoms, a GP may consider:

• Antidepressants
• Anti-anxiety medication
• Sleep aids (short-term only)
• Antipsychotics (used cautiously due to increased stroke risk in dementia).

Always consult a GP before changing or stopping medication.

How symptoms of sundowning can be managed

Supporting someone through sundowning can be emotionally demanding. The key principles are routine, reassurance and calm consistency.

Practical steps include:

1. Structure the day carefully

• Plan stimulating activities for the morning
• Encourage light exercise and outdoor time
• Avoid long afternoon naps
• Offer the main meal at lunchtime rather than evening.

2. Create a calming evening environment

• Turn lights on before dusk
• Close curtains early to reduce visual confusion
• Minimise clutter
• Lower noise levels
• Keep the temperature comfortable.

3. Adjust food and drink

• Limit caffeine after midday
• Offer lighter evening meals
• Ensure adequate hydration.

4. During an episode

• Stay calm and speak clearly
• Avoid arguing or correcting
• Offer reassurance
• Redirect attention gently.

Remember: behaviours are caused by brain changes, not intention.

Does sundowning get worse when the clocks change?

Many of us will naturally experience tiredness when the clocks change. However people with dementia become confused and anxious as the change in time can be at odds with their internal clock and expected routine.

Sundowning symptoms will often be more pronounced in the days and weeks following the clocks going back, so here are a few additional steps you can take to help them through seasonal changes:

• Try not to introduce anything new to their routine the week leading up to and after the time change. Sticking to the same scheduled activities and tasks will provide stability and safety.
• If you do need to shift their routine forward by an hour, do so in small increments over 7 to 10 days.
• During the day, take your loved one outside for a walk or to spend some time in the garden. Natural sunlight helps to regulate their body clock.
• Turn on lights and close curtains and blinds before it starts to get dark. Seeing the sky change from day to night when they’re not expecting it can be triggering.
• Likewise, if light is coming into the bedroom too early and waking your loved one, invest in some blackout curtains.

Worried about wandering?

Our former Head of Clinical Alexis Cable has shared some practical steps you can take to manage this symptom of dementia.

When to seek medical help

Contact a GP if:

• Symptoms appear suddenly
• Behaviour changes drastically
• There are signs of infection (e.g. fever, pain, urinary symptoms)
• Sleep disruption becomes severe
• Behaviour poses safety risks.

Sudden confusion may indicate delirium, which requires urgent medical assessment.

Supporting someone with dementia at home

Research shows 85% of people would prefer to remain in their own home if diagnosed with dementia. With the right support, this is often possible.

At Elder, we match families with experienced live-in carers who understand dementia care and the challenges of sundowning.

Sources

https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/symptoms/sundowning

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