Sundowning in Dementia

Every afternoon, the shift begins. Your parent with dementia, who was relatively calm and cooperative all morning, becomes increasingly confused, agitated, and difficult as the day wears on. By evening, they may not recognize you, want to "go home" even when they're home, pace restlessly, or become combative.

This pattern has a name: sundowning (or sundown syndrome). It affects up to 20% of people with Alzheimer's disease and related dementias, typically peaking in the middle stages. Understanding what causes it and what helps is essential for surviving—and managing—these challenging hours.

Why Sundowning Happens

The exact causes aren't fully understood, but research points to several factors:

Brain Changes

• Disrupted circadian rhythms: The brain's internal clock is damaged by dementia
• Impaired melatonin production: Natural sleep-wake hormones become irregular
• Damage to the suprachiasmatic nucleus: The brain region controlling daily rhythms
• Reduced ability to process sensory input: The brain becomes overwhelmed by day's end

Physical Factors

• Fatigue: Mental exhaustion from coping all day
• Hunger or thirst: May not recognize or communicate these needs
• Pain or discomfort: Becomes harder to identify as day wears on
• Medication effects: Some medications wear off in evening
• Sleep disturbances: Poor nighttime sleep creates daytime problems
• Medical issues: UTIs, constipation, and other problems worsen behavior

Environmental Triggers

• Fading light: Shadows and dim light increase confusion
• End-of-day transitions: Dinner preparation, visitors leaving, TV noise
• Caregiver stress: They pick up on your exhaustion and tension
• Overstimulation: Too much activity earlier in the day
• Understimulation: Too little engagement leading to restlessness

Prevention Strategies

Morning and Afternoon

• Bright light exposure: Natural sunlight or light therapy in the morning helps regulate circadian rhythms
• Consistent daily routine: Predictability reduces anxiety
• Limit daytime napping: Short naps okay, but long naps disrupt nighttime sleep
• Regular physical activity: Morning walks, light exercise to use energy
• Meaningful engagement: Activities that provide purpose and connection
• Limit caffeine: None after early afternoon

Afternoon Preparations

• Early, lighter dinner: Large late meals can cause discomfort
• Reduce activity levels: Wind down before the danger zone
• Close curtains before sunset: Prevent shadowy, anxiety-provoking light
• Turn on lights early: Bright, even lighting before it gets dark
• Avoid stressful activities: No bathing, doctors' appointments, or demanding tasks in late afternoon
• Check for unmet needs: Bathroom, hunger, thirst, discomfort

Managing Sundowning in the Moment

When Agitation Begins

Specific Behavior Responses

"I want to go home" (even when at home)

• Don't argue that they are home
• Ask about "home"—they may mean childhood home or feeling of safety
• Validate: "You want to feel safe and comfortable"
• Redirect: "Let's have some tea first" or "It's dark out; let's wait until morning"
• Create comfort: favorite blanket, music from their era, familiar photos

Pacing and restlessness

• Don't try to stop the movement—accompany it
• Walk with them; gentle movement can be soothing
• Ensure the path is safe and clear
• Offer a snack or activity that uses hands
• Try rocking chair or gentle rhythmic movement

Aggression or combativeness

• Give space—don't crowd or corner them
• Lower your voice and body language
• Remove yourself briefly if safe to do so
• Consider what triggered it (pain? fear? misunderstanding?)
• Get help if there's danger

Creating a Sundowning-Friendly Environment

Lighting

• Install brighter bulbs throughout the home
• Use full-spectrum lighting that mimics natural light
• Night lights in hallways, bathroom, bedroom
• Close blinds before sunset to prevent unsettling shadows
• Avoid glare from uncovered windows or shiny surfaces

Sound and Stimulation

• Turn off television news (especially with violence or upsetting content)
• Play calming music from their era
• Reduce household noise and activity
• Limit visitors during sundowning hours
• Use white noise or nature sounds if helpful

Safety Measures

• Door alarms to prevent wandering
• Hide car keys and remove weapons or dangerous items
• Clear pathways of tripping hazards
• Install locks that are difficult for them to operate
• Consider bed rails or motion sensor alarms

Calming Activities for Evening Hours

• Familiar music: Songs from their young adulthood
• Simple, repetitive tasks: Folding towels, sorting items
• Gentle touch: Hand massage, brushing hair
• Looking at photos: Old family albums, familiar images
• Rocking or swinging: Rhythmic movement is soothing
• Pet therapy: Calm animals can reduce anxiety
• Simple snacks: Sometimes eating helps
• Warm bath or foot soak: If tolerated and safe
• Reading aloud: Even if they don't fully follow
• Prayer or spiritual practices: If meaningful to them

Medication Considerations

Medications are typically a last resort after non-drug approaches fail, because they carry significant risks in elderly people with dementia.

First-Line Options

• Melatonin: May help regulate sleep-wake cycle; relatively low risk
• Trazodone: Sedating antidepressant sometimes used for sleep and agitation
• Adjustment of existing medications: Changing timing or dosage

Used with Caution

• Antipsychotics (risperidone, quetiapine): FDA black box warning for increased mortality in dementia patients; sometimes necessary for severe symptoms
• Benzodiazepines (lorazepam): Can worsen confusion and increase fall risk
• Anticholinergics: Should generally be avoided in dementia

Taking Care of Yourself

Sundowning is exhausting for caregivers. The hardest hours of the day come when you're already depleted.

Strategies for Survival

• Get respite during sundowning hours: Have someone else take over the difficult shift
• Lower your expectations: Nothing productive happens during sundowning—just get through it
• Rest earlier in the day: You can't pour from an empty cup
• Have an emergency plan: Know who to call if things escalate
• Consider overnight help: If sundowning extends into night and disrupts your sleep
• Join a support group: Others understand what you're going through

When Sundowning Becomes Unmanageable

Consider additional help or placement if:

• The person is regularly aggressive or violent
• You are unable to sleep due to nighttime wandering or disturbance
• Your own health is deteriorating
• The person is at risk of hurting themselves or others
• You are burning out or experiencing caregiver depression

Memory care facilities are designed to manage these behaviors with trained staff, appropriate environments, and the ability to provide 24-hour supervision. Needing this level of care is not failure—it's a natural progression of the disease.