Every evening, it's the same. Around 4 or 5 p.m., your parent becomes agitated, confused, or anxious. They may pace, ask to "go home" when they're already home, become suspicious, or get aggressive. By morning, they're calmer—until the next afternoon.
This pattern is called sundowning, and it affects up to 66% of people with dementia at some point. Understanding what's happening and implementing proven strategies can make evenings calmer for everyone.
Sundowning (also called "sundown syndrome") refers to a pattern of increased confusion, agitation, anxiety, or aggression that occurs in late afternoon and evening in people with dementia. It typically starts around 4-6 p.m. and can last into the night.
Common Sundowning Behaviors
- Confusion: Not recognizing familiar places or people
- Agitation: Restlessness, pacing, inability to settle
- Anxiety: Fear, worry, panic
- Suspicion: Paranoid thoughts, accusations
- Demanding to "go home": Even when home
- Mood swings: Sudden crying, anger, or emotional outbursts
- Wandering: Trying to leave the house
- Shadowing: Following you everywhere
- Sleep resistance: Refusing to go to bed
- Aggression: Verbal or physical (hitting, pushing)
Why Sundowning Happens
Brain Changes
- Dementia damages the brain's internal clock (circadian rhythm)
- The suprachiasmatic nucleus (biological clock) deteriorates
- Confusion increases as cognitive reserves deplete throughout the day
Physical Factors
- Fatigue: Mental and physical exhaustion by evening
- Hunger/thirst: Low blood sugar or dehydration
- Pain: Discomfort that increases with tiredness
- Medication timing: Effects wearing off or side effects
- Infection: UTIs commonly cause worse confusion
- Constipation: Discomfort contributing to agitation
Environmental Triggers
- Low light: Shadows and dim lighting increase confusion
- Too much stimulation: Busy afternoons leading to overwhelm
- Too little stimulation: Boredom during the day
- Change in routine: Visitors, appointments, disruption
- Caregiver stress: Your own end-of-day fatigue affecting them
If sundowning symptoms suddenly get much worse, look for underlying medical causes—especially urinary tract infections, which cause dramatic increases in confusion. Pain, constipation, and medication changes can also cause sudden worsening.
Strategies to Reduce Sundowning
Light and Environment
- Bright light therapy: Expose to bright light (natural or light box) during the day
- Increase evening lighting: Turn on all lights before dusk—avoid shadows
- Close curtains before sunset: So they don't see darkness falling
- Reduce noise and stimulation: Calm environment in late afternoon
- Keep familiar objects visible: Photos, comfortable items
Daily Routine
- Consistent schedule: Same times for meals, activities, bed
- Morning activities: Schedule appointments and activities earlier in day
- Afternoon rest: Short nap (not too long—30-60 minutes max)
- Gentle late-day activity: Light exercise or walk before dinner
- Limit caffeine: No coffee or tea after noon
- Earlier, lighter dinner: Heavy meals late can disrupt sleep
Physical Comfort
- Afternoon snack: Prevent low blood sugar
- Hydration: Offer fluids regularly (but reduce before bed)
- Check for pain: They may not be able to express discomfort
- Comfortable clothing: Loose, familiar clothes
- Bathroom routine: Ensure regular toileting to prevent discomfort
Calming Strategies
- Soft music: Familiar songs from their era
- Simple activities: Folding towels, sorting items
- Gentle touch: Hand massage, back rub if they find it comforting
- Calm voice: Slow, low, reassuring tone
- Avoid arguments: Don't correct or reason—redirect
- Validation: "I understand you want to go home. Tell me about your home."
"Home" often means a feeling of safety, not an actual place. Try: "I'm here with you. You're safe. What did you love about your home?" Redirect to comforting memories rather than trying to convince them they ARE home.
During a Sundowning Episode
Do
- Stay calm—your anxiety makes theirs worse
- Speak slowly and simply
- Offer comfort: "You're safe. I'm here."
- Redirect to a simple activity or snack
- Reduce stimulation—turn off TV, lower lights slightly
- Offer to walk with them if they're pacing
- Put on familiar music
Don't
- Argue or try to reason
- Physically restrain them
- Ask complex questions
- Say "Don't you remember?"
- Leave them alone if they're very agitated
- Match their agitation with your own
Medical Approaches
Rule Out Underlying Causes
- Test for urinary tract infection
- Review all medications (timing and side effects)
- Assess for pain, constipation, dehydration
- Check vision and hearing (sensory loss increases confusion)
Medication Options
Medications are generally a last resort after non-drug approaches fail:
- Melatonin: May help regulate sleep cycle (generally safe)
- Trazodone: Sometimes used for sleep and agitation
- Low-dose antipsychotics: Last resort for severe agitation; carries risks
Antipsychotic medications (Seroquel, Risperdal, etc.) carry a black box warning for increased death risk in elderly dementia patients. They should only be used when non-drug approaches fail and agitation poses a serious safety risk. Always discuss risks carefully with the doctor.
Taking Care of Yourself
Sundowning is exhausting for caregivers. By evening, you're tired too.
- Get respite: Have someone else cover evening hours sometimes
- Prepare in advance: Have calming activities ready to go
- Lower your expectations: Evenings don't have to be productive
- Tag team: If there are two caregivers, trade off evening duty
- Remember it's the disease: They're not doing this on purpose
Track Patterns and Find What Works
Our Daily Care Log helps you identify triggers and track what strategies work best.
Get the Complete Caregiver Kit- Sundowning affects up to 66% of people with dementia
- Brain clock changes, fatigue, and environment all contribute
- Bright light during day and good lighting at evening help
- Keep a consistent routine with calmer afternoons
- Address physical needs: snacks, hydration, pain, toileting
- Don't argue during episodes—redirect and comfort
- Check for infections and medication issues if suddenly worse
- Medications are last resort due to risks in elderly