Sundowning in Dementia: What It Is and How to Manage It
Every afternoon around 4 PM, your parent transforms. The calm, cooperative person you know becomes anxious, confused, agitated—even aggressive. By evening, they may not recognize you, try to leave the house, or become deeply distressed.
This is sundowning, and it affects up to 20% of people with Alzheimer's and other dementias. Here's what causes it and how to make evenings more peaceful.
What Is Sundowning?
Sundowning (also called "late-day confusion") is a pattern of increased confusion, agitation, and behavioral changes that occur in the late afternoon and evening in people with dementia.
It typically:
- Starts around 4-5 PM and continues through the night
- Is worse in middle-stage dementia
- May fluctuate day to day
- Often improves after daylight returns
Common Sundowning Behaviors
- Increased confusion and disorientation
- Anxiety, fear, or paranoia
- Restlessness and pacing
- Agitation or anger
- Yelling or calling out
- Shadowing (following the caregiver everywhere)
- Wanting to "go home" (even when they are home)
- Trying to leave the house
- Resisting care (bathing, changing clothes)
- Increased difficulty communicating
- Sleep disturbances
What Causes Sundowning?
The exact cause isn't fully understood, but likely factors include:
- Disrupted circadian rhythm: Dementia damages the brain's internal clock
- End-of-day fatigue: Mental and physical exhaustion accumulates
- Low lighting: Shadows and dim light increase confusion
- Unmet needs: Hunger, thirst, pain, need for the bathroom
- Less structure: Evenings often have fewer activities and cues
- Sensory overload: Too much noise, activity, or stimulation earlier in the day
- Caregiver stress: Your tension can be picked up on
Sudden onset or worsening of sundowning could indicate a medical issue: urinary tract infection, pain, medication side effects, dehydration, or other illness. If the pattern changes suddenly, see a doctor.
Strategies That Work
1. Increase Light in the Afternoon/Evening
Bright light helps regulate the body clock. Turn on lights before it gets dark. Consider a light therapy box (10,000 lux) for 30 minutes in the morning. Make sure pathways are well-lit to reduce shadows and confusion.
2. Establish a Consistent Daily Routine
Predictability reduces anxiety. Keep wake times, meals, activities, and bedtime consistent. Schedule more demanding activities (bathing, appointments) for the morning when they're at their best.
3. Limit Caffeine and Sugar
Avoid caffeine after noon. Limit sugar in the afternoon. Both can contribute to sleep disruption and agitation.
4. Encourage Daytime Activity
Physical activity during the day promotes better sleep. A walk, gentle exercise, or engaging activities help use energy. Avoid napping too late in the day.
5. Create a Calm Evening Environment
Lower stimulation in late afternoon: turn off the TV news, reduce noise, play soft music. Close curtains before dark to avoid disorienting reflections. Keep the environment peaceful and safe.
6. Address Unmet Needs Before Sundowning Starts
Check: Are they hungry? Thirsty? Need the bathroom? In pain? Cold or hot? Attending to physical needs before the difficult hours can prevent escalation.
7. Offer a Late Afternoon Snack
A light, healthy snack around 4 PM can prevent low blood sugar that might contribute to agitation. Avoid heavy meals close to bedtime.
8. Try Redirection and Distraction
When agitation starts, try redirecting to a calming activity: folding towels, looking at photos, listening to favorite music. Don't argue or try to orient them to reality—it often makes things worse.
What to Do (and Not Do) During an Episode
DO
- Stay calm and speak softly
- Validate their feelings: "I can see you're upset"
- Offer comfort: hold their hand, give a hug
- Reduce stimulation
- Redirect to a calming activity
- Play familiar music
- Ensure the environment is safe
- Use simple, reassuring phrases
DON'T
- Argue or try to reason
- Take it personally
- Restrain them (unless for safety)
- Ask them to remember things
- Make sudden movements
- Raise your voice
- Dismiss their feelings
- Say "don't you remember?"
When They Want to "Go Home"
"I want to go home" is common during sundowning—even when they are home. They often mean they want to return to a time when they felt safe, or to a childhood home.
Helpful responses:
- "Tell me about home. What do you miss?" (Let them talk)
- "You're safe here with me."
- "Let's have some tea first, then we can talk about it."
- Redirect to a comforting activity
Unhelpful: "This IS your home!" (causes more distress)
Medications for Sundowning
If behavioral strategies aren't enough, talk to the doctor about options:
- Melatonin: May help regulate sleep-wake cycle (often tried first)
- Trazodone: Sometimes used for sleep and anxiety
- Antipsychotics: Used carefully for severe agitation (carry risks for dementia patients—black box warning)
- Anti-anxiety medications: Sometimes helpful but can increase fall risk and confusion
Many medications used for agitation carry significant risks in elderly dementia patients. Non-drug approaches should be tried first. If medications are used, start low, go slow, and monitor closely.
Taking Care of Yourself
Sundowning is exhausting for caregivers. The very hours when you're most tired are when your parent needs the most. Strategies:
- Get respite care so you can have breaks
- Consider having someone else handle evenings sometimes
- Prepare dinner earlier in the day
- Accept that some days will be harder than others
- Join a support group for dementia caregivers
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