Sundowning: Symptoms, Causes, Treatment, and More

The Alzheimer’s Association estimates more than 6.9 million people are living with Alzheimer’s disease today,  and about one in five of these people will experience sundowners syndrome, also known as sundowning. According to Dr. Sandra Petersen, the senior vice president of health and wellness at Pegasus Senior Living, sundowning is a term used to describe a state of confusion that occurs in the late afternoon and evening. It’s a set of symptoms, thought to be triggered by fading light, that can cause behaviors such as confusion, anxiety, and aggression. Mood swings, heightened irritability, pacing, and wandering are also symptoms associated with sundowning.

“While sundowning is most commonly associated with dementia, particularly Alzheimer’s disease, similar symptoms can occasionally be seen in people without dementia, especially those experiencing significant stress or sleep disturbances,” says Dr. Petersen.

Understanding the symptoms of sundowning and knowing how to manage them best can significantly help those living with dementia and their families. In this article, Dr. Petersen will help us understand more about sundowning, common symptoms and triggers, behavior management, treatment options, and caregiver self-care tips.

What Causes Sundowning Syndrome?

Dr. Petersen says the exact cause of sundowning is not fully understood, but it is believed to be related to changes in the brain that affect the body’s circadian rhythm—the body’s internal clock. The timing of the emergence of symptoms varies, but they typically begin or intensify as natural light begins to fade. Factors such as fatigue, low lighting, and increased shadows can also contribute to the symptoms.

Sundowning most commonly occurs during the middle and later stages of dementia, though it can happen at any stage. As the condition progresses, the symptoms tend to worsen.

Symptoms of Sundowners Syndrome

Sundowning affects different people in different ways, but some of the common symptoms are:

Confusion – includes disorientation and confusion about where they are and who other people are.
Anger – shouting or becoming argumentative.
Extreme agitation – becoming upset or anxious or being unusually demanding.
Emotional outbursts – sudden mood swings, crying, yelling, or aggression.
Hallucinations – hearing and seeing things that aren’t there.
Restlessness – rocking, pacing, or wandering.
Paranoia – becoming suspicious and hiding objects.
Insomnia – having difficulty sleeping.
Pacing, wandering, and shadowing ( following the caregiver).

Contributing Factors and Triggers

Factors that may intensify the symptoms of sundowner’s syndrome include:

• Overstimulation throughout the day, leading to mental exhaustion.
• Fatigue from daily activities or challenges.
• Unfamiliar environments or new routines, which can cause disorientation.
• Shadows that deepen in the evening may distort surroundings and increase agitation.
• Nonverbal cues from others, especially if they show signs of stress or frustration, which your loved one may pick up on.
• Confusion between dreams and reality during sleep, leading to disorientation.
• A reduced need for sleep, common in older adults.
• Changes in routine or an increase in idle time, which may decrease mental engagement.
• Medications wearing off, as some prescriptions can have side effects that disrupt sleep.
• Loud or unexpected noises, which can heighten restlessness and disorientation.

Sundowning and Sleep Disruptions

Sundowning frequently disrupts sleep patterns. The confusion, agitation, and restlessness characteristics of sundowning often persist into the night, making it difficult for the affected person to get restful sleep. Lower melatonin production—a hormone crucial to regulating sleep—is common among those with dementia and has been linked to both sundowning and sleep disturbances. Experts believe this decline in melatonin may contribute to the confusion and behavioral changes observed in sundowning.

This cycle of sleep disturbances and behavioral challenges can create a vicious loop: sundowning disrupts sleep, which in turn worsens sundowning symptoms. The increased insomnia and nighttime awakenings associated with sundowners syndrome can be especially challenging for caregivers, who may struggle to manage symptoms as they, too, are naturally exhausted at the end of the day—while their loved one remains awake, confused, or agitated.

Dr. Petersen advises caregivers to limit their loved one’s naps to minimize sleep disruptions. “Too much daytime sleep can interfere with nighttime rest,” she says. “And you may want to try relaxation techniques, reading, or light activities before bedtime. Perhaps most importantly, be sure to maintain a peaceful, quiet, and comfortable sleeping environment.”

How to Manage Sundowning

As a caregiver, it can be frustrating to try to manage a loved one’s increasing confusion and agitation, sleep disturbances, and other sundowning symptoms. And it may be especially difficult when a caregiver isn’t getting their own sleep needs met.

However, caregivers can do things to prevent or reduce the symptoms and employ tactics to cope better if their loved one’s symptoms worsen. Dr. Petersen suggests:

Adhere to a regular schedule. Set regular times for going to bed, waking up, eating meals, or going for walks. Schedule doctors’ appointments and other outings, friendly visits, and bath time in the morning when the person with sundown syndrome is most alert. “Schedules help keep the individual from becoming stressed about ‘what to do next,’ avoiding a shift into fight or flight responses,” says Dr. Petersen.

Encourage more outdoor exercise. Sunlight can actually help reset the internal clock, which is important for people who have difficulty distinguishing day from night.

Recognize patterns and triggers. Changes in the environment, such as loud noises, fatigue, discomfort, or taxing activities, can trigger sundowning symptoms. Use a journal or a smartphone to keep track of patterns that seem to develop or situations that suddenly trigger symptoms.

Avoid stimulants. Caffeine, alcohol, tobacco, and sugar can contribute to sleep disturbances. Also, have lunch be the bigger meal of the day, and keep the dinner meal smaller and simpler.

Limit stimulation as the evening progresses. Dim the lights in the home, lower the blinds, and consider playing soft, soothing music or using calming scents like lavender to encourage drowsiness. Other things to try include making the room temperature more comfortable or adding a white noise machine to provide a constant, soothing sound.

Calm environment. Reducing noise and distractions in the evening can help create a more peaceful setting.

Treatment Options

Consider light therapy. Studies suggest it can reduce confusion and agitation. Lighting products that mimic the sun’s rising and setting may help regulate the body’s internal clock. Bright daylight tones, for example, may be helpful in the mornings, while cool, dimming lights may help in the evening. It may also be helpful to keep the home well-lit in the evening to reduce shadows. Placing night lights in the bedroom may also be calming. While light therapy devices, such as light boxes, full-spectrum light bulbs, and dawn simulators, have an upfront cost, they are generally accessible for home use and can be a cost-effective option for managing sundowning symptoms in the long term.

Medication. In some cases, providers may prescribe medications to help manage symptoms, especially if the person is experiencing psychosis, extreme agitation, or paranoia.

Patience. Understanding. Calm.

Dr. Petersen emphasizes that caring for someone with sundowning syndrome requires patience and empathy. She advises, “Remain calm. Individuals experiencing sundowning often mirror the emotions around them, so maintaining a calm demeanor can help them feel more secure. Offering reassurance can greatly reduce their anxiety. Creating a safe environment is also essential to minimize the risk of wandering or accidents. Finally, consider calming activities such as soothing music, aromatherapy, or gentle massage to help them relax.”

When to Seek Help

When caring for a loved one with sundowning syndrome, experts from Keystone Health say to seek help in the following situations:

• Symptoms become more frequent or severe.
• Sleep disturbances persist – chronic sleep deprivation can worsen dementia symptoms.
• Safety concerns arise – safety risks such as wandering or attempting to leave the house.
• Current management strategies are ineffective.
• You suspect an underlying medical condition like a urinary tract infection, sleep apnea, or pain, all of which can exacerbate sundowning.
• Caregiver burnout. If you’re feeling overwhelmed, exhausted, or unable to cope with the demands of caregiving.
• Medication side effects. Call the doctor if you suspect medication may be the cause of the symptoms or making them worse.

“Remember, it’s always better to seek help sooner rather than later when dealing with sundowning syndrome,” says Dr. Petersen. “Early intervention can help improve the quality of life for both the person with dementia and their caregiver.”

What caregivers can do for themselves

Taking care of someone experiencing sundown symptoms can be stressful and overwhelming. Here are some things caregivers can do to better cope with a difficult situation:

Be calm and gentle. Talk in soothing tones, and try not to overreact, argue with them, or shout. Those responses can be triggers.

Allow movement. If the person experiencing symptoms feels the urge to get up and walk or pace, let them. Don’t try to restrict their movement. Just stay close by and keep an eye on them.

Keep them safe. Night lights can help improve visibility; gates to block stairs can also be used. Consider using baby monitors, motion detectors, or door sensors that sense movement.

Ask if they need something. Communication is affected in the mid- to late stages of Alzheimer’s disease, and your loved one may struggle to communicate a need or want. Ask them if they need a drink, want to use the restroom, or would like to be read to.

Reassure them. Tell them everything will be OK. It may help to stroke their arm or rub their back.

Consider hiring a part-time home health aide or seeking out respite care. Local resources for caregivers are available in nearly every community.

You’re Not Alone

Caregivers need not be alone as they go through this journey with their loved ones. Utilize the numerous resources in the WYLM Dementia Caregivers Toolbox, which offers tips, books, videos, and links to support groups.

Where You Live Matters

Where You Live Matters is powered by the American Seniors Housing Association (ASHA), a respected voice in the senior housing industry. ASHA primarily focuses on legislative and regulatory advocacy, research, and educational opportunities and networking for senior living executives, so they can better understand the needs of older adults across the country.

Other sources include:
UCLA Health
Alzheimer’s Society
Cleveland Clinic
WebMD
National Library of Medicine