Sundowning, or sundown syndrome, is a state of increased confusion, anxiety, and agitation, and behavioral changes ,that typically occurs in people with dementia during the late afternoon and evening.
Sundowning is a common phenomenon in people with dementia, particularly Alzheimer’s disease.
It’s not a separate disease but a set of symptoms often linked to dementia progression.
Estimates suggest it affects around 20–45% of people with Alzheimer’s or other forms of dementia, and it’s most common in the middle to later stages.
It is not a disease itself but a collection of symptoms triggered as natural light fades.
Symptoms often peak in the middle to late stages of dementia and can vary from person to person and include.
Common Symptoms Symptoms usually peak as daylight fades and often improve by morning.
They can include:
Increased confusion and disorientation
Agitation, restlessness, or irritability
Anxiety, fear, or paranoia
Pacing, wandering, or restlessness
Hallucinations or delusions
Mood swings, aggression, or resistance to care
Difficulty sleeping or insomnia
Behavioral changes: Pacing, wandering, rocking, or following a caregiver closely.
Emotional distress: Intense anxiety, irritability, sadness, or sudden mood swings.
Cognitive worsening: Increased disorientation, difficulty following directions, or hallucinations and delusions.
Sleep disruptions: Insomnia or difficulty staying asleep at night.
These symptoms can vary in intensity from day to day and may be distressing for both the person experiencing them and caregivers.
It’s exact cause is unknown, but believed to involves a combination of factors:
Circadian Rhythm Disruption: Damage to the brain’s internal clock makes it hard to distinguish day from night.
Disruption in the body’s circadian rhythm is possibly due to changes in the brain in the suprachiasmatic nucleus or reduced melatonin production.
Environmental Factors: Low lighting can create confusing shadows; high noise levels or crowded rooms can be overstimulating.
Low light levels, shadows, or difficulty seeing clearly in dimming light.
Physical Fatigue: Exhaustion from the day’s activities reduces the brain’s ability to cope with stressors.
Fatigue built up from the day.
Unmet Needs: Hunger, thirst, pain, boredom, or a full bladder may manifest as agitation if the person cannot articulate their needs.
Management Strategies:
Maintain Routine: Establish consistent times for waking, eating, and sleeping to provide a sense of security.
Adjust Lighting: Close blinds before dusk and turn on bright indoor lights to eliminate shadows.
Encourage Daytime Activity: Physical exercise and exposure to morning sunlight help regulate the body’s internal clock.
Reduce Evening Stimulation: Limit loud TV, excessive visitors, or caffeine in the afternoon.
Use Soothing Distractions: Play calm music, offer a favorite snack, or engage in a simple, familiar activity like folding towels.
Overstimulation earlier in the day or changes in routine/environment.
Progression of the underlying dementia.
Many non-drug approaches can help reduce episodes or make them more manageable.
Focus on creating a calm, predictable evening routine:
Keeping a consistent schedule — Regular times for meals, activities, and bedtime.
Increase exposure to natural light during the day and use bright indoor lighting early evening to avoid abrupt dimness; close curtains to reduce shadows.
Limit caffeine, naps, and stimulating activities like loud TV later in the day.
Address basic needs proactively — Offer snacks, check for pain/discomfort, ensure bathroom access.
Create a calming environment — Soft music, familiar activities-reading aloud, gentle touch, or distraction techniques.
Avoid arguing or correcting confusion by using reassurance, redirection, or validation instead.
Encourage physical activity earlier in the day to promote better sleep at night.