When your loved one has Alzheimer’s disease or dementia, the approach of sundown can trigger sudden changes in their mood and behavior that are difficult to manage — just when tired caregivers need a break. You may notice increased confusion, restlessness, and agitation beginning in the late afternoon or evening, sometimes persisting through the night.
This is known as sundown syndrome, or sundowning, a condition experienced by as many as 20 percent of people with Alzheimer’s disease.
Not only is sundown syndrome distressing for those with dementia, but navigating it can be stressful and exhausting for their caregivers. Understanding sundown syndrome — its symptoms, why they happen, and how to identify and cope with them — can help you manage this challenging time of day.
Recognizing sundown syndrome and its symptoms
While not a formally recognized psychiatric diagnosis, “sundowning” is a term that describes a group of symptoms in people with memory loss that begins or worsens as daylight begins to fade.
Common behaviors associated with sundowning include:
- Pacing
- Rocking in a chair
- Wandering
- Violence
- Shadowing
- Crying
- Insomnia
- Yelling
Experiencing sundowning can cause many emotions, including:
- Sadness
- Anxiety
- Fear
- Agitation
- Restlessness
- Irritability
- Confusion
- Paranoia
- Hallucinations and delusions
It’s important to remember that sundown syndrome looks different for everyone who experiences it; symptoms can stop abruptly, change, and fade over time, which can be very difficult for caregivers to manage.
In some cases, symptoms can persist throughout the night, making it hard for people with Alzheimer’s disease to fall and stay asleep. A disrupted sleep routine often means they and their caregivers may not be getting enough rest to function well during the daytime. This insomnia-fatigue cycle can worsen sundowning over time.
Studies show that sundowning behavior in people with Alzheimer’s disease can increase when they sense frustration, anxiety, or stress from their caregivers. Be patient, but most importantly, practice good sleep hygiene and recognize when you need a break and rest. Your sleep is just as important as your loved one’s; you can’t help them cope with sundowning symptoms if you’re both exhausted.
Differentiating sundown syndrome from general delirium
While it is typical for people with memory loss to experience similar feelings and behaviors due to delirium, the key difference between sundowning and delirium is the onset and duration of symptoms.
Delirium is usually caused by a specific physical condition, such as a urinary tract infection, and only lasts for a few months or until the condition is treated. It happens suddenly and comes and goes throughout the day. Sundowning is much longer-term and occurs each day for a few hours around sunset when light levels change, typically between 4:30 p.m. and 11 p.m. It may be worse during the fall and winter months when the daylight hours are shorter.
If you think your loved one is experiencing sundown syndrome, be sure to talk with their medical provider. Sometimes, sundowning can be mistaken for other unmet needs or unidentified issues, such as pain, side effects from medications, or a sleep disorder or other illness that cause increased delirium. A medical exam can help determine this.
Understanding why sundowning happens
Although there are no established causes, risk factors, or physiological explanations for sundown syndrome, research points to a disruption in the body’s natural clock that occurs in people with dementia, which impacts how they respond to changing light levels at sundown.
While it can happen at any stage of dementia, sundown syndrome is more common during the middle and later stages when your loved one is working much harder to complete daily tasks that used to come much easier. Expending more energy means they can wear out as the day progresses.
Rather than one specific cause, a variety of factors can trigger sundowning, including:
- Fatigue or exhaustion
- Hunger, dehydration, pain, or other unmet physical needs
- Not enough exposure to sunlight during the day
- Overstimulation from a noisy or busy environment
- Disruptions to schedules or routines
- Changes to hormone levels throughout the day
- Sensory impairment, such as hearing or sight loss
- Mood disorders such as anxiety or depression
- Side effects of prescribed drugs
Treating the underlying trigger is the key to any management strategy; when you identify what causes the symptom, you can treat it directly. For example, if your loved one has insomnia, it might have been triggered by a busy and overstimulating day. The best treatment may be to give them a simpler, easier schedule with less stimulation.
Try keeping a journal for a few days to identify your loved one’s triggers. Note any sign of distress or sudden change in their thoughts and behaviors in the late afternoon or evening. What physical signs do they show? What may have triggered them? How was this day different from others?
Treating sundown syndrome and managing its symptoms
Since the exact causes of sundown syndrome aren’t fully understood, there is no cure. But there are a variety of techniques you can try to manage your loved one’s sundowning triggers and lessen the severity of their symptoms, from behavioral and environmental approaches to medication intervention.
Adjust your loved one’s immediate environment with these approaches:
- During the daytime, open window coverings for maximum exposure to bright light.
- At dusk, close the window coverings and turn lights on to eliminate any shadows caused by the late daylight; shadows can confuse people with dementia.
- Incorporate calming activities they’ll associate with being in their space during the evening, like doing a puzzle, having a snack, or enjoying a phone call with a loved one.
- Minimize loud background noises. If needed, create some low, calming background noise (like white noise) to help to lessen the impact of loud and sudden noises.
- Minimize clutter in rooms and/or the number of people in the room.
- Monitor screen time on the TV and smart devices; certain content can be upsetting for people with dementia.
Incorporate these healthy daily behaviors:
- Maintain a predictable routine for bedtime, waking up, meals, and activities; this helps your loved one know what to expect throughout their day, which comforts them.
- Get daily outside physical activity and exercise.
- Eliminate caffeine and alcohol, especially in the late day.
- Keep daytime naps short and earlier rather than later in the day.
Behavioral and environmental strategies should be the first line of intervention for sundown syndrome, but symptoms can sometimes be treated with medications like antidepressants, antianxieties, and melatonin to help with sleep. Always consult with your loved one’s healthcare provider before beginning any medication.
It may not be possible to prevent or resolve your loved one’s sundowning entirely. Still, there are strategies that can reduce the distress as symptoms are happening:
- Listen and empathize with them. It can be difficult to identify the source of their fear or agitation. Listening and acknowledging their struggle may help your loved one regain awareness and find some relief.
- Communicate calmly and gently. Speak in a gentle voice, and give one direction at a time in concrete terms that won’t confuse them. Offer reassurance by holding their hand or gently stroking their back.
- Redirect where possible. Engage in a calming activity they love, like puzzles or coloring; initiate a conversation about their favorite topic or memories; give them a simple task, such as folding laundry; or, if it’s safe, take them on an evening walk.
- Never use physical restraint. Sundowning confusion can cause your loved one to wander, yell, and maybe even become aggressive; physically restraining them can increase agitation, frustration, anxiety, and anger. Let them pace, rock, and wander under supervision. Lock your doors and place stop signs (like the red ones in the street) on them to discourage wandering.
Once you understand sundown syndrome and how it impacts your loved one, you can use what you’ve learned from each occurrence to make it easier to manage.
Learning from each episode and experience is an effective way to deal with sundowning. In the same journal you use to record what triggers your loved one’s symptoms, record how you manage them. How long does each episode last? What worked to calm them? What didn’t work?
