What is Sundowning in Dementia Care?

Sundowning is a term used in dementia care to describe a pattern of behaviour that typically happens in the late afternoon, evening, or night-time. People living with dementia may experience increased confusion, agitation, restlessness, or anxiety at these times. The changes in behaviour are often more pronounced compared with the person’s behaviour earlier in the day, and sundowning can vary in severity from day to day.

The name comes from the fact that symptoms tend to appear or worsen as the sun goes down. While it is not a separate condition, it is a recognised symptom pattern in various types of dementia, including Alzheimer’s disease. Understanding sundowning is important to help carers and families respond effectively and create a more calming environment.

How Sundowning Presents

Sundowning can manifest in several ways. A person experiencing it may:

• Become more irritable or argumentative
• Pace or wander around without clear purpose
• Shout or call out repeatedly
• Show increased confusion about where they are or who people around them are
• Experience hallucinations, such as seeing people who are not there
• Have trouble sleeping, either by finding it hard to fall asleep or waking up frequently
• Attempt to leave the home or place they are staying

Not all individuals with dementia will experience sundowning, and for those who do, symptoms may vary widely in intensity and frequency. Carers often report that days with more complex or stimulating activities may lead to stronger sundowning behaviours later on.

Possible Causes of Sundowning

Medical researchers do not fully understand why sundowning happens, but several factors are believed to play a part. Dementia affects the brain in ways that can make it more difficult for a person to process stimuli and regulate emotions. Certain triggers and conditions may make symptoms more intense later in the day.

Some possible contributing factors include:

• Fatigue from the day’s activities
• Reduced lighting, which can make surroundings appear unfamiliar or confusing
• Changes in the body’s sleep-wake cycle or circadian rhythm
• Hunger or thirst
• Side effects of medication
• Discomfort from pain or illness
• Increased shadows and altered perception as daylight fades

At night, the brain may be less able to cope with the demands of interpreting the environment. This can add to confusion and distress.

Impact on the Person and Their Carers

Sundowning can be distressing for the person with dementia because they may feel unsafe or lost. They may not understand why they feel unsettled, leading to frustration or fear. Emotional distress can then increase the behaviours described above.

For carers, sundowning can be challenging because it tends to happen at a time when everyone may be tired from the day’s activities. It can disrupt evening routines, require extended supervision, and result in sleep disturbance for both the person and their carer. This can contribute to carer stress and exhaustion, which makes managing the situation harder.

Common Signs to Look Out For

If you suspect someone may be experiencing sundowning, watch for patterns in behaviour over several days. Common signs include:

• An increase in restlessness after late afternoon
• Heightened confusion or difficulty following conversation
• Repetitive questioning or statements
• Mood swings, such as moving from calm to angry quickly
• Pacing around or attempting to leave the home repeatedly
• Misinterpreting surroundings (for example, thinking strangers are present)

By identifying these patterns, carers can plan ways to reduce triggers and prepare calming strategies for evenings.

Approaches to Reduce Sundowning Symptoms

Carers can try various methods to lessen sundowning behaviours. While not everything works for everyone, certain approaches often make a difference.

Create a Calm Evening Environment

Keeping surroundings peaceful can lower agitation. Soft lighting can reduce the effects of increasing shadows as daylight fades. Avoid loud noises, rapid movement, or visually confusing spaces during late afternoon and early evening.

Keep a Regular Daily Routine

Predictability can help reduce confusion. Eating meals, engaging in activities, and going to bed at similar times each day can help regulate the body’s internal clock.

Manage Exposure to Stimuli

Avoid overwhelming the person in the hours before sundowning typically occurs. Limit busy or noisy activities during late afternoon and choose calming tasks such as light conversation, reading, or gentle music.

Support Physical Needs

Make sure the person has eaten and drunk enough fluids during the day. Unmet needs can lead to discomfort and irritability at night. If they experience pain, discuss management options with a healthcare professional.

Gentle Distraction

If agitation increases, redirect attention to something soothing such as a favourite hobby, a simple game, or a short walk in a familiar area.

Safe Space

Provide an area where the person can move about without risk. This can help calm those who feel compelled to walk or pace.

The Role of Sleep

Poor sleep and daytime tiredness can increase sundowning behaviours. Sleep disturbances are common in dementia, and lack of rest makes it harder for the brain to function well. Promoting healthy sleep patterns may help reduce evening agitation.

Some tips that might help include ensuring the bedroom is comfortable, avoiding caffeine later in the day, and having a calming bedtime routine. Sometimes, brief daytime rest can be beneficial, but overly long naps may interrupt night-time sleep.

Behaviour Patterns and Triggers

Keeping a diary of behaviours can help identify triggers that lead to sundowning. This means noting the time symptoms start, what the person was doing beforehand, and any environmental factors in place at that time. Over time, carers may be able to adjust routines to minimise triggers they can control.

For example, if late afternoon visits from multiple people increase agitation, it may be better to schedule visits earlier in the day. If certain lighting causes confusion, adjusting lamps or curtains may help.

Seeking Professional Advice

Medical advice can be helpful where sundowning is frequent or severe. Health professionals can check if underlying medical problems are adding to symptoms, such as infections, medication side effects, or untreated pain. In some cases, changes to medication or daily routines can lessen the impact.

Professional support can also guide carers on practical measures and provide reassurance that they are not alone in facing the challenge.

Supporting Carers

Supporting someone who experiences sundowning requires patience and preparation. Carers benefit from having breaks and support from others to reduce stress and maintain their health. Carer support groups can be a source of shared ideas and encouragement.

Family and friends can help physically, such as by providing supervision during known sundowning periods, or emotionally, through conversation and reassurance.

Strategies for Safety

In cases where sundowning leads to wandering, safety becomes a priority. Some steps that may help include:

• Locking doors at night and keeping keys out of sight
• Installing alarms or sensors to alert carers when someone tries to leave
• Removing hazards from walking areas
• Ensuring the person has identification in case they do leave the home

These steps can give carers more confidence that the person is safe, especially during periods of heightened restlessness.

Emotional Support

People experiencing sundowning benefit from emotional reassurance. Remaining calm and speaking in a gentle tone can help ease distress. Physical gestures, such as holding a hand or sitting close, can offer comfort without adding to confusion.

Validation techniques, where carers acknowledge what the person is feeling rather than correcting their statements, can reduce agitation. For example, if someone speaks about needing to go home when already at home, responding with reassurance rather than contradiction can lessen distress.

Final Thoughts

Sundowning in dementia care refers to a repeated pattern of behaviours that increase in the late afternoon or evening. It can involve agitation, confusion, restlessness, or other changes that disrupt the end of the day for both the person and their carer. While the exact causes are not completely understood, factors such as fatigue, lighting changes, hunger, and disruptions to daily rhythm are believed to contribute.

By recognising the signs and identifying possible triggers, carers can take steps to reduce sundowning symptoms and create a calmer environment in the evening. Small changes in routine, lighting, diet, and activity level often make a big difference. Medical advice can be useful if symptoms persist.

Sundowning can be demanding to manage, but understanding it and preparing for it can help protect the wellbeing of both the person with dementia and those providing care.