Sundowning and Dementia

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Important takeaways:

• Sundowning can affect people with dementia at any stage but is particularly common in the middle or late stages of the disease
• Record any signs from your loved one, for example, behaviour changes particularly early evening/overnight during sundowning episodes
• Looking after yourself is important for you and your loved one you are supporting

Understanding sundowning

What is sundowning? The sundowning dementia meaning refers to the state of confusion people living with dementia may experience in the late afternoon or early evening.

One in five people living with dementia experience sundowning symptoms, which can cause a person to become agitated, distressed or have hallucinations and delusions which can continue into the night, making it hard for them to get enough sleep. 

Sundowning in dementia symptoms and behaviours can heighten during a season change as a person’s internal body clock adjusts to a new routine. 

There are several causes for sundowning. As the day goes on, a person living with dementia becomes more tired, which can make dementia symptoms worse – hunger, thirst and physical pain can also play a part.

Sundowning often makes a person with dementia feel very that they are in the wrong place, or that they forgot to do something important during the day.

They may say they want to go home even if they are at home, or that they need to pick their children up from school, even if they are adults.

Recognising the signs of sundowning

When it comes to sundowning dementia symptoms, it’s important to recognise any signs from your loved one, for example, behaviour changes particularly early evening/overnight.

In the early stages of sundowning, symptoms can be subtle and difficult to spot, including: 

• Irritability
• Confusion
• Restlessness and agitation 
• Disorientation and other similar behavioural changes 

Dementia sundowning symptoms will likely become more noticeable or worse as sundowning increases, with some of the most common symptoms including:  

• Crying
• Anger
• Yelling
• Paranoia
• Pacing
• Wandering
• Trouble sleeping 
• Hiding objects
• Hallucinations

Sundowning across dementia stages and types

Many people ask at what stage of dementia is sundowning, and the reality is, sundowning can happen at any stage of dementia, but it usually starts occurring in the mid to late stages. 

However, once a person starts experiencing sundowning episodes, they can potentially occur every afternoon or evening.

Regardless of the type of dementia a person is living with, sundowning will likely manifest itself in similar ways, for example, vascular dementia sundowning symptoms and alzheimer’s sundowning may also include feelings of confusion, agitation and irritability, and may lead to trouble sleeping, wandering and hallucinations as sundowning progresses.

Managing sundowning effects

The NHS says challenging behaviour associated with dementia needs to be seen as a manifestation of unmet need (such as tiredness, hunger and thirst) which a person living with dementia may not be able to express. 

Other daily factors have been shown to exacerbate sundowning symptoms:

• Disturbance to a daily routine
• Spending a day in an unfamiliar place
• Fatigue
• Lack of exposure to sunlight during the day
• Disruption of the body’s ‘internal clock’
• Being bored or in pain
• Low lighting
• Increased shadows
• Difficulty separating reality from dreams
• Presence of an infection such as a urinary tract infection
• Depression

Look at any behaviours as a form of communication, as this will help you discover, and hopefully address any triggers that are negatively affecting your loved one. 

There are a few techniques you can utilise to help manage and reduce the impact of sundowning symptoms. For example:

• Talk in slow, soothing ways
• Keep a predictable routine for bedtime, waking, meals and activities
• Plan for activities and exposure to light during the day to encourage nighttime sleepiness
• Reduce or avoid alcohol, caffeine and nicotine, which can all affect sleep
• Limit caffeine and sugar to morning hours

• Use distraction techniques: go into a different room, make the person a drink, have a snack
• Ask them what the matter is. Listen carefully to their response and if possible, see if you can deal with the reason for their distress 
• Speak in short sentences and give simple instructions to try to avoid confusion 
• If it’s safe to do so, offer physical affection. Hold the person’s hand, sit close to them, stroke their arm or give them a hug
• Limit daytime napping
• Turn on a night light to reduce agitation when surroundings are dark or unfamiliar
• In the evening, try to reduce background noise and stimulating activities, including TV viewing, which can sometimes be upsetting
• In a strange or unfamiliar setting, bring familiar items, like photographs, to create a more relaxed, familiar setting
• Get outdoors for some exercise
• Play familiar, gentle music in the evening or relaxing nature sounds

If sundowning episodes worsen, you can do the following:

• Keep track of when sundowning occurs and note what happened beforehand to help identify triggers
• Get support from the GP and Community Mental Health team to manage and reduce effects
• Discuss with a doctor the best times to take medication to minimise any side effects that may contribute to sundowning dementia symptoms
• Speak with a doctor for further treatment suggestions if changes to the environment or behavioural interventions are ineffective

Ways to help your loved one during a sundowning episode include:

• Approaching them calmly if they appear agitated; reassuring them that everything is OK and ask if they need anything
• Allowing a person the space to move or pace while supervising them
• Gently reminding them what time of day it is
• Avoiding arguing or physically restraining them, as this may worsen agitation or distress

Support and resources for caregivers

Looking after yourself is important for you and your loved one you are supporting, especially during periods of sundowning dementia when they may feel more confused or anxious.

Here are a few ways you can maintain your personal well-being: 

• Share how you feel
• Try to be realistic
• Find ways to stay organised
• Take a break and make time for yourself: Respite is necessary. You can’t give your all as a carer; you have to save a bit of yourself just for you.
• Look after your physical health
• Rest when possible and enjoy some self-care as it can help reduce tiredness, particularly towards the end of the day

 If you would like some support, you can contact the following organisations who can offer information and access to local support groups:

• Carers UK
• Carers Network
• Carers Trust
• Crossroads Caring for Carers
• Care Information Scotland
• The Alzheimer’s Society

Consulting healthcare professionals

Sundowning can be draining on your loved one with dementia, but also for you as a caregiver; managing the symptoms requires patience and extra support for you both.

If you have concerns about your loved one’s sundowning symptoms, speak with their GP, as a medical exam could help identify the cause of sundowning, such as pain, an illness or medication side effect.

The GP or doctor can also help develop strategies to cope with the symptoms and provide ways to support you both through this.

For example, at home, carers can note their loved one’s feelings of boredom, frustration, annoyance and tiredness with behaviour charts, and a Community Psychiatric Nurse (CPN) or dementia support worker can help carers understand these charts and develop strategies to help their loved one. 

The Alzheimer’s Society offers useful guidance to manage Behavioural and Psychological Symptoms of Dementia (BPSD).

Sundowners syndrome beyond dementia

Sundowning is exhibited in those with cognitive impairment, meaning a person without dementia with cognitive impairment can experience sundowning, too.

For example, the general loss of brain mass as a person ages can also make them susceptible to confusion and disorientation, which is why elderly people without a dementia diagnosis may also experience sundowning. 

Hospital and professional approaches to sundowning

Medication and hospital treatments can be used to help manage sundowning episodes and their effects, including: 

• Antipsychotics: Haloperidol and risperidone are the only antipsychotics licensed in the UK for treating non-cognitive symptoms of dementia
• Sedatives
• Mood stabilisers 
• Antidepressants
• Bright light therapy
• Music therapy

These medications and treatments can help people living with sundowning dementia symptoms and act as a calming agent to help them feel less stressed when symptoms can cause them distress.

Frequently asked questions

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