Tips for Managing Sundowning in Dementia Patients

Whether you are a caregiver or a family member of someone living with dementia, you may notice changes in their behavior as you enter the late afternoon or early evening. Sundowning—also known as ‘sundown syndrome’ or ‘late-day confusion’—is a common manifestation among people living with dementia. 

Late afternoon and early evening can be a challenging time of day for dementia patients as well as their caregivers and loved ones. Fortunately, there are a number of strategies that may help to prevent and manage sundowning in dementia patients.

In this article, we will discuss potential causes of sundowning in dementia patients and tips for coping with and managing sundowning.

Potential Causes of Sundowning in Dementia Patients

Sundowning refers to the emergence or increment of neuropsychiatric symptoms, such as confusion, agitation, anxiety, irritability, and disorientation, occurring in the late afternoon and early evening. Based on data available from the Alzheimer’s Association, researchers believe approximately 20% of patients diagnosed with Alzheimer’s disease experience sundown syndrome. This clinical phenomenon has also been reported in other causes of dementia, including vascular dementia, frontotemporal dementia, and Lewy body dementia.

Although the underlying cause of sundowning in dementia patients is not yet fully understood, researchers believe sundowning may be related to impaired circadian rhythm, environmental and social factors, and impaired cognition. 

More specifically, potential factors that may contribute to sundowning in dementia patients include:

• Mental and physical fatigue due to a confusing or unfamiliar environment
• Disturbance of the patient’s ‘biological clock’ (circadian rhythm)
• Fluctuations in hormone levels throughout the day
• Mood disorders (e.g., anxiety and depression)
• Disorientation 
• Reduced sleep quantity or quality
• Low lighting and shadows
• Nonverbal behaviors of others

Sundowning can be aggravated by feelings of hunger, thirst, fatigue, pain, and boredom. Other factors, such as side effects from medications or changes in daily routine, can also contribute to the phenomenon.

Tips for Coping With Sundowning in Dementia Patients

In the early afternoon and early evening be cognizant of the patient’s behavior. Watching for signs, such as pacing, wandering, shadowing (closely following you wherever you go), crying, and other confusion- or anxiety-related behaviors.

To help patients cope with and manage late-day confusion, be sure to take the time to listen to their frustrations and concerns. Always be patient, bring a comforting presence, and try to understand the potential causes of their behaviors. Offer reassurance that they are safe and everything is alright. Take notes on the timing of sundowning and activities that occur beforehand to help identify potential triggers.

You may also consider:

• Reducing noise and activity in the room to reduce stress
• Distracting the patient with a favorite activity, image, object, or snack
• Playing soothing music, reading a book, playing a card game, doing a puzzle, or going for a walk
• Closing the blinds or curtains and turning on the lights prior to sundown

In addition, keep in mind that it is not always sundowning—similar behaviors can result from other feelings or needs such as needing to use the bathroom, being hungry or thirsty, or being in pain. 

Tips To Prevent Sundowning in Dementia Patients

While these behavioral changes are not always preventable, there are steps you can take that may help prevent sundowning and manage sleep issues associated with dementia. You may consider:

• Providing a predictable, stable routine for bedtime, waking, activities, and meals
• Limiting daytime napping or decreasing daytime napping duration
• Ensuring sufficient physical activity during the day
• Including time outside in the sunlight during the day (or by a window with sunlight)
• Encourage good sleep hygiene 
• Avoiding or limiting sugar, caffeine, alcohol, and nicotine intake to the morning hours
• Providing a larger lunchtime meal and smaller/lighter evening meal
• Keeping the living space or patient’s room well-lit during the evening hours
• Engaging the patient in soothing activities around the time sundowning symptoms typically arise
• Reducing stimulation in the evening hours
• Scheduling any appointments or outings in the morning or early afternoon hours

Caregivers and family members may also consider talking to the patient’s healthcare team about other solutions or other potential causes of sundowning-like behaviors, particularly if non-drug approaches are unsuccessful.