Understanding Sundowning: Symptoms, Causes and Coping Strategies

For many of our elderly loved ones, late afternoons and evenings are filled with panic, confusion and behavioral changes. It’s called sundowning. A broad term for behavioral disturbances that commonly peak later in the day — though they can occur at other times — sundowning can be especially unsettling on first appearance.

“Sundowning as a caregiver is difficult,” shares Dezarae Stone, a patient care assistant with CareYaya in Chapel Hill, North Carolina.

Attending to her grandmother with sundowning syndrome was demanding.

“At the end of the day, you’re tired from working and caring for your loved one … but that’s when my grandma had the highest level of confusion and needed the most,” she recalls. “Nights were often accompanied by many soft spoken words of reassurance to combat paranoia, redirection to her bed after wandering and showing her the clock or opening up the blinds as proof it’s the middle of the night.”

Although sundowning is a challenge, arming yourself with knowledge about how sundowning occurs and how to cope will shape you into a better support person or caregiver.

What Is Sundowning (Sundowner’s Syndrome)?

Sundowning isn’t a disease on its own. Rather, sundowning is the emergence or worsening of neuropsychiatric symptoms, like agitation, confusion or aggressiveness, in the late afternoon or early evening, according to Frontiers in Medicine.

Sundowning affects up to two-thirds of patients with dementia, and it may be a sign that the disease is progressing. Dementia is an umbrella term for cognitive decline interfering with daily activities, while Alzheimer’s disease is a specific type of dementia.

[Signs It’s Time for Memory Care]

Causes of Sundowning

Researchers are still learning about the causes of sundowning. In a review published in Frontiers in Medicine, the authors hypothesize there are multiple elements — neurobiological, pharmacological, physiological, medical and environmental — that contribute to sundowning.

Possible causes of sundowning include:

— Physical changes in the brain, including altered neurotransmitters (the body’s chemical messengers) and melatonin production. Melatonin, or the “darkness hormone,” helps regulate your sleep.

— Disrupted circadian rhythms, or the body’s internal clock, causing changes to blood glucose levels and body temperature.

— Medications.

Sleep disorders.

— Chronic pain.

[READ: Sleep Tips for Seniors]

Factors That Aggravate Sundowning

Just as the causes of sundowning are multifactorial, there are many factors that can worsen sundowning.

The following may aggravate sundowning symptoms:

— Mental and physical exhaustion.

— Unfamiliar or confusing environments.

— Increased stress.

— Environmental factors, like little exposure to sunlight, noise and overstimulation.

Care facilities that may also play a role in the prevalence of sundowning in their residents.

If you are looking to place your loved one in a senior care facility, like memory care or assisted living, assess the environment for potential sundowning triggers.

Facilities with short staffing, for example, may have difficulty adhering to a stable daily schedule and may cause stress. Some facilities also wake up their least cognitive residents as early as 4 a.m. to get a head start on the day. This contributes to sleep deprivation and may increase stress and confusion. Other facilities may have poor lighting, lots of alarms and disruptions to residents that could lead to overstimulation.

[SEE: Nursing Home Red Flags You Should Watch Out For]

Signs of Sundowning Dementia

Signs of sundowning dementia will vary for each individual.

Common signs of sundowning include:

— Delusions, which are firmly held beliefs that are false or not real, like that a family member is stealing their possessions.

Depression or crying.


— Confusion or disorientation.

— Agitation or aggression.

— Apathy.

— Pacing or wandering.

Men and women may even manifest symptoms differently, says Dr. Gary Small, chair of psychiatry at Hackensack University Medical Center in New Jersey.

“Women are more likely to experience symptoms of depression, psychosis and delusion, while men are more likely to experience apathy,” he explains.

How Is Sundowner’s Syndrome Diagnosed?

Sundowning is usually diagnosed after caregiver-reported observations. Providers will take a medical history of their patients and ask them about hallucinations, delusions, mental health and sleep. They will also inquire if the caregiver has noticed concerning behaviors in their loved one or care recipient.

Next, providers need to rule out other possible causes of symptoms, like:

— Delirium, which can be caused by medications, illicit drugs or sleep deprivation.

— Other neurological disorders, like Parkinson’s disease.

— Mental health conditions, like anxiety or depression.

— Infections, especially urinary tract infections, which often cause confusion.

— Chronic pain.

What’s the difference between delirium and sundowning? Delirium usually has a faster onset and often goes away once the trigger is removed. Sundowning is a chronic issue and can be reduced with adjustments to routine and lifestyle, but it will not go away. Not everyone with dementia will experience sundowning, but almost everyone with sundowning syndrome has some type of dementia.

Sundowning Treatment: Coping With Sundowning

Sundowning has many potential triggers, so the underlying cause or causes can be difficult to pinpoint, which may complicate treatment, Small says.

Avoiding unnecessary medications is crucial in this population to avoid drug-to-drug interaction and polypharmacy, which is the use of multiple medications at the same time.

“The best initial treatment to sundowning is nonpharmacologic,” explains Dr. Lisa Gibbs, chief of the division of geriatric medicine and gerontology and the Ronald Reagan Chair in Geriatric Medicine at the University of California–Irvine. She is also the interim chair of the family medicine department at UCI Health in Orange, California.

Tips and natural remedies to reduce sundowning

Because sundowning has many possible causes, the treatment should also have a multidimensional approach. Gibbs recommends first identifying any precipitating factors.

For example, “if the pain from arthritis is a problem throughout the day, then treating the pain may alleviate the physical discomfort that can result in agitation or confusion,” she says. She also implores caregivers to pay attention to sleep deprivation, hunger and other physical needs of their elderly loved one or patient.

Small suggests starting with these non-medical treatments:

— Assess the surroundings to see if they may trigger sundowning. Reducing noise, cleaning clutter and adjusting lighting may make a big difference.

— Employ distraction techniques. A snack, a walk or music can be very helpful for individuals experiencing sundowning. Also consider light therapy or music therapy.

— Search for other possible underlying causes. Your loved one may be tired, hungry or in pain. These can exacerbate sundowning symptoms.

— Speak to a doctor about possible medication-related causes.

Tips for caregivers to manage sundowning symptoms

Peggy Misciagna, who has been married to her husband Tom for 38 years, shares that sundowning has slowly become part of their daily routine. After Tom’s diagnosis, the pair became involved with the Alzheimer’s Association, an organization that helps maximize quality care and support for those affected by Alzheimer’s and other dementias.

Misciagna noticed possible early signs of dementia when Tom had unusual struggles with his performance at work, and was forgetting to pay some of their bills. It took nearly a decade after his initial Alzheimer’s diagnosis for sundowning symptoms to set in. But now, Misciagna counts on sundowning each day around 3 or 4 p.m.

Misciagna shares that some of the following remedies have worked for her and Tom include:

— Consistent validation, like telling your loved one, “I’m right here. You’re safe.”

— Open communication, such as being transparent about care plans, appointments and disease prognoses with your loved one.

— Making time for naps.

— Establishing a routine, but being flexible as symptoms and sundowning manifestations may change.

— Physical touch, like hugs.

Misciagna says she takes everything one day at a time.

“I just give him reassurance. I tell him I wish there was something more I could do for you, but that’s about all that you can do, is just give them reassurance,” she says.

Can medications help reduce sundowning?

Small says some medications given in small doses may be helpful in reducing sundown symptoms.

Potential treatments include:

— Melatonin.

Antipsychotic drugs, like risperidone or Seroquel.

Anti-anxiety medications, like Ativan.

Antidepressant medications, like trazodone.

It’s important to remember that medications can cause sundowning, side effects and can interact with other medications. Nonmedical treatment is recommended first for sundowning.

Medications that cause sundowning

Many medications can cause sundowning, Small explains. This includes medications that are used for sedating or reducing anxiety. He also says to be wary of medications that have anticholinergic effects, which impact certain chemical messengers that play a role in dementia symptoms. This includes a wide array of medications, from over-the-counter sleep aids, to antihistamines, to some antidepressants.

This is why working with a medical professional who is trained in neurologic disorders or geriatric populations is essential. Some of the same medications that treat sundowning could worsen the condition depending on the circumstances and the individual.

Preventing Sundowning

“Prevention is key, if possible,” Gibbs says.

To prevent sundowning, Gibbs suggests:

Caregivers create a daily routine. This prevents unnecessary change or unfamiliarity, which can cause fear and agitation in those struggling with sundowning. Structure maintains a sense of comfort and predictability early into the course of Alzheimer’s disease and dementia.

— Caregivers stay attuned to their own stress levels. “Individuals with dementia may mirror caregiver behavior and feelings, whether calmness, stress or frustration. Caregiver self-care is just as critical,” she says.

— Caregivers visit and tour any potential senior care facilities to validate that the facility will not worsen sundowning symptoms.

Stone, the aforementioned caregiver of her grandmother, says sundowning was once something she feared and dreaded. Now, she sees it as an honor to have been able to care for someone in their most vulnerable times.

“I often hold on to those memories of tucking my grandma back into bed,” she says. “I still recall her eyes looking into mine, and a sideways smile letting me know she felt safe with me.”

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Understanding Sundowning: Symptoms, Causes and Coping Strategies originally appeared on usnews.com

Update 01/05/24: This story was previously published at an earlier date and has been updated with new information.

Correction 01/11/24: A previous version of this article misidentified the name of Dezarae Stone’s workplace.

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