Sundowning: Late-Day Confusion in People with Dementia

If someone you care about has cognitive impairment or dementia, you might notice them acting differently in the late afternoon or early evening. Sundowning, also known as sundowners or sundown syndrome, refers to a group of behaviors, feelings, and thoughts that people with cognitive impairment or dementia may experience in the late afternoon or evening as the sun sets, although it can occur at other times as well. It can affect a person’s memory, thinking, personality, reasoning, and mood. 

People experiencing sundowning may feel sad, anxious, fearful, restless, confused, disoriented, and irritable. In some cases, it can cause paranoia, delusions, and hallucinations. Typical behaviors include:  

• Confusion
• Pacing, wandering, or rocking in a chair
• Shadowing (when someone closely follows their caregiver everywhere they go)
• Crying
• Insomnia
• Ignoring directions
• Aggression, yelling, and in some cases even violence

Causes of sundowning in seniors

Sundowning is common in people experiencing dementia due to Alzheimer’s disease. One in five people living with Alzheimer’s experiences sundowning syndrome at some point. 

However, sundowning behaviors are not specific to any one disease or condition. Sundowning can also occur in the context of other illnesses that cause dementia and impair cognitive abilities, such as vascular dementia, diffuse Lewy body disease, and frontotemporal dementia. Some medical conditions, such as kidney or liver dysfunction, thyroid disease, and others, may also be accompanied by sundowning.

Factors that may aggravate or even trigger sundowning include: 

• Unfamiliar surroundings
• Low lighting or increased shadows
• Fatigue or boredom
• Pain
• Depression
• Hunger or thirst
• Disruptions of the body’s internal clock
• Difficulty separating reality from dreams
• Presence of an infection, such as a urinary tract infection
• Effect of certain medications

If a person experiences symptoms of sundowning, it is essential to consult with their medical team to review their current medications, assess for possible infection, run pertinent blood tests, and conduct a thorough evaluation to identify any potential causes. Addressing these factors can help reduce the risk or severity of sundowning before considering medications to manage symptoms. 

The role of cognitive reserve

While the exact cause of sundowning remains uncertain, cognitive reserve may play a pivotal role in its underlying mechanisms. Cognitive reserve refers to the brain's ability to adapt to neural changes, which are often influenced by educational and life experiences. Cognitive reserve is essential for the brain to function smoothly in the face of stress, aging, or damage. 

Enhanced cognitive reserve, built over time, can serve as a protective factor against dementia. As the sun sets, reduced sensory input and unfamiliar surroundings can cause symptoms like confusion, delirium, and sundowning in people with compromised cognitive reserve due to conditions such as dementia. 

Medication for sundowning 

The most effective way to address sundowning is to identify and treat the underlying factors that cause or exacerbate symptoms, but other options are available. The individual behaviors, feelings, and thoughts of people who go through sundowning can sometimes be treated with medications, including:

• Antidepressants and/or anxiolytics, which can help by treating underlying symptoms.
• Antipsychotics, which are commonly prescribed, but evidence is mixed. (Most studies do not directly target sundowning, focusing instead on delusions, hallucinations, and agitation.)
• Melatonin, which may help, but current research is inconclusive.
• Cholinesterase inhibitors, which have been shown to decrease the behavioral disturbances in patients experiencing sundown syndrome.

Non-medication treatments

Light therapy has shown promising results in small studies, but larger controlled trials have not been conducted. Besides the lack of robust supporting evidence, ensuring a gradual transition from daylight to artificial light may ease behavioral changes occurring in the late afternoon and is commonly suggested by health care providers. 
Environmental changes, music therapy, aromatherapy, and caregiver education can also help.

Sundowning tips for caregivers

If you are the caregiver for someone experiencing sundowning, there are many things you can do to help: 

• Natural light can help reset the body’s internal clock and have a positive influence on mood. It’s best to go outside if possible, but even sitting by a window can help. Avoid blue light from devices such as cell phones and TVs in the evenings and make sure there is darkness or low light at bedtime. If the person is agitated in the dark or unfamiliar surroundings, you may turn on a nightlight.
• Physical exercise can enhance physical, mental, and emotional well-being, and improve sleep, all of which can help prevent sundowning.
• Limit sugar, alcohol, and caffeine in the evening to help the brain power down.
• Keeping to a stable, predictable schedule that has meaning. Sticking to regular times for sleeping, meals, and activities, as well as limiting daytime napping, helps regulate the body’s internal clock.
• Avoid excessive stimulation (auditory or visual) in the evening. Minimize unnecessary noise from visitors, loudspeakers, clattering dishes, loud conversations, or any other sound that can be controlled. Play familiar, gentle music or relaxing nature sounds, such as the sound of waves.
• In strange or unfamiliar settings, bring familiar items such as family photographs to help create a more relaxed and reassuring environment.
• If the person wears eyeglasses or hearing aids, make sure they are available and function correctly.

What if sundowning persists?

If sundowning persists, seek medical advice. A medical exam may identify a specific trigger, such as pain, a sleep disorder or other illness, or a medication side effect. In addition, a medical evaluation will help diagnose underlying conditions that, if treated, can reduce the risk of further episodes.

If medication is prescribed to help your loved one relax, control agitation, or sleep better at night, be sure to find out about possible side effects. Some medications can increase the chances of confusion, dizziness, and falls. Using such medications is only recommended for short periods of time and under close medical supervision.

Dementia caregiver support in Boston 

At the Deanna and Sidney Wolk Center for Memory Health, we provide support to family caregivers and their loved ones with dementia. We can assess your needs, provide you with the skills and support you need to navigate caregiving, and tailor resources to your specific requirements. Our services for caregivers and loved ones include skill-building and support groups, as well as the opportunity to meet one-on-one with a family caregiver specialist for individualized therapy. 

We are committed to providing culturally responsive care, and our recommendations are based on your needs, including your social, spiritual, and financial circumstances. 

If you or someone you know is struggling with the daily tasks of being a family caregiver to a loved one with dementia, we are here and happy to help. Contact us today to get started.