Sundowning in Dementia
What Caregivers Need to Know
Read time: 11 minutes
It’s 4:30 PM, and everything changes. Your mother, who was calm and pleasant all morning, is suddenly agitated, pacing the hallway, and insisting she needs to “go home” – even though she’s been living in your home for two years. The light is fading outside, and so is her grip on where and when she is.
You’re not imagining it, and you’re not alone. What you’re experiencing has a name: sundowning.
If you care for someone with dementia who becomes increasingly confused, anxious, or agitated in the late afternoon and evening, understanding sundowning is your first step toward managing it. You may not be able to eliminate every difficult episode, you can significantly reduce their frequency and intensity.
For exhausted caregivers, that matters enormously.
What is Sundowning?
Sundowning, also called “late-day confusion” or “sundown syndrome,” describes a pattern of increased confusion, agitation, and anxiety that emerges in the late afternoon and evening in people with dementia. According to the Alzheimer Society of British Columbia, an estimated 66% of people living with dementia experience sundowning at some point in their illness.
Sundowning isn’t a separate diagnosis – it’s a cluster of behavioral symptoms that follow a predictable daily pattern. For many families, it’s one of the most challenging aspects of dementia care because it intensifies during what should be the quietest hours of the day.
Sundowning can occur at any stage of dementia, though it most commonly peaks during the middle stages and may lessen as the disease progresses.
When Does Sundowning Happen?
Sundowning typically follows a pattern:
- Starts: Late afternoon, usually between 3-4 PM
- Peaks: Early evening, around 5-7 PM
- Duration: Can last several hours, though this varies considerably
- Frequency: Daily for some; intermittent for others
The pattern is highly individual. Some people experience mild restlessness; others become severely disoriented or distressed. Learning your loved one’s specific pattern – when it begins, what seems to precede it, how long it lasts – is one of the most useful things you can do as a caregiver.
Recognizing the Signs
The Alzheimer Society of BC notes that a person experiencing sundowning “may become suspicious, upset, or disoriented, see or hear things that are not there, and believe things that are not true.”
Behaviorally, this can look like:
Behavioral Changes:
- Increased confusion – “Where am I?” or “I need to go home” (even when already home)
- Restlessness and pacing; difficulty sitting still
- Agitation or aggression – Verbal outbursts, resistance to help, combative behavior
- Paranoia – “You’re trying to poison me” or “Someone stole my things”
- Shadowing – following the caregiver from room to room, unable to tolerate being alone
- Wandering – Attempting to leave the house, searching for something or someone
Emotional Changes:
- Heightened anxiety; visible distress
- Rapid, unprovoked mood shifts
- Sudden crying or emotional outbursts
Cognitive Changes:
- Disorientation — not recognizing familiar people, places, or the time of day
- Hallucinations — particularly involving shadows or movement in low light
- Repetitive questioning or urgent, demanding requests
The intensity of these symptoms ranges from mildly unsettling to genuinely frightening – for the person with dementia and for the people caring for them. If sundowning behavior includes violence, puts your loved one at risk of self-harm, or you are reaching your own breaking point, contact your physician or a dementia helpline without delay.
What Causes Sundowning?
“Behaviour may appear to be caused by sundowning but is [can] actually [be] an attempt to meet or communicate a need” ~ The Alzheimer Society of BC cautions caregivers to remember
Researchers do not yet fully understand sundowning, but several interacting factors are consistently implicated. Keeping a behavioral log can help distinguish sundowning from unmet physical needs, hunger, pain, or the need for a hearing aid, for example.
Disrupted Circadian Rhythm
Dementia damages the area of the brain responsible for regulating the body’s internal clock. When this system breaks down, the brain loses its ability to reliably distinguish day from night, making the daily transition to evening disorienting and distressing rather than natural.
Mental Fatigue
By late afternoon, a person with dementia has spent the entire day expending significant cognitive energy – recognizing faces, following conversations, managing emotions, navigating familiar spaces. The mental reserves available to cope with stimulation and uncertainty are depleted. As the Alzheimer Society of BC describes it, fatigue “can decrease the person’s ability to cope with stress and stimuli, triggering late-day confusion.”
Hormonal Disruption
Dementia interferes with normal melatonin production (which helps us sleep) and alters cortisol patterns (our stress hormone), disrupting the body’s ability to transition smoothly from wakefulness into the evening rest cycle.
Low Light and Shadows
“Low or inconsistent lighting can increase shadows, causing confusion and an increase in visual mistakes – when the brain mistakes an object for something it is not due to the brain’s changing ability to interpret visual stimuli.” ~ The Alzheimer Society
As natural light fades, shadows lengthen and visual perception becomes less reliable. For someone with dementia, the glare from windows at sunset can compound the problem.
Over-stimulation
Evening is typically a busy time in most households – people arriving home, meals being prepared, televisions on. What registers as ordinary background activity to most people can become genuinely overwhelming for someone with dementia at the end of a long, cognitively taxing day. Notably, the Alzheimer Society also flags the opposite extreme: lack of stimulation or boredom during the day can itself increase restlessness by late afternoon.
Diet and Medications
The Alzheimer Society of BC identifies two additional, often-overlooked contributors: consuming sugar, caffeine, or large meals later in the day can disrupt sleep and worsen sundowning; and the side effects of certain medications may increase confusion, restlessness, or sleep disturbance. If sundowning worsens around the time a medication is due, raise this with your physician.
Unmet Physical Needs
Sometimes what presents as sundowning is a person’s only available way of signaling that something is wrong. Consider whether the behavior could be communicating hunger, thirst, the need to use the bathroom, pain, uncomfortable clothing, or an uncomfortable room temperature.
Underlying Medical Issues
A sudden onset of sundowning – or a marked worsening – should prompt medical attention. A urinary tract infection, dehydration, constipation, new medication, or a sleep disorder can all trigger or significantly amplify sundowning behavior. This is not necessarily a sign of dementia progression; it may be a treatable condition.
5 Strategies to Manage Sundowning
While you can’t cure sundowning, you can often reduce its frequency and intensity. These strategies focus on prevention and creating the right environment for calmer evenings. The following approaches are consistently supported by both clinical guidance and caregiver experience.
1. Maximize Morning Light Exposure
Open curtains fully first thing in the morning, spend time outdoors before 3 PM when possible, and consider a light therapy box (10,000 lux) for 20–30 minutes in the morning. Robust light exposure early in the day reinforces the brain’s circadian signaling, helping distinguish day from night and making the evening transition less abrupt.
2. Manage Lighting as the Day Progresses
“If you notice confusion and agitation start to increase as the sun begins to go down, close the blinds and curtains to reduce shadows and turn on additional lights and lamps to prolong the effect of daylight.” ~The Alzheimer Society
Turn on indoor lights before sunset – don’t wait for the room to dim. Use warm, soft lighting rather than harsh fluorescents, and place night lights in hallways and bathrooms. The Society also notes that while television can be calming for some, it can increase the presence of shadows and may not suit everyone.
3. Establish a Consistent Daily Routine
Predictable structure reduces the cognitive load on a person with dementia. When someone knows what to expect, they expend less mental energy orienting themselves – preserving more capacity for managing emotions in the evening.
Keep wake times, meal times, and activities consistent day to day. Schedule more demanding activities – bathing, appointments, outings – for the morning when energy is highest, and plan quiet, enjoyable activities for the late afternoon window before sundowning typically begins.
4. Be Strategic About Stimulation – In Both Directions
Limit visitors and phone calls after mid-afternoon, lower the television volume, and minimize background noise as evening approaches. At the same time, the Alzheimer Society recommends planning “quiet and relaxing activities just before the person typically begins to show signs of sundowning” – watching a favourite program, looking through a photo album, helping with a familiar household task like folding laundry. Purposeful, calming activity is preferable to either overstimulation or empty, unstructured time.
The Society also suggests an evening ritual – a consistent sequence of calming activities (a cup of decaffeinated tea, soothing music, a gentle hand massage, for example) that cues the body and mind to wind down. Predictable sequences can be quietly orienting for someone who struggles to track time.
5. Address Physical Needs Proactively
Serve dinner earlier (around 5 PM rather than 7 PM), ensure adequate hydration throughout the day, offer regular bathroom breaks, and check for signs of pain or physical discomfort. Avoid caffeine and sugar in the afternoon. Review the medication schedule and note whether symptoms intensify as doses wear off. Meeting physical needs before they escalate into distress prevents many sundowning episodes before they start.
What to Do When Sundowning Happens
Even with the best prevention strategies, sundowning will sometimes occur. When it does:
- Stay calm.
- Anxiety is contagious. Speak in a soft, even tone and keep sentences short and simple. Use calm, grounding phrases: “I’m here with you” or “You’re safe.” Offer a familiar comfort object – a favourite blanket or pillow. Physical touch, if welcomed, can be calming.
- Don’t argue or correct.
- If they insist they need to “go home” even though they are home, trying to convince them otherwise will escalate the situation. Instead, redirect: “Let’s have some tea first” or “Tell me about your home.” Engaging the emotion behind the request rather than the literal content of it.
- Check the basics.
- Run through a mental checklist: Bathroom? Hungry? Thirsty? Too hot or cold? In pain? Uncomfortable clothing?
- Distract and redirect.
- Sometimes the best response is to shift their attention: “Can you help me with this?” or “Let’s look at these family photos together.”
- Know when to step back.
- Sometimes less intervention is better. If you are making the situation worse, take a brief break if another caregiver is available. Tag-team caregiving during evening hours can make an enormous difference.
When to Seek Additional Support
The Alzheimer Society is direct on this point: “Caregiving is a learned skill that takes practice.” It is also not a task designed to be carried alone. Consider seeking additional support if:
- Sundowning occurs daily and lasts three or more hours
- You feel unsafe during episodes
- Your loved one is at risk (wandering, aggressive behavior)
- Your own physical or mental health is suffering
- You can no longer maintain employment or other responsibilities
Options include part-time evening caregivers, adult day programs (which can meaningfully reduce the afternoon fatigue that drives sundowning), respite care, and – when home care is no longer sufficient – memory care.
Frequently Asked Questions
- Does sundowning mean the dementia is getting worse?
Not necessarily. Sundowning can occur at any stage of dementia, though it most commonly peaks in the middle stages. A sudden onset or significant worsening, however, warrants a call to your doctor – it may indicate a new and treatable medical issue, such as an infection, rather than disease progression.
- Can sundowning be prevented completely?
In most cases, no – but it can often be significantly reduced. Think of it like managing a chronic condition: the goal is not elimination but meaningful reduction in frequency, intensity, and duration.
- My parent insists on “going home” every evening even though they are home. What should I do?
This is one of the most common sundowning behaviors. Avoid arguing that they are already home – this tends to escalate distress. Instead, engage the feeling behind the request: “We’ll go in the morning,” “Tell me about your home,” or “Let’s have dinner first.” The Alzheimer Society recommends redirecting toward a calming activity rather than correcting the belief itself.
- Should I wake my loved one from an afternoon nap?
It depends. The Alzheimer Society suggests that if napping interferes with nighttime sleep or appears to worsen evening confusion, limit naps to 30 minutes or encourage skipping them. That said, some individuals benefit from a short early-afternoon rest to reduce overall fatigue. Track the pattern in your specific situation before deciding.
Sources: Alzheimer Society of British Columbia, “Late-Day Confusion (Sundowning)” (October 2020).