What is ‘Sundowning?’

carer hand holding elder hand in hospice care

People who have spent a great deal of time with those with Alzheimer’s disease begin to notice behavioral patterns that are common between them.

One of the most commonly recognized behavioral patterns associated with dementia is confusion, agitation and aggression associated with the late afternoon when the sun is setting. This phenomenon is known as sundowning and has been well-recognized within the medical and healthcare setting as well as in the literature in the fields of neurology and brain health.

Understanding what sundowning is and when and why it happens can help the caregivers, family members and loved ones of people with dementia to cope with this behavior, to promote the comfort and wellness of those they care for and develop strategies to combat unwanted behaviors.

Elderly man

Behavioral Aspects of Sundowning

Sundowning is a distinctive behavioral pattern that many people with Alzheimer’s exhibit. Typically, sundowning occurs exactly when it sounds like it would: at the sunset hours, between 4 and 6 p.m. in most states.

It has been referred to in some areas of the literature as “late-day confusion.”

Most behaviors typical of sundowning are related to an increase in confusion that has been found to occur in many dementia patients at this time of day. Some may be interpreted as cries for attention or frustration at not being understood or unable to communicate one’s desires: yelling or calling out, grabbing or pushing or wandering.

An older adult with dementia who acts untrusting or suspicious at sunset should be suspected to be sundowning, as these are common behaviors. It may also present as a person who is being unreasonably demanding, untrusting, restless or irritable.

Causes of Sundowning

Although it is a well-known phenomenon, doctors and the research community within medicine are not entirely clear why sundowning happens.

Some have suggested the confusion and disorientation that result in sundowning are from changes in the brain and neurochemistry related to our circadian rhythms, or internal body clock.

By this theory, the area of the brain that tells you when you are awake or asleep breaks down and no longer transmits the signals indicating what time of day it is. This can mean the person who is sundowning no longer understands the time of day, why they are where they are and what they should expect to happen next.

Treating any disturbances to the circadian rhythms and establishing regular routines is one intervention that has shown a great deal of efficacy in treating sundowning syndrome associated with dementia. This includes strategies such as maintaining similar sleep and waking times throughout the week, regular mealtimes and even the use of sleep aids.

Smiling female nurse playing cards with senior man at nursing home

How to Reduce Sundowning Behavior

As with all aspects of dementia care, sundowning behavior can be reduced or eliminated. This is both less stressful for the client or individual as well as easier to deal with for the caregivers or family members. Reducing this behavior means less stress for all parties involved.

The presence of a supportive and caregiving companion or other person in the home consistently at the time of day when people with dementia are most likely to be affected by sundowning can help mitigate its effects. This could be a family member, friend, loved one or a professional caregiver from a dementia home care service. Consistency is key to eliminating sundowning behavior.

Similarly, there is the theory that excessive stimulation can cause or worsen symptoms of sundowning. Because of this, one other intervention that has shown some efficacy is reducing environmental stimuli for the patient. This could include noise reduction, elimination of harsh lighting and similar interventions.

Some healthcare and caregiving professionals have found that providing distracting activities or entertainment can help prevent sundowning from occurring in the first place. Offering to play a card game with a senior with dementia, offering an art project, watching a television program or providing group-based activities are all great ways to distract from boredom or confusion that may perpetuate sundowning. 

Some people have reported that including a late afternoon nap can reduce this behavior. This may be a strategy that is worth trying on a case-by-case basis. However, if a senior with dementia falls asleep and wakes up confused or disoriented, it may also exacerbate the confusion and resultant unwanted behaviors.

Using a great deal of patience, a calm voice and consistent redirection can go a very long way toward calming and soothing your loved one.

If Sundowning Happens Anyway

Sundowning behaviors may occur despite attempts to reduce them through appropriate and timely interventions that are tailored to the individual. A person with dementia may yell, attempt to escape, hit or otherwise act aggressively. Luckily, there are methods to coping and managing these behaviors to keep caregivers and elder both in a safe environment.

Stacey Warren