Table Of Content

Sundowning refers to symptoms of confusion and agitation that worsen in the later afternoon and evening in people with Alzheimer’s or dementia. Daily physical activity and avoiding triggers may help.

Caregivers may start to notice symptoms of sundowning, also known as sundown syndrome, late in the afternoon, and they may continue throughout the evening.

Experts believe that sundowning might be related to dementia’s effects on the circadian rhythm, the cycle of sleeping and waking.

Learn more about the risk factors and symptoms of sundowning and the ways you can help manage them.

Sundowning can cause a noticeable change in a loved one’s personality and behavior that typically appears in the late afternoon to early evening or around dusk.

Symptoms of sundowning may include:

  • agitation, which can appear as aggression (yelling or resisting)
  • increased irritability
  • anxiety or worry
  • difficulty sleeping
  • increased confusion and disorientation
  • restlessness, which can look like pacing or being unable to relax
  • visual disturbances or hallucinations, such as those triggered by shadows in the dark

Sundowning is experienced most often by people with Alzheimer’s disease or other types of dementia, such as Lewy body dementia.

However, not all people with dementia will experience sundowning. According to a 2023 study involving 184 people with Alzheimer’s and dementia, 21.2% of participants experienced it.

In the study, those who experienced sundowning typically:

  • were older
  • had later-onset dementia
  • had more severe impairment due to dementia
  • woke more often during the night
  • had more hearing loss
  • used anticholinergic and antipsychotic medications rather than memantine (Namenda)

However, biological and environmental factors may play a role.

One theory suggests that brain changes brought on by Alzheimer’s or other dementias may interfere with a person’s circadian rhythm. The circadian rhythm is like the body’s clock, regulating a person’s sleep-wake cycle, hormones, digestion, and other functions.

A review of research from 2022 suggests that factors like insufficient natural light exposure may increase the likelihood of sundowning. However, the researchers noted a need for more research on whether it may be more related to disrupted circadian rhythm or difficulties with image forming.

Melatonin is a hormone that regulates the sleep-wake cycle and is used in the circadian rhythm. It often decreases naturally with age.

A 2019 study suggests that people with Alzheimer’s disease, even in the early stages of the disease, may have low levels of melatonin secretion in the evening. Low levels of melatonin can make it harder to fall asleep.

One 2020 study suggests that sundowning may be more tied to emotional disruption rather than just sleep disturbance. Emotional disruption can also be tied to the circadian rhythm. The authors note further study of the circadian system may increase understanding of sundowning and help determine better treatment options.

There are multiple factors that can contribute to sundowning. These may include:

  • environmental overstimulation (too much noise, crowds, bright lights)
  • certain medications (including antipsychotics and antidepressants)
  • too little light
  • having a sleep disorder
  • having a mood disorder, including depression
  • having chronic pain
  • boredom
  • hunger
  • body temperature changes

Multiple factors likely contribute to an episode of sundowning, so it may take experimenting to find changes to a person’s schedule or lifestyle that make a difference.

For example, a 2020 study involving 46 Alzheimer’s patients in China suggested that 30-minute morning or afternoon walks can significantly reduce sundowning behaviors.

Another generally safe and well-tolerated treatment is light therapy. Exposure to natural light in the morning can help maintain a person’s circadian rhythm.

Some strategies may potentially help manage and prevent sundowning.

Strategies that may prevent sundowning

  • getting enough rest
  • scheduling activities and appointments earlier in the day
  • maintaining a routine of getting up, eating meals, and going to be around the same time each day
  • getting natural light during the day beside a window or outdoors if possible
  • reducing stimulation, like bright lights, TV, or loud music, in the evenings
  • doing soothing or relaxing activities in the evening
  • keeping the room well-lit but not bright, and closing blinds to minimize shadows, which can cause confusion

Things to avoid to help manage sundowning

  • drinking caffeine later in the day
  • drinking alcohol and nicotine
  • having an overly busy schedule
  • taking longer naps later in the day
  • having large meals in the evening, which can disrupt sleep

If someone is experiencing sundowning and becoming agitated or aggressive, the National Institutes of Health (NIH) recommends calmly listening to the person’s concerns and providing reassurance. You can try to distract them with their favorite activities or a different subject.

But if they become aggressive, you may need to keep your distance for your own safety until the behavior stops or contact emergency services.

Read more tips for reducing sundowning.

Medical treatment of sundowning may involve medication. This can include medications and supplements to treat or prevent symptoms of sundowning or to address another health condition that may be contributing to sundowning.

A doctor may also recommend taking a certain medication at a specific time of day if it causes side effects that may contribute to sundowning symptoms.

Melatonin

Melatonin may help support an individual’s sleep-wake cycle and allow them to fall and stay asleep.

The average starting dose is 3 milligrams (mg), but note that melatonin should be taken about an hour before bedtime, not right before the person tries to fall asleep.

Always talk with a doctor before taking any new supplements or giving them to a person with Alzheimer’s or dementia.

Read about our picks for which melatonin supplements to try.

Other medications

Prescription medications for Alzheimer’s or dementia symptoms may be helpful in treating sundowning symptoms or underlying conditions that affect it.

Certain medications may have side effects that are too high risk for some older adults. They may also interact with medications the person is already taking.

Consult a doctor if you think your loved one might benefit from medication changes, and make sure the doctor is aware of all current medications your loved one is taking.

Cannabinoids

Cannabinoids are compounds found in the Cannabis sativa plant that naturally contains around 540 chemicals. The most common cannabinoids used from the plant are tetrahydrocannabinol (THC) and cannabidiol (CBD).

Cannabinoids have shown some promise in helping manage symptoms of dementia. However, more trials are needed to support their effectiveness and safety. Cannabinoids may potentially interact with neurotransmitters involved in neuropsychiatric symptoms, such as memory loss, disorientation, and moods.

A 2019 research overview summarized that 4 out of the 12 studies the authors examined found medical cannabis treatment significantly improved “a range of neuropsychiatric symptoms associated with dementia.” The remaining 8 studies did not find any evidence to suggest it was effective.

Because sundowning happens at the end of the day, it can be difficult to manage for loved ones or caregivers who may be overtired.

If sundowning occurs every day, or if symptoms get more severe, it may indicate that dementia or Alzheimer’s is getting worse.

If sundowning becomes too much for a spouse or other caregiver to handle, they may consider a change in living or caregiving arrangements. Being in a more secure, monitored environment could also be beneficial for their safety.

Deciding to change your loved one’s living arrangements can be emotional and overwhelming, and it may be financially difficult. Reach out to family and friends for support, and stay in regular communication with your doctor about recommendations.

If possible, consider seeing a therapist to help cope and have a safe space to talk.

Read more about how to care for yourself if you have caregiver burnout.

Sundowning is a set of behaviors in the late afternoon and evening primarily seen in people with Alzheimer’s disease and dementia. Symptoms may include increased:

  • agitation
  • confusion
  • disorientation

Research on sundowning is ongoing, and the relationship of dementia symptoms to the circadian rhythm is one promising avenue.

Watching a loved one experience sundowning can be difficult and upsetting. For some caregivers, managing sundowning at the end of a long day may contribute to burnout.

However, making adjustments to some environmental, health, and lifestyle factors may help better manage and prevent the symptoms.

Talk with your loved one’s doctor if you witness new or worsening dementia symptoms or if you’re having difficulty managing a home care routine.