Understanding Sundown Syndrome

By Dr. Catherine Madison, Neurologist at Seniors At Home’s Center for Dementia Care

“Sundowning”, or sundown syndrome, is a common condition that affects up to 80% of people with dementia at some point in the course of their illness. Patients with dementia who sundown become confused and agitated in the late afternoon and evening hours, and occasionally throughout the night.

Senior with caretaker

People who sundown often have trouble sleeping. Instead of resting, they may pace the floor, wander, yell, or become combative. They may also become forgetful, confused, agitated, anxious, or restless.

If you have a loved one who experiences sundowning, learning more about this behavior and what can trigger it may help you help you manage their episodes.

What Causes Sundowning?

The causes of sundowning are not well understood. Some research suggests that sundowning may be related to changes to the brain’s circadian pacemaker, the cluster of nerve cells that keeps our body on a 24-hour clock. Studies in mice suggest that chemical changes in the brain that are characteristic of Alzheimer’s disease may play a role as well.

Sundowning typically peaks during the middle stages of Alzheimer’s and symptoms improve as the disease progresses.

Factors that may increase the risk of sundowning include:

  • Pain
  • Severe constipation
  • Poor nourishment
  • Being on too many medications
  • Infection
  • Noisy and disruptive sleeping environment

Coping Strategies for Sundowning

Sundowning syndrome may prevent people with dementia from sleeping well. It may also make them more likely to wander. Because of the stress it puts on caregivers, sundowning is also a common cause of caregiver burnout.

Here are some suggestions to help you cope with a loved one who is sundowning:

  1. Maintain a schedule
    As much as possible, encourage the person with dementia to adhere to a regular routine of meals, waking up and going to bed. This will allow for more restful sleep at night.
  1. Modify the timing of activities
    A person who rests most of the day is likely to be awake at night. Being more active during the day may help Alzheimer’s patients sleep better in the evening hours. Discourage daytime naps if possible, and encourage exercise, like walking, but no later than four hours before bedtime. Plan doctor appointments, trips, and bathing in the morning or early afternoon.
  1. Encourage a healthy diet
    Reduce their intake of nicotine and alcohol, and limit caffeine and sugar to the morning hours. Offer them a large meal at lunch and keep the evening meal early and simple. Keep snacks light before bedtime.
  1. Practice light therapy
    Keep the home well-lit in the evening to reduce the agitation that occurs when surroundings are dark or unfamiliar. Exposure to bright light, including the sun, during the day may reduce some sundowning symptoms, especially when used in combination with exercise, like walking.
  1. Provide calm reassurance
    Caregivers should gently help their loved ones remember where they are and what time it is. Avoid arguing if they cannot find your reality and offer reassurance that they are OK.
  1. Seek medical advice
    A doctor can look for physical problems like pain, infections, or bladder problems that may be contributing to nighttime confusion and agitation. They should also regularly review prescription medications to make sure they are still needed.
  1. Arrange a positive sleeping environment
    Allow the patient to change bedrooms or to sleep in a favorite chair or couch. Keeping the room partially lit may also help to reduce confusion when the person wakes during the night. The person’s sleeping area should be at a comfortable temperature. Provide nightlights and other ways to keep the person safe, such as appropriate door and window locks. Door sensors and motion detectors can be used to alert family members when a person is wandering, as can safety systems.
  1. Limit environmental distractions
    Particularly during the evening hours, distractions such as television, chores, or loud music should be avoided.

Sundowning can be a distressing experience for the person with dementia and their loved ones.

Remember, Seniors At Home is here to help. Our Center for Dementia Care offers support and expert advice for coping with sundowning and other issues experienced by people with memory loss. We’re all in this together!