A physician explains ‘sundowning’ and how families can help loved ones with the behavior associated with dementia.

Published: August 28, 2020 | Updated: January 31, 2023

If you or a loved one has been diagnosed with Alzheimer’s disease or dementia, you may have heard the term “sundowning.” The term refers to a state of confusion occurring in the late afternoon and spanning into the night. While the exact cause of sundowning is unknown, health care providers are learning more about the condition. Brandon C. Dennis, Psy.D., neuropsychologist with Norton Neuroscience Institute, answered some common questions about the behavior.

What is sundowning or sundown syndrome?

Sundowning is a group of symptoms where patients with dementia have behavioral disturbances that seem to get worse over the course of the day. They’re usually the worst in late afternoon or early evening.

What are the signs of sundown syndrome?

The signs of sundowning can go anywhere from increased confusion to more agitation and irritability to sometimes increased motor activity. Wandering is common as the disease progresses. Other behaviors associated with sundowning include delusions, false beliefs or even hallucinations — seeing or hearing things that aren’t there.

Does sundowning explain why people with dementia sleep a lot or don’t sleep well?

With dementia, circadian rhythm disturbances — arousals, awakenings, less slow-wave or deep sleep — that are a part of normal aging become more prominent, and they’re more disabling. It’s a change in the actual sleep architecture, which is something that’s regulated by the brain. In other words, the issues in the brain causing changes in dementia also are disturbing sleep.

A health care provider will want to make sure sleep apnea, restless legs syndrome or some other medical condition like chronic pain isn’t interfering with sleep or causing agitation later in the day.

How common is sundowning among those with dementia?

I would say anywhere from two-thirds to 75%. It’s pretty common.

What medications are used for sundown syndrome?

The problem with sleep medications is they impact the brain and also can cause side effects for other cognitive functions. They can, especially in patients who already have a thinking disorder like dementia, make things worse.

There have been several controlled trials for new drugs, and there is some promise, but they may not be as effective as we hope.

How can a loved one deal with sundowner syndrome?

As sundowning is behavioral, cues in the home and environment that can stimulate a regular sleep-wake cycle are most likely to help. Natural light, for example, is the most important cue. Having lights on — keeping the home well-lit — helps the person stay oriented.

Physical activity and making sure they’re up and doing things to wear themselves out will help them sleep.

Meals are something that we don’t think often about, but they really set kind of the bookends of our day. A steady and consistent routine will help set the course for the day and into bedtime.

We see patients with dementia tend to deteriorate more rapidly when they are socially isolated. When you have regular social interactions, when you have a regular schedule, when you have activities, visits and things to keep that schedule going, things tend to go better.

For patients living in a facility such as nursing care or assisted living, changes in staff can be disruptive. Sometimes working with the facility or the staff to kind of minimize those disruptions and keep them on a routine schedule can help.

What safety measures should be taken to protect a sundown patient?

Make sure a door can’t be opened from the inside in the case of wandering. Cameras, motion sensors and other security devices can be inexpensive and very useful in alerting you when the patient is up and about.

Are there resources to help families with sundowning?

Having a family member with sundowning can be very frustrating for everyone involved. Families aren’t alone. There are some great resources through Norton Healthcare, including the Norton Neuroscience Institute Resource Center, the Alzheimer’s Association and others. The patient’s primary care physician is a great resource to make a referral for more assistance with those kinds of things.