Sundowners syndrome: causes and coping strategies for caregivers

If you’re caring for a loved one with dementia, you know there can be highs and lows throughout the day, but your love and care carries throughout. You may notice though that sometimes the lows or challenges might come at a certain time of day.

This is sometimes referred to as sundown syndrome, and it’s something that can occur with people who have dementia.

What is sundown syndrome?

Sundown syndrome, sometimes called sundowner’s syndrome, affects many older adults in the middle to later stages of Alzheimer’s disease or dementia. It can cause confusion, agitation, and overwhelming sadness. Symptoms often become most troubling in the late afternoon, evening, or nighttime as the sun begins to set, which is where the name comes from. When these feelings and behaviors appear, it’s called “sundowning.” The symptoms can be confusing, frustrating, and exhausting for the person living with dementia and anyone supporting them.

The exact cause of sundown syndrome isn’t known. Some doctors believe it results from overwhelming sensory stimulation during the day. Others suspect a hormonal imbalance, while another hypothesis suggests that Alzheimer’s disease affects the area of the brain involved in the normal day-night cycle. Although sundowning is connected to Alzheimer’s disease and dementia, the medical community hasn’t reached a consensus about its precise causes.¹

We do know that conditions such as depression may worsen sundowning symptoms, leading to emotional changes that affect people living with dementia, their family members, and their caregivers. Fortunately, there are ways to manage sundowning symptoms and reduce some of this stress.

What are the symptoms of sundown syndrome?

Sundowning usually occurs in the late afternoon or early evening, and its behavioral symptoms may be easy to notice, especially when they’re out of character for your loved one. According to the Alzheimer’s Association, sundowning behaviors can include restlessness, agitation, frustration, anger, or increased confusion.

Some people may pace the room repeatedly, while others may have trouble sleeping. These behaviors can feel frightening and frustrating for family caregivers, especially when they happen at the end of a long day filled with other responsibilities.

What causes or triggers sundowning behaviors?

Sundowning symptoms, most often associated with Alzheimer’s disease or other forms of dementia, appear as the day progresses and may become more noticeable as the sun goes down. The timing can depend on your loved one’s circadian rhythm. This internal body clock may influence when they begin experiencing confusion or depression.

Several risk factors can make sundowning symptoms worse:

• Fatigue, lack of sleep, or other sleep disturbances

• Too much stimulation or activity later in the day

• Internal or hormonal imbalances

• Low light and longer periods of darkness during the winter months

• Unfamiliar routines, disorienting situations, or stressful environments

How to manage sundowning symptoms

If you’re supporting someone who experiences sundowning, planning around their daily routine, moods, and most difficult time of day may help. The goal is to remove triggers and conditions that can worsen symptoms. Although you can’t always prevent sundowning, research suggests that several strategies may help you manage the symptoms:

• Reduce caffeine and alcohol: Avoid alcohol and caffeine after the evening meal so your loved one is more prepared to sleep when bedtime arrives.

• Improve sleep habits: Establishing a bedtime routine may help ease symptoms by making your loved one feel more comfortable and calm before falling asleep. Focus on minimizing sleep disturbances and other issues that interfere with rest.

• Provide light: Consider using a light box or nightlight to keep your loved one’s room gently lit as the house gets dark. Clear, soothing lighting may reduce confusion associated with dementia and help your loved one feel safer in their bedroom at night.

• Offer comforting objects: Surround your loved one with familiar objects before bedtime, such as favorite books, photos, soothing music, or a well-loved movie. These meaningful objects and experiences may offer comfort during a difficult time, connect them with memories, calm their nerves, and help them feel more secure.

• Limit stimulation in the late afternoon and early evening: Create a calming afternoon and evening routine that limits exposure to too many people, activities, or other sources of stimulation.

• Seek medical attention: If you’re concerned about a loved one and aren’t sure how to manage their sundowning symptoms, talk with a doctor about possible underlying conditions that may be disrupting sleep or increasing agitation at night. Ask whether unmet physical needs, including diet, vision, or hearing concerns, could be contributing. The National Institute on Aging also recommends reviewing medications systematically with your loved one’s doctor to make sure prescriptions aren’t contributing to the symptoms.²

The important thing to remember is that although you can’t “fix” sundown syndrome, you can use strategies that may ease anxiety and depression. A calm, predictable daily routine can provide reassurance for your loved one and greater clarity for everyone supporting them.

Common questions about sundown syndrome

Here are some common questions and answers about sundown syndrome:

When does sundowning occur?

As the name suggests, sundown syndrome symptoms occur in the late afternoon and early evening.

At what stage of dementia does sundowning usually begin?

Every person experiences the progression of dementia differently, but sundown syndrome generally begins in the middle or later stages of dementia, according to the Alzheimer’s Association. About 20% of people with Alzheimer’s experience sundowning.

Does sundown syndrome go away?

Generally, sundown syndrome can’t be cured, but symptoms may come and go as caregivers learn how to manage them for their loved one. As a person moves through different stages of dementia, sundowning may also become a less pervasive part of how the disease presents.

Can sundown syndrome be cured?

Sundown syndrome isn’t curable, but caregivers can take steps to reduce the severity of its symptoms. Review the strategies above to help create a calmer routine and manage potential triggers.

Where can I find resources for managing sundown syndrome?

The trusted organizations below offer more information and practical guidance for coping with sundown syndrome.

• National Institute on Aging: Offers information about scientific studies and resources for caregivers managing sundown syndrome.

• Alzheimer’s Association: Provides a helpful library organized by stages and behaviors.

• Mayo Clinic: Shares an overview of helpful practices for sleep habits for people living with dementia.

• Family Caregiver Alliance: Offers a helpful resource for caregivers who need emotional support or guidance while caring for someone living with dementia.

• Cleveland Clinic: Provides an overview of the differences between delirium and sundowning symptoms, which may help caregivers distinguish between the two.︎