Sundowning: Causes, Symptoms, & Tips for Caregivers

When your loved one receives a diagnosis of Alzheimer’s disease or another type of dementia, you quickly learn that the condition affects more than just memory. For many people living with dementia, anxiety, confusion, agitation, and restlessness are increasingly more common occurrences throughout the day. This can be worrisome and frustrating for family caregivers.

If your loved one is experiencing increased agitation and confusion in the late afternoon or early evening hours, they are likely experiencing Sundown Syndrome. Here’s what you need to know in order to best care for and support them during this time of day.

What Is Sundown Syndrome?

The term Sundown Syndrome is sometimes used to describe a set of symptoms that arrive in the late afternoon or early evening hours for those living with dementia. Sundown Syndrome, sometimes also referred to as sundowning, can be challenging for the person living with dementia and their caregivers.

Sundowning is most common from dusk to night, with symptoms typically starting around 4:00 PM. However, family caregivers might notice restlessness starting as early as mid-afternoon, with symptoms peaking around dinner.

Sundowning can happen at any stage of dementia, though it is typically most prevalent during the middle stage of the disease. While there is not currently a cure for dementia or for sundowning symptoms, physicians can prescribe medications that can take the edge off the anxiety that seems to spur the rest of the sundowning experience.

The Link Between Dementia and Sundowning

The exact cause of Sundowner Syndrome is unknown, and it doesn’t affect everyone living in the middle stage of dementia. However, professionals in the field link changes in the brain due to dementia as the main factor in the condition. Further, dementia causes disruptions to the body’s natural circadian rhythm, or our “internal clock.” This can cause people living with dementia to be confused about when to wind down for the evening and when to ramp up for the day.

Other factors that might contribute to sundowning can include:

• Low light in the evening hours can cause more shadows and dark corners of the home, which can be difficult to discern. This can cause increased confusion and anxiety.
• The exhaustion from navigating the world with cognitive decline all day long comes to a close in the evening, which can cause the person to feel more stress.
• Sleep disruptions and/or inconsistency with sleeping schedules and habits
• Medication side effects

Recognizing Sundowning Symptoms

Just like dementia, sundowning can look different from person to person. However, there are some common symptoms that you can keep an eye out for:

• Increased confusion and disorientation

Seniors who are sundowning can become more confused than usual, perhaps worrying about missing their school bus or picking up their husband from work.

• Agitation, restlessness, pacing, or wandering

Even the calmest senior can begin to show signs of agitation during Sundown Syndrome. Examples include pacing, wringing hands, yelling out, cussing, and even hitting or poking.

• Repetitive questioning and/or emotional outbursts

This is the most frustrating symptom for most family caregivers, as it is exhausting trying to field the same question over and over again. Seniors can also be extra emotional and not easily consoled during this time.

• Difficulty winding down, sleeping, or eating

It is no surprise that all this restlessness, anxiety, and emotion can make eating dinner or getting ready for bed nearly impossible. It is common for those who experience Sundown Syndrome to struggle with getting to sleep and with eating.

• Increased fear or doom

Finally, sundowning is often accompanied by a feeling of fear or impending doom. This can create a fight-or-flight instinct in most seniors, which can lead to bouts of aggression.

What Causes Sundowning?

Again, no one knows for certain what causes sundowning or why it happens typically during the middle stages of the disease. However, there is some research that shows how the environment can lead to exacerbation of symptoms:

• Increased physical and mental fatigue
• Changes in lighting, including more shadows and dark corners
• Inability to express needs, such as being hungry, thirsty, or in pain
• Medication side effects
• Overstimulation from the day

When Does Wandering Typically Begin?

Wandering, or walking without purpose or destination, is a hallmark of dementia that can lead to serious safety concerns. The Alzheimer’s Association reports that 60% of people living with dementia will wander at least once, which means it is one of the most common side effects of dementia. Similar to sundowning, wandering typically comes during the middle stages of the dementia process. 

Seniors who wander can often do so in order to search for a familiar face or location. They may wander, looking to return home or to go to their job, which they had decades ago. Wandering is also thought to be a way to cope with feeling worried, anxious, or physically uncomfortable.  

Safety Concerns with Wandering

Wandering is dangerous as seniors can find themselves without seasonally appropriate clothing, without food and drink, and without a friendly face to help them safely home. Perhaps the most concerning issue with wandering is that the first time it happens, the senior and their family members are often unprepared. Mom might leave to walk to the grocery store down the block, which she has done hundreds of times before, and end up confused and lost, blocks away from her destination. This is scary for the senior and their loved ones.

Perhaps the easiest strategy to prevent this first-time wandering scare is to get your loved one attached to a GPS tracking-enabled device as soon as they have a dementia diagnosis. This might be an Apple Watch or a smartphone with the Life360 app activated or a medical alert device with GPS capabilities. Knowing that you can check in on your loved one and give exact location details to first responders if needed can give everyone peace of mind.

As your loved one moves through the dementia process, it is imperative to incorporate safety planning and wandering prevention strategies into their daily life. This might include door locks, alarms, and increased oversight by a visiting caregiver.

Environmental Approaches to Reduce Sundowning

There is no cure for sundowning, but there are strategies you can use to keep your loved one as safe and as comfortable as possible. Some of these ideas might work for you, while others might need to be adjusted to meet your loved one’s needs and preferences.

Daytime Strategies

Sundowning prevention begins long before those evening hours arrive. Set your loved one up for success by focusing on healthy habits and routines during the daytime hours:

• Get outside as often as possible, focusing on taking multiple walks throughout the day, no matter the weather
• Open the curtains early in the morning to help with time orientation
• Spend time outside during the day. Try having coffee on the patio, gardening after breakfast, or listening to the birds before lunch
• Reduce caffeine intake, and stop drinking caffeine after noon
• Stay physically active, encouraging at least one walk and one other physical activity throughout the day (chair exercise, dancing, etc.)

Evening Strategies

The evening hours should be much quieter and calmer than during the day. Focus on a routine that is built around cues that it is time for the body and mind to wind down.

• Close curtains and turn on soft lamps when it becomes dusk
• Turn on soft, calming, familiar music
• Avoid the television, especially programs that can enhance anxiety (like the news)
• Offer activities that keep their hands busy, such as folding towels, matching socks, wiping down the kitchen counters
• Remain calm, even in the face of repetitive questions or other distractions. If you are angry or frustrated, the senior will notice and become more anxious
• Try diffusing calming scents, such as lavender
• Give your loved one a relaxing hand massage with a lavender-scented lotion

Behavioral and Routine-Based Strategies

In addition to a supportive environment, a consistent routine can help to prevent sundowning or lessen the symptoms.

Establishing Daily Structure

Here are some routines and rhythms to encourage a busy and productive day, which can help for a calmer evening:

• Establish a consistent wake-up time and routine. Avoid lounging in bed for hours after waking, instead getting up and starting the day
• Drink plenty of water
• Limit naps, especially after 2pm. In fact, avoid naps altogether when possible.
• Plan a busy morning, incorporating more complex tasks or outings before lunch when possible
• Have anchor points throughout the day: wake up, coffee outside, breakfast, walk, morning newspaper, prepare lunch, eat lunch, get the mail, etc.

Creating Calming Evenings

Sundowning can make a calm evening seem impossible, but keeping your loved one busy in a peaceful environment can make a big difference in their agitation and restlessness.

• Skip leaving the house in the late afternoon and evening hours, when possible
• Don’t invite a lot of people over in the evenings
• Focus on keeping busy. Get your loved one involved in helping prepare dinner and cleaning up. Try activities like sorting or matching.
• Singing along to favorite music can be a wonderful way to regulate everyone’s nervous system

How to Respond When Sundowning Occurs

When you are caring for a loved one who is showing signs of sundowning, it can be frustrating. Remember to remain calm and pleasant. 

Stay Calm and Validate

Your attitude sets the tone for how your loved one responds and acts. When possible:

• Take a deep breath before responding to their question or behavior
• Validate their feelings (“I can tell you’re frustrated, mom, and that is ok…”
• Don’t argue or correct them. It doesn’t do anyone any good to tell them that they don’t need to find their school bus stop because they are 80 years old. They will not remember this fact due to their dementia, and it is unnecessarily cruel to upset them over and over.
• Be patient and reassuring

Redirect Gently

Redirection to a productive and easy activity can help to decrease their pacing, restlessness, and agitation:

• After validating, move to a new activity (“Mom, can you help me with the laundry? Fold these towels, please.”
• Give short, one-step directions
• Reset the activity if they finished it and are looking for another way to stay busy
• Have a snack and drink out on the counter, and direct them toward that

Use Soothing Touch and Comfort

Body language can go far when it comes to calming your loved one and being a reassuring presence.

• Hold their hand when you take a walk
• Offer a hand massage or back rub
• Offer a hug
• Offer a cozy blanket or slippers
• Sometimes, a soothing touch can be active. Manipulating zippers or buttons on a busy board or pillow can be calming for some.

Tips for Caregivers

Here are some of our favorite tried-and-true tips that can encourage busy days and calm evenings. Remember, not all of these will work for everyone. Use these tips as something to try and then adjust them for your loved one’s needs now and as they change.

Managing Daily Challenges

When possible, look for cues that sundowning behaviors are about to start. For example, does your Dad get anxious every afternoon around 5pm? Knowing this can help you prepare emotionally for what is to come, as well as to tinker around with the environment to see if you can prolong the onset of symptoms.

Other tips for managing the onset of symptoms can include:

• Have a heavier snack before symptoms begin, especially if your loved one is too restless to eat dinner
• Set the stage with a calm, peaceful environment before sundowning symptoms begin
• Make sure you are offering a way for your loved one to get plenty of physical exercise and movement during the daytime hours

Communicating with Compassion

Telling your loved one that their reality is false is ineffective and cruel. Instead, join in their reality by validating their emotions and redirecting them to another topic of conversation or activity. You might say, “I know how much you love your Mom. Tell me more about her.”

Other tips for communicating during sundowning include:

• Body language will say more than words during this overstimulating time. Don’t point your finger, cross your arms, or use other aggressive body language. Instead, keep your arms at your side, smile, and take a deep breath before speaking.
• Use photos to start conversations
• Keep a calming, familiar music soundtrack playing in the background

Self-Care for Caregivers

Sundowning symptoms can be challenging and scary for the senior as well as the family caregiver. In order to remain as peaceful and helpful as you can, it is crucial that you schedule time away from your caregiver role. You deserve to take care of yourself before you take care of others.

• Schedule respite care through home health or senior living communities near you so that you can take time off, and your loved one will still be cared for
• Drink plenty of water and eat healthy foods
• Prioritize exercise daily, even if it is just a short walk around the block
• Get outside daily
• Make an appointment with a counselor who has experience with family caregivers
• Tell your physician about your caregiving role; they need to know that about you in order to best support you
• Ask for help, whether that is from family members, neighbors, friends, or support services
• Attend a family caregiver support group

When to Seek Professional Help

The middle stage of dementia is perhaps the most challenging for family caregivers. It is never too early to begin looking for professional support for when your loved one reaches this stage.

Signs It’s Time for Memory Care

Memory care communities are senior living residences that specialize in providing care for adults living with Alzheimer’s disease or another type of dementia. These communities are designed to combat the challenges that can come with cognitive decline, keeping residents safe, comfortable, and healthy.

It might be time to begin looking for memory care support for your loved one if you notice any of these signs:

• Decreased appetite or recent weight loss
• Increased bouts of wandering or other unsafe behaviors
• Sleep disruptions that are affecting the senior or the family caregiver
• Escalating aggression or agitation
• Needing more assistance performing activities of daily living

Benefits of Professional Memory Care

Choosing a memory care residence can mean peace of mind for both your loved one and your family. Hallmarks of expert memory care senior living include:

• Around-the-clock caregiver oversight and assistance
• Staff trained in dementia care interventions and strategies
• Safety measures are in place that do not take away from dignity or independence
• Communication with the physician, pharmacist, and other members of the medical team

At Legend Senior Living, our memory care residences provide all of this and more. Stop by a memory care residence near you to learn more about our approach to dementia care, meet our care team, and ask any questions you might have.