What is Sundowning?

'Sundowning' refers to increased confusion, restlessness and agitation that often occurs in the late afternoon or evening among those living with dementia. At KYN, our specialist dementia team is experienced in identifying sundowning symptoms and implementing strategies to minimise distress.

In this guide, we explain what sundowning is, its causes, and when it happens in the dementia journey. We’ll also explore how to manage it through holistic, compassionate dementia care.

What is Sundowning in Dementia?

The term 'sundowning' describes the emergence or worsening of certain symptoms of dementia in the late afternoon, evening or nighttime. These symptoms are usually characterised by confusion, anxiety and agitation.

Often, sundowning is accompanied by disorientation, meaning the individual may not understand where they are. For example, they may ask to go home, go to work or to pick their children up from school.

Sundowning can develop at any stage of dementia, and anyone living with any form of dementia can experience it. However, it most often occurs towards the later stages of the illness.

What Causes Sundowning in Dementia?

While not fully understood, sundowning may result from a combination of factors, including:

• Fatigue - cognitive function worsens naturally at the end of the day as tiredness sets in. This is the case for everyone, but for those living with dementia, it can exacerbate symptoms such as confusion.
• Unmet needs - pain, which often worsens in the evening, may sometimes trigger sundowning, as can other unmet needs such as hunger and thirst.
• Disrupted circadian rhythms - Dementia can impair the biological clock that regulates sleep/wake cycles.
• Low lighting - Poor vision combined with dim evening light can make navigation harder, increasing disorientation.
• Overstimulation during the day - The transition from day to nighttime environments and activities can sometimes be a trigger for sundowning.
• Medication timing - Some medications prescribed for symptom management may wear off towards the end of the day, or produce side effects in the evening.

Sundowning can be difficult for both individuals living with dementia and their families, and requires sensitive support strategies. Understanding the causes can help inform care.

What are Some Examples of Sundowning Behaviours?

Every individual living with dementia is unique; not everyone will experience sundowning, or experience the same symptoms. However, some typical signs of sundowning include:

• Difficulty recognising familiar places and people - The person may mistake their own home or long-term care community for a different place, or fail to recognise close family and friends.
• Confusion and disorientation - The person may become displaced in space or time. For example, they may believe they need to catch a train or go to school, or ask to see their parents.
• Walking, pacing, rocking or repetitive movements - The person may get up and walk around, or pace repeatedly around a room or hallways. They may demonstrate repetitive motions like wringing hands.
• Shadowing caregivers - The person may wish for constant company, and may follow a loved one or carer around, often calling their name to seek reassurance.
• Delusions, hallucinations and paranoia - The person may see, hear or believe things that are not real.
• Shouting or screaming - This may occur for no clear reason or in response to hallucinations. The person may make loud repetitive statements or shout and call for help.
• Severe agitation - Increased agitation and mood changes can lead to behaviours like grabbing, hitting, pushing or throwing objects.

At KYN, our specialist nurses and carers receive full training in dementia, including assessing and recognising sundowning triggers and personalised management approaches.

In What Stage of Dementia Does Sundowning Occur?

Sundowning behaviours can occur at any point during an individual’s dementia journey.

However, it usually emerges in the middle to later stages, once the symptoms of dementia have progressed to include:

• Significant memory problems
• Impaired communication skills
• Inability to independently follow multi-step directions
• Getting lost in once-familiar places
• Needing significant help with planning, organising and decision-making
• Difficulty recognising loved ones
• Withdrawal from social situations
• Low stress tolerance leading to agitation

Any individual living with dementia may experience sundowning, regardless of the underlying cause. For example, it may affect those diagnosed with Alzheimer’s disease, vascular dementia and Lewy Body dementia, among others.

How Long Does Sundowning Last in Dementia?

, sundowning will occur at the same time each day and will last for a few hours. It normally begins during the late afternoon or evening, once the sun has started to set, as the name suggests. In some cases, it may begin later at night. It often comes on suddenly, and may affect the individual’s ability to sleep at night.

How Is Sundowning Treated?

Sundowning, typically, only lasts a short time and can resolve on its own by morning following a period of sleep.

However there are strategies that can help reduce the occurrence and impact of sundowning, supporting both the individual and their caregivers to achieve a better quality of life.

• Maintain a routine - Keeping a consistent daily routine can help orient the individual and reduce confusion. This includes regular meal times, bedtime and wake-up times.
• Increase sunlight exposure - Exposure to natural light in the morning can help regulate the body's internal clock and potentially reduce sundowning symptoms. Consider taking a morning walk or sitting by a window.
• Limit naps - Excessive daytime napping can disrupt nighttime sleep. If the individual needs to nap, try to keep it short and not too late in the day.
• Create a calm environment - Aim to reduce noise, use soft lighting and create a peaceful environment throughout the day and in the evening. Soft music or nature sounds can be soothing.
• Reduce reflections – if curtains are left open in the evening as the sun goes down, this can create a reflection which people living with dementia may find confusing and frightening. Use curtains or sheer to reduce reflections in windows, glass doors and mirrors.
• Avoid caffeine and alcohol - Both can interfere with sleep. It's best to limit or avoid them, especially in the afternoon and evening.
• Stay active - Engaging in physical activity during the day can help improve sleep at night. Even simple activities like walking or gardening can be beneficial.
• Engage in evening activities - Distracting and calming activities in the evening, such as puzzles, reading or crafts, can help redirect the person’s attention and reduce agitation. Try to avoid loud noises such as shouting on the TV and radio as this can add to distress.
• Stay calm and patient - It's essential for caregivers to remain calm and patient, even when the individual is agitated. Responding with reassurance, empathy, and a gentle tone can help defuse tense situations.

In some cases, medication might be prescribed to help manage severe symptoms of sundowning. The right care plan depends on the individual, so it’s important to consult the person’s healthcare provider before making any changes to medication.

KYN's dementia care team are trained in evidence-based therapies that can help ease the distress of sundowning, without the use of medication, while respecting the person’s independence and dignity. Contact us today to learn more about how we support our residents living with dementia.