Sundown Syndrome: What is "Sundowning" and How is it Managed?

You may have a loved one or know someone suffering from Alzheimer’s as there are 5.7 million Americans currently living with the disease. Alzheimer’s and other dementias have many unique challenges that can affect seniors in different ways such as sundowning. Sundowning is a symptom for people with Alzheimer’s or other dementias that has multiple causes and displays differently for each individual. Sundowning can be alarming for the seniors who experience it, and for their families and caregivers who witness it happening.

This post will introduce you to a series of potential strategies you can use to decrease the magnitude of these challenges, offering suggestions to manage the symptoms of sundown syndrome to lessen the sense of apprehension that each day's sunset might be bringing you.

If your loved one does not currently display any symptoms of sundowning but does have Alzheimer's disease or dementia, this post may also be helpful for you. Knowing what sundowning is and being able to identify the symptoms will allow you to intervene early should your loved one start experiencing episodes in the future.


What is Sundowning?

According to the Alzheimer’s Association, sundowning is a syndrome that causes “increased confusion, anxiety, agitation, pacing and disorientation beginning at dusk and continuing throughout the night.” It is a syndrome that occurs in people with Alzheimer’s disease or other forms of dementia. It is estimated that 1 in 5 individuals living with memory loss experience sundowning.


Who is at Risk of Developing Sundowning Symptoms?

Any person with dementia can exhibit symptoms of sundowning. Symptoms are often worst in the “middle stages” of the progression of Alzheimer’s disease or dementia, but it is possible for sundowning to occur at any stage.

If sundowning seems to manifest suddenly, it may be caused by an underlying health condition. If your loved one’s sundowning symptoms set in quickly or worsen rapidly, take them to their doctor for a check-up. The Mayo Clinic notes that conditions like urinary tract infections and sleep apnea can contribute to the severity of sundowning.


How does Sundowning Manifest in Seniors?

Symptoms of sundown syndrome can include:

  • Agitation (being upset or nervous)

  • Restlessness

  • Irritability

  • Confusion

  • Disorientation

  • Being Demanding

  • Being Suspicious

  • Yelling

  • Pacing

  • Hearing or seeing things that aren’t there

  • Mood Swings


How to Handle and Potentially Reduce Symptoms

Sundowning affects different people in different ways. Since each situation is unique, there are quite a few possible strategies that can be employed to respond to sundowning syndrome.

Ideally, these strategies will result in a reduction of the number of sundowning episodes your loved one experiences, but some strategies can also be used to attempt to lessen the severity of an episode once it has already begun.

Establish a Routine. A predictable daily routine is useful for treating all symptoms of dementia, including sundowning. Routines provide consistency, which can decrease agitation as a trigger of sundowning. Since tiredness can also be a trigger, implementing a regular bedtime can contribute to a steady sleep schedule and more restfulness generally, which is greatly beneficial in combatting sundown syndrome.


Identify Triggers. Every senior who experiences sundowning has their own set of individual triggers, circumstances or events which are likely to bring about a sundowning episode. In order to decrease the frequency with which your elderly loved one experiences symptoms, it’s important to identify their triggers.

Perhaps watching the nightly news tends to confuse or upset your loved one, and evenings might be better spent engaging in a more calming activity, like listening to music. Maybe your loved one’s sundowning is triggered by hunger, and it would be beneficial to bump dinner time up by half an hour in their daily schedule. Keep a journal to track situations that may be leading to your loved one’s sundowning symptoms. Once triggers are identified, you can eliminate them to the best of your ability.


Encourage Daily Activity. Studies have shown that some degree of daily physical activity improves seniors’ “rest-activity” rhythms, leading to more restful nights and even greater alertness during the day. If seniors spend too much time in stationary positions and are napping or dozing often, they may struggle to fall asleep at night, creating a cycle of tiredness which can trigger sundowning symptoms. Physical activity can be as simple as doing basic exercises or yoga in the home, or going out for a leisurely walk.


Adjust or Increase Lighting. Make sure your elderly loved one is exposed to natural light each day. Natural light will help to regulate their circadian rhythm, which contributes to a steady sleep/wake schedule. If regular exposure to natural light isn’t possible, you may want to consult with your loved one’s doctor and discuss getting a light therapy lamp.

Artificial light can also be used to help reduce sundowning symptoms - for seniors with dementia, shadows “can create confusion and hallucinations, especially with common objects that look different when it is darker.” To avoid confusion, turn on indoor lights at dusk, and keep your loved one’s living space well-lit.


Create Calm. Sundowning has been described as “complete disorientation; frequently [with] some degree of agitation and panic.” If your loved one has sundowning syndrome, try to create a calming or soothing environment, especially later in the day. Surround your loved with familiar or favourite items: put on an old episode of their preferred television show, encourage them to look through an album of photographs, or find an easy activity that they can enjoy, like building with Lego.

You may also want to see if your loved one responds positively to aromatherapy or music therapy. The scent of lavender essential oil can produce sedative effects for some, while music therapy can be effective in reducing anxiety.


Modify Mealtimes. Hunger and excessive fullness can both be triggers for sundowning. It’s important to make sure your loved one is eating enough on a daily basis, and it’s also important to make sure they’re not eating particularly large meals late in the day - the digestive process can keep them up at night.

Encourage your loved one to eat a substantial lunch, and a lighter meal or a couple snacks later in the day. Try to minimize the caffeine, alcohol, and sugar they consume to whatever extent you are able, particularly if you notice that any of these substances act as triggers for your loved one’s sundowning.


Explore Medications. If non-medicinal interventions are not making a significant impact, speak with your loved one’s doctor about potential pharmaceutical treatments. Common treatments include melatonin, anti-anxiety medications, drugs like Ambien to help regulate sleep schedules, and antipsychotics if delusions or hallucinations are extreme. Your loved one’s doctor should carefully monitor their reactions to any medications to make sure that the benefits outweigh the risks.


Some of these strategies might seem more suited to your loved one’s personality, health condition, and behaviours than others; you may want to implement those first.


How does Sundowning Impact Caregivers?

Caring for a senior with dementia, even when sundowning is not a concern, can be mentally, emotionally, and physically demanding. The Alzheimer’s Association reports that caregivers for persons with dementia “frequently report experiencing high levels of stress,” including anxiety and depression.

Caregiver burnout is detrimental to the mental and physical health of the caregiver in question, and a burned out caregiver can also trigger sundowning symptoms - a tired, angry, or frustrated caregiver can unintentionally give a sundowning senior nonverbal signals that something is amiss, which can in turn produce agitation and confusion.

It is important for both you and the senior you care for that you practice self-care and find a support system. If you are feeling overwhelmed by your caregiving responsibilities, ask for help. See if family members or friends can step into the caregiving role for a period of time, or explore the option of getting a certified caregiver with experience in dementia care to assist in maintaining your loved one’s routine, handling their sundowning symptoms, and providing them with comfort and companionship.


Sundowning can be a very challenging element of Alzheimer’s disease and dementia, both for the person struggling with the symptoms, and for their loved ones and/or caregivers. Although these strategies are not cures for sundowning, the right mix can prevent or lessen sundowning episodes to provide relief for you and your loved one.