Sundowning and dementia: making evening hours easier for everyone

As afternoon fades to evening, many carers notice a familiar pattern beginning to emerge. The person they're caring for, who may have been relatively calm during the day, suddenly becomes restless, confused or agitated. This phenomenon, known as sundowning, affects up to 66% of people with dementia according to Bupa, turning what should be peaceful evening hours into some of the most challenging parts of the day.

If you've experienced this dramatic shift in behaviour as daylight wanes, you're certainly not alone. Sundowning can be one of the most exhausting aspects of dementia care, leaving both you and the person you're supporting feeling drained and distressed. However, understanding why sundowning occurs and learning effective management strategies can transform these difficult hours into more manageable, even peaceful, times.

The good news is that sundowning, whilst challenging, is predictable. This predictability means you can plan ahead, implement preventive strategies and create environments that minimise its impact. With the right approach, evening hours can become a time for calm connection rather than crisis management.

What is sundowning?

Sundowning, also known as sundown syndrome, refers to the increased confusion, anxiety, agitation and restlessness that many people with dementia experience during late afternoon and early evening hours. The term was first coined in the 1960s by researchers who noticed this distinct pattern of behavioural changes.

These changes typically begin around 3 or 4 pm and can continue well into the evening. The behaviours associated with sundowning can vary significantly from person to person but commonly include increased confusion, agitation, pacing, demanding to "go home" (even when they are at home), hallucinations, paranoia or becoming upset about events from the distant past.

Though it can arise in the early stages, sundowning is typically a sign that the dementia is more advanced. It's important to understand that these behaviours aren't intentional or controllable – they're a direct result of changes in the brain caused by dementia.

The phenomenon can be particularly distressing because the person may seem perfectly fine during the day, only to become a different person entirely as evening approaches. This Jekyll and Hyde-like transformation can leave carers feeling confused and emotionally depleted.

Why does sundowning happen?

Understanding the underlying causes of sundowning can help you respond with greater patience and implement more effective management strategies. Several factors contribute to this challenging phenomenon.

Brain changes and disrupted circadian rhythms play a central role. Dementia damages the brain's internal clock, which regulates sleep-wake cycles. According to the Alzheimer’s Society, the body clock of a person with dementia may become damaged, making it harder for them to feel awake and alert during the day, and sleepy during the evening.

Accumulated fatigue throughout the day can overwhelm someone whose brain is already working harder than usual to process information and navigate daily tasks. By late afternoon, mental and physical exhaustion can make it difficult to cope with even simple situations, leading to increased confusion and agitation.

Changes in lighting and shadows can be particularly problematic. As natural light diminishes, shadows lengthen and familiar environments can appear different or threatening. The brain affected by dementia struggles to process these visual changes, potentially leading to hallucinations or paranoid thoughts.

Hormonal fluctuations also contribute to sundowning. Cortisol levels naturally fluctuate throughout the day, and in people with dementia, this can contribute to increased agitation during certain hours. The Sleep Foundation notes that disrupted melatonin production can further compound these issues.

Recognising your person's sundowning patterns

Every person with dementia experiences sundowning differently, so identifying your specific person's patterns is crucial for effective management. Keep a simple diary noting the time, triggers and types of behaviours you observe.

Common triggers to watch for include hunger or thirst (people with dementia may forget to eat or drink regularly), the need for the toilet, pain or discomfort they cannot communicate, overstimulation from too much activity during the day, or disruptions to their usual routine.

Environmental factors such as increased noise from traffic or family members returning home, changes in lighting as curtains are drawn or lights are turned on, or the general bustle of preparing evening meals can all contribute to increased agitation.

Typical behaviours might include repetitive questioning, pacing or wandering, insisting they need to go somewhere (often work or to pick up children), becoming suspicious of familiar people, experiencing hallucinations or becoming upset about long-past events as if they happened recently.

Recognising these patterns allows you to anticipate and prepare for challenging periods rather than being caught off guard each evening.

Strategies that really work

Adjusting daily routines can significantly reduce the impact of sundowning. Try to schedule more stimulating activities earlier in the day and gradually wind down as afternoon approaches. Avoid scheduling appointments, visitors or demanding tasks during typical sundowning hours.

Establish a consistent daily routine that the person can rely on. This might include regular meal times, a mid-afternoon rest period and calming activities as evening approaches. Predictability helps reduce anxiety and confusion.

Managing lighting and environment is crucial. Begin adjusting lighting before natural light fades – turn on lamps and close curtains early to maintain consistent illumination. Avoid harsh overhead lights that can create confusing shadows. Instead, use warm, even lighting throughout the home.

Consider the overall environment during typical sundowning hours. Reduce noise levels by turning off the television or radio, minimise household activity and create a calm atmosphere. Some people find that playing soft, familiar music can be soothing.

Calming activities for late afternoon can help redirect restless energy into positive outlets. Gentle activities might include looking through photo albums, simple crafts, folding laundry, listening to favourite music or going for a short walk if weather permits.

Avoid activities that might overstimulate, such as watching exciting television programmes, engaging in complex conversations or introducing new people or situations. The goal is to create a peaceful transition into evening.

The importance of consistent bedtime routines cannot be overstated. Begin preparing for bedtime at the same time each evening with familiar, calming activities. This might include a warm bath, changing into comfortable nightwear, having a light snack or reading together.

Creating a peaceful evening environment

Your home environment plays a crucial role in managing sundowning. Simple modifications can make a significant difference to how the person experiences evening hours.

Temperature control is important – ensure the home is comfortable as people with dementia may not communicate when they're too hot or cold. Security and familiarity can be enhanced by ensuring doors and windows are securely closed before sundowning typically begins, as the person may become worried about safety during these vulnerable hours.

Minimising stimulation means reducing the number of people present during sundowning hours when possible, keeping conversations calm and simple, avoiding decision-making or complex discussions and maintaining predictable, quiet surroundings.

Consider using validation techniques rather than trying to correct confused thinking. If they believe they need to go to work, acknowledge their dedication rather than reminding them they're retired. This reduces arguments and helps them feel understood.

When sundowning becomes overwhelming

While many sundowning episodes can be managed at home, there are times when professional support is necessary. Contact your GP if sundowning behaviours become aggressive or dangerous, if sleep disruption is severe and affecting daytime functioning, if the person seems to be in physical distress or if you're finding it impossible to manage safely.

Medication can sometimes help with severe sundowning, though it should always be carefully considered and monitored. Non-pharmacological approaches are typically tried first, including light therapy, structured activity programmes or changes to the care environment.

Remember that seeking help isn't a sign of failure – it's responsible caregiving. Connect with other carers through local support groups where you can share experiences and learn from others who've navigated similar challenges.

Finding peace in difficult hours

Managing sundowning requires patience, preparation and often some trial and error to find what works best for your specific situation. What matters most is approaching these challenging hours with understanding rather than frustration, recognising that the behaviours aren't intentional but are symptoms of the disease process.

Many carers find that accepting sundowning as part of the dementia journey, rather than fighting against it, helps them develop more effective coping strategies. By creating calm, predictable evening routines and environments, you can often reduce the severity and duration of sundowning episodes.

Remember to take care of your own wellbeing during these challenging hours. Consider respite care options that can give you a break during typical sundowning times, and don't hesitate to ask family or friends for support during evening hours when possible.

For more comprehensive guidance on supporting someone through the various challenges of dementia, explore our resources on managing emotions and behaviours. With understanding, preparation and support, even the most challenging sundowning episodes can become more manageable, helping preserve quality of life for both you and the person you're caring for.