Sundowning: What To Expect And How To Cope

If you have a loved one who lives with Alzheimer's disease or another type of dementia, you may have heard of the term “sundowning” or observed its effects. Sundowning is a phenomenon in which certain symptoms of dementia can become more pronounced during or after sunset. Also referred to as “sundowner’s syndrome,” it is not a disease or clinical diagnosis, but rather a series of behaviors that may become more pronounced during nighttime hours. It can be challenging to cope with sundowning, both for the individual with dementia and for their caregivers. Therapy may be a helpful resource, providing information, professional support, and personalized guidance.

As a caregiver, coping with sundowning can be challenging

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Symptoms of sundowning 

While some of these behaviors may be observed at any time of day in someone with dementia, sundowning specifically refers to an increase in these behaviors in the late afternoon or early evening. Around 20% of people with an Alzheimer's diagnosis will experience sundowning at some point. 

What can contribute to sundowning behaviors?

Several factors may contribute to sundowning or make sundowning worse:

• Sleep disturbances, such as sleep apnea or not getting enough sleep due to disrupted circadian rhythms
• Low lighting, which can confuse people with Alzheimer's disease, who may see shadows and interpret them as hallucinations, potentially becoming confused and frightened
• Certain medications
• Being in a new or confusing environment
• Perceiving stress or frustration in the people around them
• Physical illness or pain (seen commonly alongside urinary tract infections or UTIs)
• Dehydration
• Overstimulation

Strategies that may reduce sundowning behaviors

While there isn’t always one specific cause of sundowning behaviors, some strategies may create an environment that protects against worsening symptoms. These include the following:

• Creating a structured schedule for activities, mealtimes, and sleeping to promote quality sleep
• Observing your loved one in the afternoons and evenings to identify specific triggers that could be avoided in the future
• If possible, spending a good part of the day with your loved one in bright light outdoors to improve mood and help with sleep problems
• Keeping stimulation low throughout the day by staying in known, safe environments and avoiding loud noises, crowds, and breaks in routine as much as possible
• Helping them get regular exercise
• Limiting or avoiding their consumption of caffeine, alcohol, and nicotine
• Engaging in soothing activities, like listening to preferred music, looking at old photographs, or having afternoon (decaf) tea
• Scheduling doctor’s appointments earlier in the day when they are more alert

What to do if your loved one is experiencing sundowning behaviors

According to the National Alzheimer’s Association, if your loved one is experiencing sundowning symptoms, there may be effective ways to help them while avoiding more confusion and anger. Try to approach them calmly, as showing frustration or irritation can worsen symptoms. Offer reassurance and ask if they need anything. While you may remind them of the time in a calm and gentle manner, it’s usually best to refrain from arguing. Simply listen and reassure them calmly. If they are pacing or otherwise showing signs of agitation, do not attempt to physically hold them back, but allow them to pace freely with supervision until they calm down. 

When to get medical help

If you notice signs of sundowning, it can be best to contact your loved one’s healthcare provider right away. They will likely want to test for illness (as mentioned previously, UTIs can increase agitation, confusion, and delusion in elderly patients) and may determine any physical causes of sundowning symptoms. 

If sundowning is determined to be dementia-related, the physician can work with you and your loved one to develop an appropriate treatment regimen. The National Institute for Mental Health typically recommends options like music therapy and light therapy to reduce symptoms, as well as environmental changes. Vision correction or hearing aids may be required and should be used daily. 

In certain cases, sundowning can be treated with prescription medications, such as antidepressants or anti-anxiety medications. Doctors may also recommend the use of melatonin to promote sleep. 

How to care for yourself when taking care of others

When caring for people with Alzheimer's disease or dementia, it can be important to remember that you must also take care of your own physical and emotional needs. Caregiver burnout can be common and may affect people who are responsible for those with chronic illnesses. 

Below are a few ways to address your own mental health while caring for others:

• Ask for help from family and loved ones: It can be unhealthy to do everything on your own. Identify specific needs and work on ways to address them. For example, you can start a meal group in which members commit to cooking or purchasing one meal per week so that you don’t have to do all the cooking.
• Join a support group for other caregivers: Sharing your experiences with people in the same circumstances can be cathartic, and you may also learn tips and strategies from people who have experienced similar challenges.
• Care for your physical health: Try to eat nutritious meals, exercise regularly, get plenty of sleep, and take breaks when you need them.

When caring for someone who is living with dementia, it can be difficult to remember to take care of yourself as well. Therapy can be a good way to learn self-care strategies that fit into your busy life. The therapy process can also help you work through negative feelings and learn healthy coping mechanisms to manage the stress associated with caregiving duties. 

Many caregivers may not be able to leave their loved ones on their own in order to attend in-person therapy. Online therapy can offer a solution by allowing you to attend therapy sessions from home using video conference, phone call, and online chat options. 

Research suggests that online therapy can be an effective form of treatment for caregivers of individuals with dementia. For example, a 2023 systematic review and meta-analysis reported that online interventions could reduce caregivers’ depressive symptoms and stress levels.