What Is Sundowning in Dementia? Symptoms, Causes, and How to Help

Sundowning is a pattern of increased confusion, anxiety, restlessness, or agitation that develops later in the day in some people living with dementia. Symptoms often appear in the late afternoon, evening, or overnight, even if the person seemed relatively calm earlier.

Sundowning can be one of the most challenging parts of dementia care. However, practical changes to the person’s routine, surroundings, and daily care may reduce the frequency or severity of these episodes.

The most helpful approach is usually to identify possible triggers, respond calmly, check for unmet needs, and seek medical advice when symptoms are severe or suddenly worsen.

What Is Sundowning in Dementia?

Sundowning is not a separate disease or a single symptom. It describes a pattern in which dementia-related symptoms become more noticeable or difficult to manage later in the day.

Although the name suggests that symptoms begin at sunset, the timing varies. Some people become distressed in the afternoon, while others experience symptoms later in the evening or overnight.

Sundowning is more common during the middle and later stages of dementia, although every person’s experience is different.

What Are the Symptoms of Sundowning?

Common sundowning symptoms include:

• Increased confusion
• Restlessness or pacing
• Anxiety or fear
• Irritability
• Agitation or aggression
• Wandering
• Difficulty settling or sleeping
• Shouting or repeatedly calling out
• Suspicion or paranoia
• Hallucinations
• Delusions

Hallucinations may involve seeing or hearing something that is not present. Delusions may include believing that someone has stolen an item or that a familiar person is an impostor.

What Does Sundowning Look Like?

Sundowning does not look the same in every person.

One person may pace repeatedly and struggle to sit still. Another may become frightened, suspicious, or verbally aggressive. Some people may no longer recognize their surroundings, while others mainly experience sleep problems.

A person may:

• Ask repeatedly to go home
• Attempt to leave the house
• Search for a missing object
• Become upset by shadows or reflections
• Refuse care
• Follow a caregiver from room to room
• Become increasingly restless as bedtime approaches

Because the symptoms vary, dementia sundowning care should be based on the individual rather than a single standard response.

What Causes Sundowning?

The exact cause of sundowning is not fully understood. In many cases, several physical, emotional, and environmental factors may contribute at the same time.

Possible sundowning triggers include:

• Mental or physical fatigue
• Hunger or thirst
• Pain or discomfort
• Constipation
• Needing to use the toilet
• Poor sleep
• Long daytime naps
• Changes to the person’s body clock
• Reduced daylight
• Shadows or poor lighting
• Excessive noise or activity
• Hearing or vision problems
• Anxiety or emotional stress
• An unfamiliar environment
• Medication effects
• Illness or infection

What looks like challenging behavior may actually be the person’s way of communicating an unmet need.

For example, pacing may indicate pain, discomfort, or a need to use the bathroom. Attempts to leave may reflect confusion, fear, or a desire to follow an old routine.

How to Identify Sundowning Triggers

Careful observation can help caregivers recognize patterns and identify what may be contributing to late-day distress.

Keep track of:

• The time symptoms usually begin
• What happened earlier in the day
• The person’s meals and fluid intake
• Daytime sleeping
• Toileting and bowel movements
• Signs of pain or illness
• Changes in lighting
• Noise or activity in the home
• Changes to medications
• How well the person slept the previous night

A simple daily record may reveal patterns that are difficult to notice from memory alone.

There may be more than one trigger, so work through possible causes one at a time.

How to Reduce Sundowning During the Day

What happens earlier in the day can affect the person’s behaviour in the evening.

Maintain a Consistent Daily Routine

Try to keep meals, personal care, activities, and bedtime at predictable times.

A familiar schedule can reduce uncertainty and help the day feel more manageable.

Schedule Difficult Tasks Earlier

Plan appointments, bathing, outings, and other demanding activities for earlier in the day when the person may have more energy and concentration.

Avoid scheduling stressful or tiring tasks in the late afternoon whenever possible.

Encourage Daylight Exposure

Natural daylight can help support the body’s sleep-wake cycle.

Encourage time outdoors when safe, or have the person sit near a bright window during the day.

Encourage Appropriate Activity

Light physical activity and meaningful daytime engagement may help reduce restlessness and support better sleep.

Activities should be suited to the person’s abilities and energy level.

Consider Meal Timing

Some people may tolerate a larger midday meal and a lighter evening meal more comfortably.

Make sure the person has enough food and fluids throughout the day, since hunger and dehydration may contribute to agitation.

Limit Long Afternoon Naps

Long or late naps may make it harder to settle at night.

A short rest may still be helpful, but consider adjusting daytime sleep if nighttime wakefulness is becoming a problem.

How to Create a Calmer Evening Environment

A peaceful and predictable evening routine may reduce confusion and overstimulation.

Keep the Home Well Lit

Turn lights on before the room becomes dark.

Good lighting reduces shadows, reflections, and visual confusion that may frighten a person with dementia.

Close Curtains Before Dark

Dark windows may create reflections that the person mistakes for another person or movement outside.

Closing curtains before sunset may reduce this confusion.

Cover Mirrors or Reflective Screens if Needed

Mirrors, televisions, and dark screens may create reflections that become upsetting.

Cover or reposition them if they regularly trigger distress.

Reduce Noise and Activity

Loud television, music, several conversations, or a busy household may increase agitation.

Create a quieter environment as evening approaches.

Use Familiar Calming Activities

Helpful evening activities may include:

• Looking through family photographs
• Listening to soft music
• Folding towels
• Sitting in a familiar room
• Having a gentle conversation
• Following a familiar bedtime routine

Choose activities that the individual finds comforting.

Avoid Caffeine, Alcohol, and Nicotine

These substances can interfere with sleep and may increase restlessness.

Try to limit them, particularly later in the day.

What to Do During a Sundowning Episode

Even with careful planning, sundowning episodes may still occur. During an episode, the main goals are to reduce distress and keep the person safe.

Stay Calm and Speak Gently

Use a soft tone and simple language.

The person may react to the caregiver’s emotional state, so speaking sharply or appearing frustrated can increase fear and agitation.

Avoid Arguing or Repeated Correction

Trying to prove that the person is mistaken rarely helps.

For example, if the person believes an item has been stolen, saying, “No one stole it—you are wrong,” may increase suspicion.

A calmer response could be:

“Let’s look for it together.”

This acknowledges the concern without creating a confrontation.

Validate the Person’s Feelings

Even if the person’s understanding of the situation is inaccurate, the emotion may be very real.

Helpful responses might include:

• “You seem worried.”
• “I’m here with you.”
• “You are safe.”
• “Let’s sit together for a moment.”

Validation can reduce distress more effectively than correcting facts.

Offer Reassurance and Gentle Redirection

After acknowledging the person’s feelings, redirect their attention toward something familiar or calming.

Possible redirection activities include:

• Looking at photographs
• Listening to familiar music
• Having a drink or snack
• Moving to a quieter room
• Sitting together
• Completing a simple familiar task

Avoid changing the subject too abruptly.

Check for Basic Needs

Before assuming the behaviour is caused only by dementia, check whether the person:

• Needs the toilet
• Is hungry or thirsty
• Is too hot or cold
• Is tired
• Is constipated
• Has sore feet or back pain
• Is wearing uncomfortable clothing
• May be unwell

Meeting a simple physical need may sometimes resolve the episode.

Supervise Pacing Without Forcing the Person to Stop

If the person is pacing, remain nearby and remove hazards from their path.

Do not physically restrain them or force them into a chair unless there is an immediate safety emergency. Restraint can increase panic, aggression, and injury risk.

Communication Tips for Sundowning

When a person with dementia is distressed:

• Use short, simple sentences.
• Give one instruction at a time.
• Allow extra time for a response.
• Speak slowly and calmly.
• Maintain a reassuring presence.
• Reduce unnecessary questions.
• Offer limited choices.
• Redirect gently.
• Focus on feelings rather than facts.

Avoid:

• Raising your voice
• Arguing
• Repeatedly correcting the person
• Rushing care
• Giving several instructions at once
• Ignoring signs of discomfort
• Forcing the person to remain still

Common Mistakes That Can Make Sundowning Worse

Avoid these common dementia care mistakes:

Letting the Home Become Too Dark

Poor lighting and shadows may increase confusion or fear.

Scheduling Tiring Activities Late in the Day

Appointments, bathing, and busy outings may contribute to exhaustion and agitation.

Creating Too Much Background Noise

Television, music, conversations, and household activity can become overwhelming.

Treating Every Episode as a Behaviour Problem

Pain, constipation, infection, hunger, or a need to use the toilet may be contributing.

Expecting One Strategy to Work Every Time

Dementia symptoms can fluctuate. A calming technique that works one evening may not work the next.

Taking the Person’s Words Personally

Shouting, accusations, or suspicious behaviour may be symptoms of fear and confusion rather than intentional hostility.

When Should You Seek Medical Help for Sundowning?

Contact a doctor or care team if:

• Sundowning becomes frequent or severe.
• The person is extremely distressed.
• Sleep problems are affecting the person or caregiver.
• The person becomes unsafe or difficult to redirect.
• Symptoms begin suddenly.
• There is a major change from the person’s usual behaviour.
• You suspect pain, constipation, dehydration, infection, or another illness.
• Hallucinations or delusions become more intense.
• Current care strategies are no longer helping.

A healthcare professional may assess for medical causes and review medications.

Non-drug approaches are generally tried first. Medication may sometimes be considered for severe symptoms, but it is not usually the first step.

Is Sundowning Always Caused by Dementia?

No.

Although sundowning is associated with dementia, late-day confusion or agitation may also be worsened by:

• Infection
• Pain
• Medication side effects
• Constipation
• Dehydration
• Poor sleep
• Hearing or vision problems
• Delirium
• Other medical conditions

A sudden increase in confusion should be assessed rather than automatically assumed to be normal sundowning.

Can Sundowning Be Cured?

There is no single cure for sundowning. However, symptoms may become less frequent, less intense, or easier to manage when triggers are identified and care is personalized.

Helpful strategies often include:

• A predictable routine
• Daytime light and appropriate activity
• A calm evening environment
• Reduced noise and visual confusion
• Gentle communication
• Attention to pain and basic needs
• Medical assessment when symptoms change

Quick Sundowning Checklist for Caregivers

When late-day confusion or agitation begins, ask:

• Was the day unusually tiring or busy?
• Has the person eaten enough?
• Have they had enough fluids?
• Do they need the toilet?
• Could they be constipated?
• Are they in pain?
• Are they too hot or cold?
• Is the room well lit?
• Are shadows or reflections causing confusion?
• Is the television or environment too noisy?
• Did they sleep poorly?
• Did they have a long afternoon nap?
• Would a familiar calming activity help?
• Is this a sudden or severe change that requires medical advice?

Bottom Line

Sundowning in dementia is a pattern of worsening confusion, restlessness, anxiety, or agitation later in the day. It may be triggered by fatigue, low lighting, overstimulation, poor sleep, pain, hunger, toileting needs, illness, or other unmet needs.

The most effective first steps are usually practical: maintain a consistent routine, encourage daylight exposure, create a calmer evening environment, communicate gently, and check for physical discomfort.

If sundowning is frequent, severe, unsafe, or suddenly worse, contact the person’s doctor or care team to rule out other medical causes.