Sundowning

Many families notice the same pattern. A person living with dementia does fairly well in the morning. Then, as the afternoon fades into evening, they become more confused, restless, worried or angry. This is often called sundowning.

Sundowning is not a disease of its own. It is a group of symptoms that tend to show up or get worse at a certain time of day.^1,3 The good news is that small changes to light, routine and the home often make evenings calmer. This page explains what may cause it and what you can try.

What sundowning looks like

Sundowning usually starts in the late afternoon or early evening and can last into the night.^2,3 The person may:^1,3

• Seem more confused or lost, even at home
• Become anxious, fearful or suspicious
• Pace, try to leave, or say they need to "go home"
• Get irritable, argue, or refuse help
• See or hear things that are not there
• Have trouble falling asleep or staying asleep

It does not happen to everyone, and it can come and go. Studies report very different numbers, from a few people in 100 to about 2 in 3, because experts do not agree on one definition.² It seems to be more common as dementia gets more severe. Some studies suggest it happens more in fall and winter, when days are shorter.²

Sundowning matters because it is hard on everyone. It is linked with more caregiver stress and burnout, and with families deciding on nursing home care.² If you feel worn out by long evenings, you are not alone. See caregiver stress and burnout.

Why it happens

Researchers think sundowning has many causes that add up.² It helps to think of them in three groups.

Changes in the brain. Dementia can damage a small area of the brain that works as the body's clock. The body may also make less melatonin (a hormone that tells you it is night). As a result, the person's sense of day and night gets mixed up.² Many older adults also need less sleep than before.¹

The body's needs. By late day, the person may be tired from a full day of trying to make sense of things. They may be hungry, thirsty, in pain, bored, or need the toilet but cannot say so.^1,3 Depression, sleep apnea (breathing pauses during sleep) and infections can also play a part.^2,3

The setting. Fading light makes shadows. Shadows can look like people or objects, which can be scary.^1,3 A new or unfamiliar place, a noisy house at dinner time, TV, and a tired or stressed caregiver can all add to the upset.^1,2 In care homes, having fewer staff in the late afternoon may also play a part.²

Some medicines can make things worse. These include certain sleep pills, calming drugs and antidepressants, and anticholinergic drugs (drugs that block a brain chemical used for memory).² See medicines that can worsen memory.

Is it sundowning or delirium?

This is the most important question to ask when confusion changes.

Delirium is sudden, severe confusion caused by a physical problem. Common causes include a urinary tract infection (UTI), pneumonia, a new medicine, or alcohol.⁵ It comes on over hours or days. The person may swing between sleepy and agitated, and attention is very poor. Delirium can often be reversed when the cause is treated.⁵

If confusion gets much worse quickly, call the doctor the same day, even if it is happening in the evening.^3,5 Sundowning-like symptoms that start suddenly can be a sign of a UTI or another illness.³ For more, see hospital stays and emergency rooms.

What helps: light, routine and a calm evening

Experts agree that non-drug steps should come first.^1,2 None of these has been well tested for sundowning in large studies. But they are low-risk, make sense, and many families find them useful.² Try one or two at a time and see what changes.

A few more ideas:

• Move during the day. A walk together can ease restlessness. Daytime exercise also helps sleep.^1,4 See meaningful activities.
• Check for basic needs. Before evening, offer a snack, a drink and a trip to the toilet. Watch for signs of pain.³
• Bring the familiar. In a new place, such as a hospital or a relative's home, bring photos and favorite objects.³
• Look at the room. Avoid bare bulbs, and cover mirrors if the person is upset by their reflection.⁴
• Ask about medicine timing. Ask the doctor or pharmacist whether any medicine could be taken at a better time of day.¹ Do not change times on your own.
• Keep a diary. Write down what happened just before each hard evening. Patterns often show up after a week or two.¹ Our behavior diary can help.

What to do in the moment

When the person is already upset, the goal is to help them feel safe, not to win an argument.

1. Stay calm yourself. Speak slowly and softly. The person can pick up on your stress.¹
2. Look for a need. Ask simple questions. Are they cold, hungry, in pain or needing the toilet?^1,3
3. Reassure, do not correct. Gently say what time it is and that all is well. Do not argue about what is real.¹
4. Change the scene. Offer a snack, music, a short walk, or a simple task like folding towels.^1,4
5. Let them move safely. If they need to pace, let them pace with someone watching. Never tie down or hold down the person.^1,4

If the person keeps trying to leave the house in the evening, read about wandering and getting lost. For seeing or hearing things that are not there, see hallucinations and delusions. For angry outbursts, see agitation and aggression. Our guide on talking with someone who has dementia has more tips.

What about light boxes and melatonin?

Light therapy. Some small studies of bright light boxes found fewer sundowning episodes.² But a Cochrane review (a careful summary of all the trials) found no clear benefit of bright light therapy for sleep or agitation in dementia.⁶ Natural daylight and bright rooms are still worth trying, because they are free and safe. Limited research

Melatonin. Melatonin is sold over the counter. A Cochrane review found that it had little or no effect on sleep in people with Alzheimer's.⁷ Studies of melatonin for sundowning have given mixed results.² Some experts say a low amount may help some people, alone or with daytime bright light.³ Talk with the doctor or pharmacist before trying it, as with any supplement. Limited research

Medicines: a careful last step

Most experts advise trying non-drug steps first. If they do not work, a doctor may suggest a medicine for evening agitation or sleep. Ask about the risks and benefits before deciding.¹

Some things to know:

• Sleeping pills and calming pills such as benzodiazepines have no good evidence for sundowning and may make behavior worse.²
• Over-the-counter sleep aids can make confusion worse. Ask the doctor before using them.⁴
• Antipsychotic medicines are often used, but they were not tested for sundowning itself.² As a group, they carry an FDA boxed warning (the strongest kind of warning) about a higher risk of death in older people with dementia.⁸ In 2023, the FDA approved brexpiprazole (Rexulti) for agitation from Alzheimer's dementia. It still carries that warning.⁸ See medicines for agitation and behavior.
• For sleep, a group of medicines called orexin blockers probably help people with mild to moderate Alzheimer's sleep a bit longer at night.⁷ See sleep medicines in dementia.

Never start, stop or change a medicine on your own. Talk with the doctor or pharmacist before changing anything.

When to get help

Make an appointment with the doctor if:^1,3

• The tips on this page are not helping after a few weeks
• The person is sleeping very poorly, or snoring with breathing pauses
• You think pain, depression or a medicine side effect may be part of the problem
• Evenings are becoming unsafe at home

Bring your behavior diary and a list of all medicines, vitamins and supplements to the visit. It is also fine to ask about more help at home, such as respite care or in-home care.

If you are a caregiver and feel overwhelmed, hopeless or like you might hurt yourself or someone else, call or text 988 any time. You can learn more about sleep problems in dementia and other dementia symptoms and behaviors.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.