In plain English
Sundowning is the late-afternoon and early-evening worsening of confusion, restlessness or agitation seen in many people with dementia. It is one of the more recognisable symptom patterns and usually responds well to environmental and routine changes.
What sundowning is
Sundowning describes a pattern of increased confusion, restlessness, anxiety or agitation in the late afternoon and early evening, often peaking around 4 to 7 pm. Around 20 per cent of people with dementia experience sundowning at some point, particularly in moderate stages.
Why it happens
Several contributors are recognised:
- Fatigue: cognitive reserves are lower at the end of the day;
- Light change: reduced light increases visual misperception and disorientation;
- Disrupted circadian rhythm: damaged suprachiasmatic nucleus in dementia disturbs the body clock;
- Unmet needs: hunger, thirst, full bladder, pain that are not communicated;
- Transition: from a busier daytime to a quieter evening;
- Carer change: shift changes in care homes;
- Acute trigger: infection, constipation, medication.
What helps
Light
- Increase indoor lighting in the late afternoon and evening;
- Bright light therapy (a daylight-spectrum lamp for 30 minutes mid-morning) may help reset the circadian rhythm;
- Daylight exposure in the morning helps consolidate the rhythm.
Routine
- Schedule demanding activities (appointments, baths) earlier in the day;
- Plan a calming activity for the typical sundowning time (music, a familiar TV programme, gentle walk);
- Consistent dinner time;
- Avoid excessive afternoon napping (under 30 minutes, not after 3 pm).
Environment
- Reduce noise and visual clutter;
- Familiar music;
- Curtains drawn before dusk to avoid the unsettling transition;
- Avoid TV news in the late afternoon if it triggers anxiety.
Practical
- Offer a small snack and a drink at the typical sundown time;
- Check pain, constipation, full bladder;
- Pre-empt with a walk if restlessness is the main feature;
- Aromatherapy (lavender) for some people.
Medication
Routine medication for sundowning is generally avoided. Where symptoms are severe and unresponsive to non-pharmacological approaches:
- Optimise Cholinesterase Inhibitor or Memantine;
- Treat any underlying mood or anxiety;
- Melatonin at low dose may help where sleep disturbance is the dominant issue;
- Trazodone at low dose can help with severe sundowning, used cautiously;
- Antipsychotic medication only as a last resort under specialist input.
For Carers
Sundowning often coincides with the end of the carer's day, when energy is low. Practical tips:
- Anticipate the difficult hour and plan around it;
- If possible, have help in the household at that time;
- Use the time for a quieter shared activity rather than demanding tasks;
- Be self-compassionate; this is the symptom that most often pushes families to consider extra support.
When to seek help
- Sudden onset of sundowning suggests Delirium and warrants same-day GP review;
- Severe sundowning despite environmental and routine measures;
- Sundowning causing significant carer distress.
Frequently asked questions
Is sundowning a sign of decline?
Sundowning is more common in moderate dementia. It can persist or settle as the disease progresses. Sudden onset of sundowning suggests Delirium and warrants medical review.
Does bright light therapy work?
Some evidence supports morning bright light exposure for 30 minutes a day, which may help consolidate circadian rhythm and reduce sundowning over weeks.
Should I keep my parent up to tire them out?
Generally no. Tiredness often worsens sundowning. A consistent routine with a calming late afternoon and an earlier bedtime usually works better.
Is sundowning the same as Delirium?
No. Sundowning is a recurring late-afternoon pattern in stable dementia. Delirium is an acute confusional state developing over hours to days, almost always with a medical cause.
What music helps?
Personalised music from the person's teens and twenties usually works best. Soft instrumental music in the background is also effective.
References
- Volicer L et al. Sundowning in dementia. Dementia 2018.
- Skjerve A et al. Light therapy in dementia. Aging Ment Health 2004.
- NICE NG97 recommendation 1.7.
- Dementia UK. Sundowning.