What Time Is Sundowning? Hope for Worried Caregivers

If you’re caring for someone with Alzheimer’s disease or dementia, you may have noticed a troubling pattern: as the sun begins to set, your loved one becomes increasingly confused, agitated, or distressed. This phenomenon, known as sundowning or sundowner’s syndrome, affects up to 20-45% of people with Alzheimer’s and represents one of the most challenging aspects of dementia care.

Understanding what time sundowning occurs and how to manage it can dramatically improve quality of life for both patients and caregivers. This comprehensive guide explores everything you need to know about sundowning timing, symptoms, causes, and evidence-based management strategies.

What is Sundowning?

Sundowning, also called sundown syndrome or late-day confusion, refers to a pattern of increased behavioral and psychological symptoms that occur during the late afternoon and evening hours in individuals with dementia. This is not a separate disease but rather a set of dementia-related behaviors that worsen at specific times of day.

The term “sundowning” captures the timing of these symptoms, which typically align with the setting sun and the transition from daylight to darkness. However, it’s important to understand that sundowning can potentially occur at any time, and some individuals may experience symptoms earlier or later than the typical evening hours.

What Time Does Sundowning Start? Understanding the Timeline

The most critical question for caregivers is: when does sundowning typically begin? Research and clinical observations provide clear patterns about sundowning hours.

Typical Onset Time

Sundowning typically occurs between 4:30 and 11 p.m. and can last through the night, though individual experiences vary considerably.

Late Afternoon Beginning: Most commonly, sundowning symptoms emerge during the late afternoon, with between 3 and 5 p.m. being common hours for sundowning symptoms, particularly in nursing home environments where shift changes occur around 3 p.m.

Peak Evening Hours: The intensity of symptoms usually peaks around dinnertime and continues into the night. For many individuals, the most difficult period occurs between 5 p.m. and 8 p.m. as natural light fades completely.

Duration and Variability: Sundowning usually lasts a few hours between late afternoon and early evening, though certain episodes persist for longer or shorter time spans depending on dementia severity, environmental triggers, and individual responses to interventions.

Factors Affecting Timing

Several elements influence when sundowning begins:

Seasonal Changes: During winter months with shortened daylight hours, sundowning may start earlier in the day. The transition to and from daylight saving time can also disrupt patterns and trigger earlier onset of confusion.

Individual Variations: While late afternoon is most common, some individuals experience sundowning-like symptoms in the morning hours, demonstrating the highly personalized nature of this condition.

Environmental Context: Sundowning usually begins in the late afternoon, around 4-5pm, and can continue into the evening or early night, often affected by clock changes and seasonal light patterns.

Recognizing Sundowning Symptoms

Understanding the signs of sundowning enables caregivers to respond appropriately and implement preventive strategies. Symptoms manifest across behavioral, cognitive, emotional, and physical domains.

Behavioral Changes

People experiencing sundowning may exhibit various behavioral symptoms:

• Restlessness and Pacing: Constant movement, inability to sit still, and aimless wandering throughout the home
• Agitation and Irritability: Increased frustration, angry outbursts, and resistance to care or assistance
• Aggressive Behavior: Verbal lashing out, attempts to hit or push caregivers, or hostile responses to simple requests
• Shadowing: Following caregivers very closely everywhere they go, requiring constant presence
• Wandering: Attempts to leave the home, particularly believing they need to “go home” even when already there
• Repetitive Behaviors: Asking the same questions repeatedly or performing repetitive movements like rocking

Cognitive and Perceptual Symptoms

Mental functioning deteriorates noticeably during sundowning episodes:

• Increased Confusion: Greater disorientation regarding time, place, and familiar surroundings
• Recognition Problems: Difficulty identifying family members or familiar caregivers
• Hallucinations: Seeing things that aren’t present, particularly in shadows or poorly lit areas
• Delusions: False beliefs, such as paranoia about theft or conviction that loved ones are imposters
• Memory Lapses: More pronounced short-term memory difficulties than usual baseline

Emotional Symptoms

The emotional impact of sundowning can be profound:

• Anxiety: Heightened worry, fearfulness, and sense of impending danger
• Paranoia: Suspiciousness toward caregivers and family members
• Mood Swings: Rapid shifts between emotional states, from calm to distressed
• Depression: Sadness, tearfulness, or expressions of hopelessness
• Fear: Intense emotional reactions to normal environmental changes

Physical and Sleep-Related Symptoms

Sundowning significantly impacts sleep patterns and physical well-being:

• Sleep Disturbances: Difficulty falling asleep, frequent nighttime awakenings, reversed sleep-wake cycles
• Insomnia: Complete inability to sleep during nighttime hours despite exhaustion
• Physical Restlessness: Continuous movement, inability to relax physically
• Changes in Appetite: Refusing food or demanding to eat at inappropriate times

Who Experiences Sundowning?

Sundowning primarily affects individuals with various forms of dementia and cognitive impairment. Up to 20–45% of people with Alzheimer’s disease are believed to experience sundowning, making it a common challenge in dementia care.

Conditions Associated with Sundowning

Alzheimer’s Disease: The most common dementia type where sundowning occurs, affecting roughly one in five patients. Almost all people with Alzheimer’s disease will have some form of sundowning at some point during disease progression.

Vascular Dementia: Patients with dementia caused by reduced blood flow to the brain also experience late-day confusion patterns.

Lewy Body Dementia: This dementia type, characterized by abnormal protein deposits, often includes prominent visual hallucinations that worsen during sundowning.

Parkinson’s Disease with Dementia: Advanced Parkinson’s patients who develop cognitive impairment may experience sundowning behaviors.

Frontotemporal Dementia: Though potentially less common than in Alzheimer’s, sundowning can occur in this form of dementia affecting the frontal and temporal brain lobes.

Mixed Dementia: Individuals with multiple types of dementia simultaneously may experience particularly challenging sundowning episodes.

Sundowning Across Dementia Stages

Sundowning can present at any stage of a person’s dementia journey; however, it is more common during the middle stage and later stages of disease progression.

Early Stage: Mild instances of late-day agitation and confusion may occur but are often subtle and inconsistent.

Middle Stage: Sundowning seems to occur more frequently during the middle stages of Alzheimer’s disease and mixed dementia, with symptoms becoming more pronounced and regular.

Late Stage: Sundowning seems to subside with the progression of the person’s dementia in advanced stages, possibly because overall activity levels decrease significantly.

The relationship between dementia progression and sundowning frequency isn’t linear—symptoms typically intensify through middle stages before potentially decreasing in very advanced dementia when overall activity diminishes.

What Causes Sundowning? Understanding the Underlying Factors

Despite extensive research, the exact causes of sundowning remain incompletely understood. However, multiple contributing factors have been identified through clinical studies and observations.

Circadian Rhythm Disruption

The body’s internal biological clock, regulated by the suprachiasmatic nucleus (SCN) in the hypothalamus, becomes damaged in dementia. Researchers believe it’s a disruption in circadian rhythms—in other words, a disruption to a person’s natural body clock.

This disruption affects:

• Sleep-wake cycle regulation
• Hormone production patterns, particularly melatonin
• Temperature regulation
• Alertness and cognitive function throughout the day

In healthy individuals, sunset triggers biochemical changes preparing the body for sleep. In dementia patients, this system malfunctions, leading to confusion and agitation rather than natural tiredness.

Fatigue and Mental Exhaustion

After a full day of activities and cognitive demands, individuals with dementia experience accumulated mental fatigue. Mental and physical exhaustion from a full day of activities makes it increasingly difficult for an already-compromised brain to process information and regulate emotions.

The brain’s reduced capacity to compensate for cognitive deficits becomes more apparent as energy reserves deplete throughout the day.

Environmental Factors

Changes in the physical environment contribute significantly to sundowning:

Lighting Changes: As day morphs into night, shadows develop and quality light decreases, making it more difficult to see and thus increasing anxiety for people with memory loss issues.

Poor lighting creates disturbing shadows and reduces visual clarity, potentially causing:

• Misinterpretation of ordinary objects
• Increased fear and confusion
• Visual hallucinations or illusions

Noise and Stimulation: Changes in household activity patterns, television programming, and ambient noise levels during evening hours can overwhelm someone with dementia.

Temperature Changes: Evening temperature drops or heating system adjustments may cause physical discomfort contributing to agitation.

Unmet Physical Needs

Basic physical discomforts often trigger or worsen sundowning behaviors:

• Hunger or Thirst: Unrecognized need for food or fluids
• Bathroom Urgency: Difficulty communicating the need to use the toilet
• Pain: Chronic or acute pain that cannot be effectively communicated
• Medical Issues: Urinary tract infections, constipation, or other conditions causing discomfort
• Medication Side Effects: Interactions or adverse effects from multiple medications

Institutional and Caregiver Factors

For individuals in care facilities or receiving in-home care, staffing patterns influence sundowning. A shift change traditionally happens around 3 p.m., with staff having meetings and some people leaving, creating commotion that can affect mood or cause confusion.

This change coincides with reduced structured activities and one-on-one attention, potentially leading to boredom, feelings of abandonment, and subsequent agitation.

Sleep Disturbances

Poor sleep quality at night creates a vicious cycle. Dementia patients often experience:

• Reduced deep (stage 3 and 4) sleep
• Increased nighttime wakefulness
• Progressive REM sleep loss
• Sleep disorder conditions like restless leg syndrome

Sleep deprivation exacerbates daytime fatigue, making evening sundowning more severe, which in turn disrupts nighttime sleep further.

Sundowning vs. Delirium: Critical Differences

While sundowning and delirium can appear similar, distinguishing between them is crucial because delirium represents a medical emergency requiring immediate attention.

Key Distinguishing Features

Timing Pattern:

• Sundowning happens at a certain time of day (usually in the late afternoon or evening), while delirium can happen at any time
• Sundowning follows a predictable daily pattern

Onset:

• Delirium is characterized by a sudden onset of a cognitive change
• Sundowning develops gradually over time as dementia progresses

Underlying Cause:

• Sundowning stems from dementia-related brain changes and daily rhythms
• Delirium indicates an acute medical problem: infection, medication toxicity, metabolic disturbance, or other urgent conditions

Reversibility:

• Sundowning typically improves by morning and follows a chronic pattern
• Delirium requires treatment of the underlying medical cause to resolve

When to Seek Immediate Medical Care

Contact healthcare providers urgently if you observe:

• Sudden, dramatic worsening of confusion beyond typical sundowning patterns
• New onset of severe behavioral changes not previously present
• Signs of infection: fever, decreased urination, increased confusion
• Symptoms occurring outside the typical late-afternoon/evening timeframe
• Loss of consciousness or extreme lethargy
• Inability to recognize even the closest family members (if new)

Delirium is a medical emergency that can indicate serious conditions like pneumonia, urinary tract infections, medication toxicity, stroke, or metabolic crises.

Evidence-Based Strategies for Managing Sundowning

Managing sundowning effectively requires a comprehensive, multi-faceted approach combining environmental modifications, behavioral strategies, and sometimes medical interventions.

Environmental Modifications

Optimize Lighting Throughout the Day:

• Maximize natural light exposure during morning and afternoon hours
• Use bright, full-spectrum lighting indoors to extend “daytime” perceptually
• Establish a regular and habitual routine by exposure to natural light to help set their internal clock
• As evening approaches, gradually dim lights rather than sudden darkness
• Use night lights in hallways, bathrooms, and bedrooms to prevent falls and reduce nighttime confusion
• Close curtains and blinds at dusk to minimize disturbing shadows

Reduce Evening Stimulation:

• Lower television and music volume during late afternoon hours
• Avoid intense or violent programming that may increase agitation
• Limit visitors during typical sundowning hours
• Create a calm, quiet atmosphere with minimal background noise
• Remove or cover mirrors if reflections cause confusion or fear

Maintain Comfortable Environment:

• Keep the home at a consistent, comfortable temperature
• Ensure adequate but not excessive ventilation
• Remove clutter that might be confusing or create tripping hazards
• Keep familiar objects and photographs visible for reassurance

Establishing Structured Routines

Consistent Daily Schedule: Dementia patients thrive on predictability. Schedule activities such as doctor appointments, trips and bathing in the morning or early afternoon hours when the person living with dementia is more alert.

Create and maintain regular times for:

• Waking up and morning routine
• Meals (breakfast, lunch, early dinner)
• Activities and exercise
• Rest periods
• Evening routine and bedtime

Morning and Early Afternoon Activities:

• Schedule mentally demanding tasks early in the day when cognitive function is optimal
• Plan physical exercise for morning hours to promote nighttime sleep
• Complete bathing and personal care before mid-afternoon
• Discourage excessive napping, especially in the afternoon to promote nighttime rest

Early Dinner Timing: Consider serving the evening meal between 4 p.m. and 5:30 p.m., before typical sundowning intensifies. This ensures:

• Hunger isn’t triggering agitation
• Adequate time for digestion before bedtime
• Meeting nutritional needs during more alert hours

Activity and Engagement Strategies

Appropriate Daytime Stimulation:

• Encourage daytime activity, as more mental and physical activity during the day can help reduce sundowning
• Balance activity levels too little causes boredom and restlessness; too much leads to overwhelming fatigue
• Include outdoor walks, even brief ones, to provide fresh air and natural light
• Engage in meaningful activities that provide purpose without frustration

Calming Afternoon Activities: As the day progresses, transition to quieter, more soothing activities:

• Listening to favorite music, particularly songs from the person’s youth
• Looking at family photo albums and reminiscing
• Gentle hand activities like folding towels or sorting soft objects
• Watching favorite television programs or movies
• Simple craft activities that don’t require complex decision-making
• Reading aloud or being read to

Avoid Overstimulation: Don’t schedule:

• Visitors during late afternoon and evening hours
• Outings or errands after mid-afternoon
• Complex or frustrating tasks during sundowning hours
• Large family gatherings in the evening

Addressing Physical Needs

Proactive Need Assessment: Before typical sundowning hours, ensure the person:

• Has eaten adequate food and consumed sufficient fluids
• Has used the bathroom recently
• Is physically comfortable without pain
• Is wearing comfortable, appropriate clothing
• Has taken required medications

Medical Issue Monitoring: Watch for signs indicating underlying medical problems:

• Urinary tract infections (UTIs): increased confusion, frequent urination, discomfort
• Constipation: abdominal discomfort, decreased appetite
• Dental pain: refusal to eat, facial grimacing
• Other infections or illnesses that may not be easily communicated

Medication Review: Work with healthcare providers to:

• Review all medications for potential interactions or side effects contributing to confusion
• Optimize medication timing—some medications may be better tolerated if taken earlier in the day
• Avoid medications that may worsen confusion (certain sleep aids, anticholinergics)
• Consider whether any medications could be reduced or eliminated

Communication and Behavioral Approaches

Calm, Supportive Communication:

• Approach the person calmly without sudden movements
• Speak slowly, clearly, and in a reassuring tone
• Use simple sentences and give one instruction at a time
• Maintain eye contact at their level

Validation Instead of Correction:

• When someone is experiencing delusions, their reality is very true for them, and it is often impossible to convince a person who has delusions of the truth
• Validate their feelings: “I understand you’re worried” or “I can see you’re upset”
• Don’t argue about facts or try to reason with them during episodes
• Validate their feelings and don’t argue with their reality

Distraction and Redirection: When agitation occurs:

• Gently redirect attention to something pleasant or familiar
• Offer a favorite snack or beverage
• Suggest a calming activity
• Take a short walk together
• Look at photographs together
• Play soothing music

What to Avoid:

• Raising your voice or showing frustration
• Asking “Why are you doing this?” or demanding explanations
• Physically restraining unless absolutely necessary for safety
• Making sudden movements or approaching from behind
• Challenging their perceptions or memories during episodes

Light Therapy Interventions

Research supports the use of light therapy to help regulate circadian rhythms and reduce sundowning symptoms.

Morning Light Exposure:

• When possible, spend time outside in the sunlight during the day to help regulate sleep-wake cycles
• Aim for 30-60 minutes of bright light exposure in morning hours
• Use light therapy boxes (2,500-5,000 lux) if natural sunlight is limited
• Position the person within one meter of the light source during morning activities like breakfast or watching television

Benefits of Light Therapy: Studies demonstrate that patients treated with bright light combined with appropriate evening light management show:

• Improved sleep quality and duration
• Reduced frequency and severity of sundowning episodes
• Better regulation of circadian rhythm
• Decreased confusion and agitation

Consult with healthcare providers before implementing light therapy, particularly for individuals with certain eye conditions or who are taking photosensitizing medications.

Music and Sensory Approaches

Music Therapy: Music can be remarkably effective in managing sundowning:

• Create playlists of favorite songs from the person’s youth (ages 18-25 typically hold strongest musical memories)
• Play calming, familiar music during typical sundowning hours
• Avoid music that is too loud, unfamiliar, or has jarring elements
• Consider live music or singing together if the person enjoys it

Other Sensory Interventions:

• Aromatherapy: Some caregivers find calming scents like lavender helpful
• Touch: Gentle hand massage, foot rubs, or shoulder massage can be soothing
• Comfortable Textures: Provide soft blankets, stuffed animals, or familiar objects to hold
• Pet Therapy: If appropriate and safe, interaction with calm pets can reduce agitation

Medical Treatment Options for Sundowning

While non-pharmacological approaches should always be the first line of intervention, medication may be necessary when sundowning behaviors are severe, pose safety risks, or significantly impair quality of life.

FDA-Approved Medication

Brexpiprazole (Rexulti): Brexpiprazole (Rexulti) is FDA-approved for agitation associated with Alzheimer’s dementia, working by targeting the serotonin and dopamine chemical pathways in the brain.

This atypical antipsychotic represents the first medication specifically approved for dementia-related agitation and can be effective for severe sundowning behaviors.

Other Medication Approaches

Melatonin:

• Natural hormone supplement that may help regulate sleep-wake cycles
• Typically given in low doses (1-3 mg) in the evening
• May be combined with morning bright light therapy
• Results vary considerably among individuals
• Generally well-tolerated with minimal side effects

Antidepressants:

• May help if underlying anxiety or depression contributes to sundowning
• Selective serotonin reuptake inhibitors (SSRIs) are commonly used
• Can take several weeks to show full effect

Antipsychotics:

• Reserved for severe cases with aggressive or dangerous behaviors
• Carry significant risks including increased stroke risk and mortality
• Should be used at lowest effective dose for shortest necessary duration
• Require careful monitoring by healthcare providers

Anxiolytics (Anti-anxiety Medications):

• May help reduce anxiety contributing to sundowning
• Must be used cautiously as some can worsen confusion
• Risk of falls and excessive sedation

Important Medication Considerations

• All psychoactive medications carry risks in elderly individuals with dementia
• Benefits must clearly outweigh potential adverse effects
• Start with lowest possible doses (“start low, go slow”)
• Never use over-the-counter sleep medications without physician approval—many can worsen confusion
• Medication should complement, never replace, behavioral and environmental interventions
• Regular review and reassessment of medication necessity and effectiveness
• Some medications may actually contribute to sundowning and should be eliminated if possible

Always work closely with healthcare providers specializing in geriatric care or dementia when considering medication options.

Caregiver Strategies and Self-Care

Managing sundowning takes a profound toll on caregivers, both physically and emotionally. Caregiver wellbeing directly impacts the quality of care provided.

Recognizing Caregiver Burden

Sundowning creates unique challenges for caregivers:

• Occurs during evening hours when caregivers are already fatigued
• Disrupts caregivers’ ability to relax, prepare dinner, or wind down
• Creates sleep deprivation when sundowning continues into nighttime hours
• Emotional distress from witnessing loved one’s confusion and agitation
• Social isolation as caregivers cannot leave home during difficult hours

Essential Self-Care Strategies

Accept Your Limitations:

• Understand that you cannot prevent all sundowning episodes
• Your best efforts may not always work, and this doesn’t reflect failure
• The behaviors stem from brain changes, not your caregiving abilities

Seek Regular Respite:

• Arrange for predictable breaks through adult day programs
• Use in-home respite care services during typical sundowning hours
• Consider short-term residential respite care for longer breaks
• Don’t wait until burnout occurs—schedule respite proactively

Connect with Support Networks:

• Join caregiver support groups, either in-person or online
• Connect with other caregivers who understand sundowning challenges
• Share strategies and emotional support
• Consider individual counseling if caregiving stress becomes overwhelming

Maintain Your Own Health:

• Prioritize adequate sleep, even if it means asking for overnight help
• Exercise regularly to manage stress and maintain physical health
• Eat nutritious meals and stay hydrated
• Continue hobbies and activities you enjoy
• Maintain medical and dental care for yourself

Ask for and Accept Help:

• Be specific when people offer help: “Can you sit with Mom from 5-7 p.m. on Tuesdays?”
• Build a support network of family, friends, and professionals
• Consider hiring professional caregivers specifically for sundowning hours
• Delegate tasks that others can handle

When to Seek Professional Help

Contact healthcare providers or consider additional support when:

• Sundowning behaviors suddenly worsen or change dramatically
• Current management strategies are no longer effective
• Behaviors pose safety risks to the person or caregiver
• You feel overwhelmed, depressed, or unable to cope
• Physical or verbal aggression occurs regularly
• You’re experiencing caregiver burnout symptoms: exhaustion, irritability, hopelessness

Planning for Progression

Sundowning typically intensifies as dementia progresses through middle stages before potentially subsiding in very advanced disease. Planning ahead helps families make informed decisions.

Anticipating Changing Needs

Document What Works: Keep a journal tracking:

• Specific triggers that worsen sundowning
• Strategies that successfully calm or prevent episodes
• Times of day when symptoms are worst
• Foods, activities, or approaches that help
• Medications and their effects

Share this information with all caregivers and healthcare providers.

Evaluate Care Options: As sundowning becomes more challenging to manage at home, consider:

• Increased in-home professional caregiving, particularly during evening hours
• Adult day programs that tire the person appropriately and provide structure
• Memory care facilities specializing in dementia management
• Skilled nursing facilities for advanced stages

Update Care Plans Regularly:

• Review management approaches every few months
• Adjust strategies as dementia progresses
• Communicate changes to all team members
• Revisit goals of care with healthcare providers

Memory Care Facilities and Sundowning

Professional memory care settings offer specific advantages:

• Staff trained in evidence-based dementia care approaches
• Structured environments designed to minimize sundowning triggers
• Optimized lighting and reduced stimulation during vulnerable hours
• Activity programming appropriate for various dementia stages
• Higher staff-to-resident ratios during challenging evening hours
• Round-the-clock monitoring and response to behavioral changes

Frequently Asked Questions About Sundowning

What time does sundowning usually start?

Sundowning most commonly begins between 3 p.m. and 5 p.m., with symptoms typically peaking during the evening hours between 5 p.m. and 8 p.m. However, timing varies considerably among individuals, and some may experience symptoms earlier or later in the day. Seasonal changes, particularly shorter winter days, can cause sundowning to start earlier.

How long do sundowning episodes last?

Duration varies significantly. Episodes typically last several hours during late afternoon and evening, though some individuals experience symptoms that persist throughout the night. In severe cases, nighttime sleep disruption caused by sundowning can extend the disturbed period for 8-12 hours or longer.

Can sundowning occur in the morning?

Yes, although less common. While the name “sundowning” refers to late-day symptoms, some individuals with dementia experience similar patterns of confusion, agitation, and behavioral changes during morning hours. The underlying mechanisms—circadian rhythm disruption and accumulated fatigue—can manifest at different times for different people.

At what stage of dementia does sundowning start?

Sundowning can appear at any stage of dementia but is most common during the middle stages of disease progression. Early-stage dementia patients may show mild, inconsistent symptoms. Middle-stage patients typically experience the most frequent and severe sundowning episodes. In very advanced dementia, sundowning may actually decrease as overall activity levels decline significantly.

Is sundowning the same as delirium?

No. While both involve confusion and behavioral changes, they’re distinct conditions. Sundowning follows a predictable daily pattern (usually late afternoon/evening), develops gradually with dementia progression, and is chronic. Delirium can occur at any time of day, has sudden onset, indicates an acute medical problem requiring urgent attention, and is potentially reversible when the underlying cause is treated.

Does sundowning mean dementia is getting worse?

Not necessarily. Sundowning frequency and severity often intensify as dementia progresses through middle stages, but this progression isn’t always linear. Some individuals experience sundowning relatively early in their disease course, while others may not develop it until later stages. Sudden worsening of sundowning, however, should prompt medical evaluation to rule out treatable conditions like infections.

Can sundowning be prevented completely?

Unfortunately, no. Sundowning stems from fundamental brain changes caused by dementia that cannot be fully reversed or prevented. However, the severity, frequency, and impact of sundowning episodes can often be significantly reduced through comprehensive management approaches including environmental modifications, structured routines, appropriate activities, and sometimes medications.

What should I do during a sundowning episode?

During an active episode: remain calm and speak soothingly, don’t argue or try to reason, validate their feelings without correcting their reality, check for unmet physical needs (hunger, thirst, bathroom, pain), gently redirect to calming activities, and ensure safety without physically restraining unless absolutely necessary. Take deep breaths yourself and remember the behaviors result from brain changes, not willful actions.

Are there any medications specifically for sundowning?

Brexpiprazole (Rexulti) is currently the only FDA-approved medication specifically for agitation associated with Alzheimer’s dementia, which includes severe sundowning behaviors. Other medications sometimes used off-label include low-dose melatonin for sleep-wake cycle regulation, certain antidepressants for anxiety, and antipsychotics for severe cases, though these carry significant risks and should be carefully considered with healthcare providers.

Will my loved one with dementia always have sundowning?

Not necessarily. Sundowning patterns can change over time. Some individuals experience sundowning for a period and then symptoms diminish, while others have persistent episodes throughout middle and later dementia stages. Research suggests sundowning may actually decrease in very advanced dementia when overall activity and awareness decline significantly.

Can changing diet help with sundowning?

Dietary factors can influence sundowning. Avoiding caffeine and sugar in the afternoon and evening, ensuring adequate hydration throughout the day, serving larger meals at lunch with lighter dinners, and addressing any nutritional deficiencies (particularly vitamin D) may help reduce symptom severity. However, diet alone is unlikely to eliminate sundowning and should be part of comprehensive management.

How does sundowning affect sleep?

Sundowning significantly disrupts sleep patterns for both the person with dementia and their caregivers. Evening agitation and confusion make falling asleep difficult, and when sundowning continues into nighttime, it causes frequent awakenings and overall sleep deprivation. This creates a vicious cycle where poor nighttime sleep increases daytime fatigue, which in turn worsens evening sundowning.

Should I correct my loved one when they’re confused during sundowning?

Generally, no. Attempting to correct or argue with someone experiencing sundowning typically increases agitation and distress without improving their understanding. Their perceptions feel completely real to them due to brain changes, and logical arguments cannot override this. Instead, validate their feelings, offer reassurance, and gently redirect to calming activities.

Is sundowning only a problem in dementia?

While most common in dementia, sundowning-like symptoms can occasionally occur in older adults without dementia, particularly during periods of significant stress, illness, or sleep deprivation. Hospitalized elderly patients sometimes experience similar late-day confusion. However, regular, persistent sundowning patterns typically indicate dementia or other significant cognitive impairment.

Can sundowning happen in assisted living or nursing homes?

Yes, sundowning occurs in all care settings including assisted living facilities, memory care units, and nursing homes. In fact, institutional factors like shift changes around 3 p.m., reduced afternoon activities, and lower staff-to-resident ratios in evening hours can sometimes worsen sundowning. Quality memory care facilities implement specific protocols to minimize these triggers.

Conclusion

Understanding what time sundowning occurs, typically beginning in the late afternoon between 3 p.m. and 5 p.m. and continuing through evening hours—provides the foundation for effective management. This knowledge enables caregivers to anticipate difficult periods, implement preventive strategies, and respond appropriately when symptoms emerge.

Sundowning represents one of the most challenging aspects of dementia care, affecting up to 20-45% of individuals with Alzheimer’s disease and significantly impacting both patients and caregivers. While it cannot be completely prevented or cured, the severity and impact of sundowning can be substantially reduced through comprehensive approaches combining environmental modifications, structured routines, appropriate activities, and sometimes medical interventions.

The key principles for managing sundowning include:

• Maximizing natural light exposure and maintaining optimal lighting throughout the day
• Establishing consistent, predictable daily routines with appropriately timed meals and activities
• Reducing environmental stimulation and potential triggers during vulnerable late-day hours
• Proactively addressing physical needs before confusion intensifies
• Using calm, validating communication rather than correction or argumentation
• Considering evidence-based interventions like light therapy and music therapy
• Reserving medication for situations where behavioral approaches alone are insufficient

Remember that every person with dementia is unique. What effectively manages sundowning for one individual may not work for another. Patience, flexibility, willingness to experiment with different approaches, and ongoing communication with healthcare providers are essential for finding the right combination of strategies.

Perhaps most importantly, caregivers must prioritize their own wellbeing alongside the care they provide. Managing sundowning is exhausting and emotionally draining work. Seeking respite care, accepting help, connecting with support networks, and maintaining your own physical and mental health aren’t luxuries—they’re necessities that enable you to continue providing quality care.

By understanding sundowning timing patterns, implementing evidence-based management strategies, and maintaining realistic expectations, you can help minimize the distressing effects of late-day confusion and improve quality of life for both individuals with dementia and their devoted caregivers.