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Sundowning is a common dementia symptom where confusion, agitation, and anxiety increase dramatically in the late afternoon and evening. Also called late-day confusion, it affects up to 66% of people with dementia and typically begins around 3-4pm, continuing into the night. The exact cause isn't fully understood, but it's linked to disrupted body clocks, fatigue, and reduced light levels affecting the brain.
What Does Sundowning Look Like?
Sundowning symptoms can vary between individuals but typically include increased restlessness, pacing, confusion about time and place, aggressive behaviour, anxiety or fear, difficulty sleeping, and demanding to "go home" even when already there. Some people may become suspicious of family members or carers, whilst others experience mood swings or repetitive behaviours.
The symptoms often follow a pattern. Many people with dementia function relatively well during morning hours but deteriorate as the day progresses. By late afternoon, they may become increasingly distressed, confused, or combative. This can be exhausting for both the person experiencing it and their family carers.
Why Sundowning Happens
Several factors contribute to sundowning in dementia. The brain's internal clock becomes damaged by dementia, disrupting natural sleep-wake cycles. As natural light decreases in the evening, this confusion worsens. Mental and physical fatigue from the day's activities can overwhelm someone whose brain is already struggling to process information.
Environmental factors also play a role. Increased shadows and dim lighting can create visual confusion or fear. Busy household routines during evening hours like preparing dinner, children returning from school, partners coming home from work - can overstimulate someone with dementia. Changes in routine, unfamiliar environments, or even hunger and thirst can trigger episodes.
Certain medical conditions make sundowning worse, including infections, pain, medication side effects, and sleep disorders. Depression and anxiety, common in dementia, can also intensify late-day symptoms.
Managing Sundowning: Practical Strategies
Create a Consistent Evening Routine
Establish a calm, predictable evening schedule. Keep activities simple and avoid overstimulation. Dim overhead lights gradually and use table lamps or natural light when possible. Avoid large meals, caffeine, and alcohol in the evening, but ensure the person isn't hungry or thirsty.
Manage the Environment
Close curtains or blinds before shadows become prominent. Maintain comfortable room temperature and reduce noise from televisions, radios, or busy family activities. Consider playing soft, familiar music that the person enjoys.
Use Light Therapy
Exposure to bright light during morning and afternoon hours can help regulate disrupted body clocks. Light therapy boxes, available from medical suppliers, can be beneficial when used consistently. Ensure the person spends time in natural daylight during the day, weather permitting.
Plan Activities Wisely
Schedule more stimulating activities for morning hours when the person typically feels better. Save quiet, calming activities for late afternoon and evening. Avoid medical appointments, shopping trips, or other potentially stressful activities during the late afternoon period.
Address Basic Needs
Ensure the person isn't experiencing pain, hunger, thirst, or needing the toilet. These basic discomforts can trigger or worsen sundowning episodes. Check that clothing is comfortable and the room temperature is appropriate.
When to Seek Professional Help
Contact your GP if sundowning symptoms are severe, getting worse, or significantly impacting quality of life. They can assess for underlying medical causes such as infections, medication reactions, or other health issues that might be contributing to the problem.
Consider discussing medication options if behavioural strategies aren't sufficient. Some medications can help manage anxiety or sleep disturbances associated with sundowning, though these should always be carefully monitored.
Occupational therapists can assess the home environment and suggest modifications to reduce triggers. Community mental health teams specialising in dementia can provide additional support and strategies.
Supporting the Family
Sundowning doesn't just affect the person with dementia - it's exhausting for family carers too. The timing of symptoms often coincides with the busiest time of day for households, creating additional stress.
Consider arranging additional support during peak sundowning hours. This might involve family members sharing care duties, hiring professional carers for late afternoon periods, or exploring day centre options that extend into early evening.
Respite care becomes particularly important for families dealing with sundowning. Regular breaks allow carers to recharge whilst ensuring their loved one receives appropriate care during difficult periods.
The Role of Professional Dementia Care
Specialist dementia care services understand sundowning and can provide structured environments designed to minimise triggers. Professional carers are trained to recognise early signs of agitation and implement calming strategies before symptoms escalate.
Care homes specialising in dementia often have specific protocols for managing sundowning, including adjusted lighting, structured evening activities, and one-on-one support during difficult periods. The consistent routine and trained staff can significantly reduce the frequency and severity of episodes.
How We Manage Sundowning at Ashberry Care Homes
At Ashberry Care Homes, we understand that sundowning can be one of the most distressing aspects of dementia for both residents and their families. We've developed comprehensive approaches to minimise its impact and help residents feel calm and secure during vulnerable evening hours.
We carefully adjust lighting throughout our homes as afternoon transitions to evening, using warmer, dimmer lights rather than harsh overhead lighting. Our communal areas are designed with comfortable seating arrangements that face away from windows during late afternoon hours, reducing the visual confusion that shadows can create.
Our activity coordinators schedule engaging but gentle activities for the early evening period - familiar music sessions, reminiscence activities, or quiet crafts that provide comfort without overstimulation. We've found that one-on-one time with familiar staff members during peak sundowning hours can be particularly effective.
We maintain detailed records of each resident's sundowning patterns, allowing us to anticipate difficult periods and intervene early. Our staff are trained to recognise the subtle signs that precede sundowning episodes - restlessness, increased confusion, or changes in speech patterns - so we can provide support before distress escalates.
Most importantly, we ensure families feel supported too. We keep detailed notes about what strategies work best for each resident and share these insights during visits. Our door is always open for families to call during evening hours if they're concerned about their loved one, providing peace of mind during what can be the most worrying time of day.
Long-Term Outlook
Sundowning patterns can change over time. Some people experience it only during certain stages of dementia, whilst others may have ongoing challenges. The strategies that work can also evolve, requiring ongoing adjustment of approaches.
Working with healthcare professionals, family members can develop comprehensive care plans that address both the immediate challenges of sundowning and longer-term care needs. Early intervention with behavioural strategies often proves more effective than waiting until patterns become deeply established.
Key Points to Remember
Sundowning is a medical symptom, not something the person can control or is doing deliberately. Staying calm and patient during episodes helps prevent escalation. Consistent routines, environmental modifications, and professional support can significantly reduce symptoms.
Most importantly, families shouldn't struggle alone with sundowning. Professional help is available, from GP consultations to specialist dementia care services. Understanding that this is a recognised part of dementia progression can help families seek appropriate support and maintain their own wellbeing whilst caring for their loved one.
With the right strategies and support, sundowning can be managed effectively, allowing both the person with dementia and their family to maintain better quality of life during this challenging aspect of the condition.
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