Understanding and Managing Sundowning in Dementia Patients

Road ahead and the sunset

As the sun sets and the world transitions from the brightness of day to the calm of night, many of us find solace in the evening’s tranquility. However, for a significant number of dementia patients, this time of day can bring about a perplexing and distressing phenomenon known as “sundowning.” Characterized by a sudden onset of confusion, agitation, and restlessness as the day comes to a close, sundowning is a term that has become all too familiar to caregivers and loved ones of those with dementia. But what exactly triggers this condition, and how does it impact the daily lives of those affected? In this blog, we will delve deep into the enigma of sundowning, shedding light on its causes, manifestations, and the ways in which caregivers can navigate this challenging aspect of dementia care. Join us as we explore the twilight struggle faced by countless dementia patients and seek to understand the mysteries of the mind that unfold as the sun goes down.

Sundowning: An Overview and Its Manifestations

Sundowning, often referred to as “late-day confusion,” is a symptom commonly associated with Alzheimer’s disease and other forms of dementia. It refers to a range of behavioral and psychological changes that typically occur in the late afternoon or evening, as daylight begins to fade. Sundowning can manifest in several different ways, including: 

Increased Agitation: 

One of the most common signs of sundowning is an increase in restlessness or agitation. Patients may become more anxious, pacing back and forth or expressing discomfort.

Mood Swings: 

A person experiencing sundowning might suddenly become sad, angry, or scared without any apparent reason. Their mood can shift rapidly, making it challenging for caregivers to predict or understand their reactions.


As the day progresses, individuals may become more disoriented or confused about their surroundings. They might not recognize familiar places, people, or even understand the current time of day.


Some dementia patients may see or hear things that aren’t there during episodes of sundowning. These hallucinations can be distressing and lead to further agitation.


Feelings of suspicion or mistrust can intensify during the evening. A patient might believe that someone is trying to harm them or that their belongings are being stolen.

Sleep Disturbances: 

Sundowning can disrupt the sleep-wake cycle. Individuals might have difficulty falling asleep, wake up frequently during the night, or experience increased daytime sleepiness.

Understanding sundowning is crucial for caregivers and loved ones, as it can significantly impact the quality of life for dementia patients. By recognizing its manifestations, appropriate interventions and strategies can be implemented to provide comfort and reduce the severity of symptoms.

Sundowning Explained:

Sundowning, while commonly observed in dementia patients, is not entirely understood in terms of its exact neurological causes. However, several theories and factors related to brain changes in dementia patients have been proposed to explain the phenomenon:

  • Circadian Rhythm Disruption: The brain has an internal “clock” that regulates our sleep-wake cycle, known as the circadian rhythm. Dementia can disrupt this rhythm, leading to disturbances in sleep and wakefulness. As a result, individuals may become more agitated or confused as the day progresses.
  • Brain Degeneration: In Alzheimer’s disease and other dementias, there’s a progressive degeneration of brain cells. Areas of the brain responsible for mood regulation, sleep, and cognition are affected. This degeneration can contribute to the symptoms of sundowning.
  • Reduced Light Perception: The retina’s ability to perceive light can influence the brain’s production of melatonin, a hormone that regulates sleep. Dementia can affect the pathways between the retina and the brain, leading to reduced light perception and subsequently, disturbances in melatonin production.
  • Neurotransmitter Imbalance: Neurotransmitters are chemicals in the brain that facilitate communication between nerve cells. Dementia can disrupt the balance of neurotransmitters, particularly those involved in mood regulation, such as serotonin. An imbalance can lead to mood swings and agitation, especially in the evening.
  • Sensory Overload: As dementia progresses, the brain’s ability to process sensory information diminishes. By evening, the accumulation of stimuli from the day can lead to sensory overload, resulting in confusion and agitation.
  • Fatigue: Cognitive tasks can be more demanding for individuals with dementia. As the day progresses, cognitive fatigue can set in, making it harder for the brain to process information and leading to increased confusion and irritability.
  • Other Underlying Conditions: In some cases, other medical conditions or the side effects of medications can exacerbate the symptoms of sundowning. For instance, infections, pain, or metabolic imbalances can contribute to increased confusion and agitation.

It’s important to note that while these factors provide some insight into the potential causes of sundowning, the phenomenon is multifaceted and may vary from one individual to another. Ongoing research aims to better understand the intricate interplay of these factors and develop more effective interventions for those affected by sundowning.

How Neurologists Manage Sundowning in Dementia Patients: 

Sundowning can be a challenging symptom to manage, but with a comprehensive approach, its impact can be mitigated. When a neurologist is involved in the care of a patient experiencing sundowning, they typically employ a combination of non-pharmacological interventions and, when necessary, pharmacological treatments. Here’s how a neurologist might approach the treatment of sundowning:

Non-Pharmacological Interventions:

  • Structured Routine: Establishing a consistent daily routine can help orient the patient and reduce confusion. Predictable meal times, sleep schedules, and activities can provide a sense of security.
  • Light Therapy: Exposure to bright light during the day can help regulate the circadian rhythm and improve sleep patterns. Some studies suggest that using bright lights in the evening can reduce sundowning symptoms.
  • Evening Calmness: Reducing noise, dimming lights, and creating a calm environment in the evening can help reduce agitation. Soft music or nature sounds might also be soothing.
  • Physical Activity: Engaging the patient in regular physical activity during the day can promote better sleep at night and reduce restlessness in the evening.
  • Cognitive Stimulation: Activities such as puzzles, reading, or crafts can keep the mind engaged and reduce the onset of evening confusion.
  • Safe Environment: Ensuring the environment is safe can reduce the risk of injury. This includes removing tripping hazards, using night lights, and possibly using bed alarms for those who might wander.
  • Limiting Caffeine and Sugar: Reducing the intake of caffeine and sugar, especially in the afternoon and evening, can help improve sleep and reduce agitation.

Pharmacological Interventions:

  • Sleep Medications: If sleep disturbances are a significant issue, a neurologist might prescribe sleep aids. However, these are used cautiously, as some can exacerbate confusion.
  • Antipsychotic Medications: In cases where behavioral symptoms are severe, antipsychotic medications like risperidone or olanzapine might be considered. These are used judiciously due to potential side effects.
  • Anti-Anxiety Medications: Drugs like lorazepam or buspirone can be used to reduce anxiety and agitation. However, they should be used with caution in dementia patients due to potential side effects like increased confusion or falls.
  • Cholinesterase Inhibitors: Medications like donepezil, which are used to treat Alzheimer’s disease, can sometimes help reduce the symptoms of sundowning.
  • Mood Stabilizers: In some cases, mood stabilizers like valproic acid might be used to manage mood swings associated with sundowning.
  • Regular Medication Review: It’s essential for the neurologist to regularly review all medications the patient is on. Some drugs can exacerbate sundowning symptoms, and adjustments might be needed.

It’s important to note that non-pharmacological interventions are often the first line of treatment, with medications being introduced when necessary and under careful monitoring. Collaboration with caregivers, therapists, and other healthcare professionals is crucial for a holistic approach to managing sundowning.

In Conclusion:

In the intricate journey of understanding and managing dementia, sundowning stands out as a particularly challenging phenomenon. While its exact causes remain a subject of ongoing research, the combined efforts of neurologists, caregivers, and other healthcare professionals have paved the way for a range of interventions that can mitigate its impact. By blending non-pharmacological strategies with judicious use of medications, it’s possible to offer dementia patients a better quality of life during the twilight hours. As we continue to delve deeper into the mysteries of the brain, our collective hope is that we’ll uncover even more effective ways to support those grappling with the challenges of sundowning, ensuring their evenings are marked by peace and comfort.

Headshot of Premier Neurology & Wellness Center Practitioner Kashouty

Dr. Kashouty, a diplomate of the American Board of Psychiatry and Neurology (ABPN), practices general neurology with fellowship trained specialization in clinical neurophysiology. Dr. Kashouty finds the form and function of the nerves and muscles the most interesting part of neurology, which is what led him to specialize in neurophysiology with more emphasis on neuromuscular conditions. He treats all neurological diseases, but his main focus is to treat and manage headaches, movement disorders and neuromuscular diseases.