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Caring for Loved Ones: At What Stage of Dementia Is Sundowning a Concern?

As the sun begins to set, a strange thing often occurs in the world of senior care, especially dementia care. It’s called “sundowning,” and it can make the evenings quite challenging for both, the elderly and their caregivers. But when exactly should we start worrying about sundowning?

In this article, we’ll discuss various stages of dementia to see when sundowning becomes a real concern. Whether you’re a caregiver, a family member, or simply interested in understanding sundowning syndrome, keep reading to navigate this important aspect of caregiving.

An older woman is sitting confused and shocked while holding a phone - whats sundowning

What is Sundowning Syndrome?

Sundowning Syndrome refers to a particular pattern of behavior that mostly affects older adults, mainly those suffering from Alzheimer’s disease or other forms of dementia. It is characterized by confusion, agitation, and restlessness that worsen during the late afternoon and evening hours. As the name indicates, it typically starts as the sun begins to go down or set and is also known as ‘late day confusion’.

Medical Definition of Sundowning

Sundowning is not classified as a specific medical condition but rather as an umbrella term that describes symptoms associated with dementia, especially Alzheimer’s disease. Medical professionals often refer to it as “sundown syndrome” or “sundowning behavior.” While it’s not a definitive diagnosis, recognizing these symptoms is crucial for providing appropriate care and support to affected seniors.

A senior man is sitting and being comforted by his wife - what is sundowners dementia

Impact of Sundown Behavior on Seniors

Sundowning can be perplexing and distressing for both seniors experiencing it and their caregivers. It may present in a range of behavioral changes, which include confusion, anxiety, mood swings, restlessness, and even physical aggression. These symptoms often become more apparent as the day progresses, especially in the late afternoon and evening, and may fade away during the night.

The impact of sundowning on seniors is quite significant. It disrupts their daily routines, leading to sleep disturbances, and can result in exhaustion and increased dependence on caregivers. These behavioral changes are also distressing for family members who may not fully understand the reasons behind these unusual shifts in their loved one’s behavior.

How to Differentiate Sundowning from Other Conditions

It’s essential to differentiate sundowning from other related conditions that may affect older people, as this would influence treatment strategies and care approaches. Some of the conditions that may share symptoms with sundown syndrome include:

  1. Delirium: It is a sudden and severe state of confusion and reduced consciousness that may result from prolonged illness, salt imbalance in the body, infections, or drug interactions. Unlike sundowning, delirium typically has an acute onset and can fluctuate in severity throughout the day.
  2. Depression: It is a common mood disorder that can affect not only the elderly but people of any age. While depression causes symptoms like sadness, withdrawal, and irritability, it tends to be persistent throughout the day rather than worsening in the late afternoon and evening.
  3. Anxiety: It leads to panic, nervousness, and agitation, similar to sundowning. However, anxiety-related symptoms are not necessarily tied to specific times of day and can occur at any time.

Recognizing Sundowning Symptoms and Changes in Behavior

Diagnosis of sundowning - what is sundowning in the elderly

Caregivers can plan better and manage the challenges of any disease in the elderly when they understand its common signs, symptoms, and contributing factors. But what signs make it more crucial for caregivers to monitor changes in seniors with sundowning? Let’s find out.

Increased Confusion and Disorientation

One of the hallmark symptoms of sundowning is an increase in confusion and disorientation during the late afternoon and early evening hours. Seniors with sundowning may suddenly become unaware of their surroundings, not recognizing familiar places, even within their own homes. This heightened confusion can lead to anxiety and fear, requiring caregivers to be vigilant and provide reassurance.

Agitation and Restlessness

Sundowning often brings about a sense of restlessness and agitation. Your loved one may become restless, unable to sit still, and may constantly change positions. This uneasiness becomes distressing for both the seniors and their caregivers. Engaging them in calming activities or creating a soothing environment may help manage it.

Hallucinations and Paranoia During Sundowning

Some seniors with sundowning may suffer from hallucinations, which are vivid sensory imaginations of things that are not there. These hallucinations are particularly challenging for caregivers to handle as the seniors believe them to be real. Sundowning can also trigger paranoia in the elderly, causing them to become suspicious or fearful of others around them. Caregivers need to approach such situations with patience and empathy, as their support and comfort can go a long way in easing these distressing times.

Mood Swings and Irritability

Sundowning also results in significant mood swings, with seniors rapidly cycling through different emotional states. They may go from calm to irritable, sad, or anxious within a short time. Caregivers should be prepared for these mood fluctuations. They should know the useful strategies to help mitigate their impact on the seniors’ well-being.

What Factors Affect the Severity of Sundowning?

Many factors contribute to the severity of sundowners syndrome. Let’s discuss each of these factors to get a better understanding of how they affect the severity of sundowning behavior.

A senior woman with sundowning is having a headache due to noise - sundowning in dementia patients

Biological Factors

Biological factors play a crucial role in the severity of sundowning. These factors are related to changes occurring within the elderly’s body.

  • Changes in the Brain

Sundowning is often associated with changes in the brain, particularly in seniors with Alzheimer’s disease. As the disease progresses, brain regions responsible for regulating mood, sleep, and behavior undergo degenerative changes. These changes affect the seniors’s ability to deal with the outside environment, leading to increased vulnerability to sundowning episodes.

  • Circadian Rhythm Disruption

The body’s internal clock, known as the circadian rhythm, regulates the sleep-wake cycle and various physiological processes. Disturbance in this rhythm leads to confusion and agitation, especially during the evening hours. External factors, such as insufficient exposure to natural light during the day, worsen these disturbances.

  • Sensory Overload

Elderly with dementia may experience sensory overload, where they feel overwhelmed by external sensory stimuli such as noise, light, or unfamiliar and distracting surroundings. This overload contributes to the severity of sundowning, as their ability to process and filter sensory information diminishes.

  • Fatigue

Fatigue significantly impacts the intensity of sundowning episodes. As the day progresses, seniors with dementia may become physically and mentally tired. It makes it harder for them to manage their emotions and behaviors. This exhaustion can aggravate the symptoms of sundown behavior.

  • Sleep Disturbance

Seniors with dementia often experience broken sleep patterns or insomnia. Poor sleep quality can worsen the sundowning symptoms, as it contributes to overall irritability and cognitive impairment.

  • Dehydration

Older adults are at a higher risk of dehydration due to less awareness of thirst and difficulty in communicating their needs. Dehydration leads to physical discomfort and confusion, both of which can make sundowning behaviors more severe.

Environmental Factors

Environmental factors can significantly influence the occurrence and severity of sundowning.

  • Lighting and Noise

Inadequate lighting and excessive noise contribute to the severity of the symptoms. Poor lighting causes disorientation and increases the likelihood of falls or accidents, while loud noises agitate and distress the elderly. Create a calm and well-lit environment to help reduce the severity of sundowning episodes in them.

  • Physical Disruption in the Space

Changes in the physical environment, such as rearranging furniture or introducing unfamiliar objects, often trigger confusion and agitation in seniors with dementia. Maintaining a consistent and familiar living space minimizes confusion and agitation.

  • Change of Environment

Transitions or changes in the environment, such as moving to an assisted living, can aggravate sundowning symptoms in the elderly. Those with dementia often find comfort in familiarity, so disruptions to their living situation can exacerbate their condition.

older woman sitting and feeling depressed - sundowning depression

Medication and Underlying Conditions

Some other factors that play a significant role in increasing the severity of sundowning syndrome include:

  • Medication

Some medications prescribed for seniors with dementia may have side effects that contribute to sundowning symptoms. Since older people are usually on a list of medications, It’s essential for caregivers and the healthcare team to monitor the effects of drugs and any possible drug interactions in the elderly. Then, they would adjust prescriptions as needed to minimize these adverse reactions.

  • Comorbid Health Conditions

People with dementia often have coexisting health conditions. Conditions such as pain, infections, or metabolic disturbances can increase agitation and confusion, It may lead to sundown behavior, making it crucial to address these underlying health issues.

Caregiver Approach

The approach taken by caregivers can have a profound impact on the severity of sundowning episodes. Caregivers who provide a calm, reassuring, and empathetic presence help lessen the severity of sundowning. Communication techniques that focus on validation and redirection, rather than confrontation, are particularly effective in minimizing challenging behaviors.

Sundowning in Different Stages of Dementia

Research shows that the prevalence of sundowning in seniors with dementia, especially Alzheimer’s is up to 66%. However, symptoms of sundowning vary in different stages of dementia. In early dementia, it’s not quite obvious but with the progression of dementia, sundowning also worsens.

Sundowning in Various Stages of DementiaBehavioral ChangesPhysical Changes
Early Stages

– Confusion and delusions in the afternoon and evening hours

– Disorientation and restlessness

– May struggle to recognize familiar faces, places, or objects.

– Agitation and anxiety

– Fatigue

– Increased sensory sensitivity

– Sleep disturbance

– Drowsiness in the day

– Reduced level of activity

– Difficulty in verbal communication

Moderate to Advanced Stages

– Symptoms from early stages progress and worsen over time

– Hallucinations

– Mood swings

– Increased clinginess

– Aggressive behavior

– Increased triggers

– Increased fatigue and lethargy

– Changes in appetite

– Physical aggression

– Difficulty in ADLs

– Pacing or Wandering

– Difficulty in communicating their pain and discomfort


Managing Sundowning and Providing Care for Seniors

You need to adopt a comprehensive approach to effectively manage sundowning. Caregivers, whether they are family members or hired, can play an impactful role in using management strategies to improve the overall well-being of their senior loved ones.

senior woman sleeping with an alarm clock on the side table - sundowning dementia treatment

Develop a Routine

Seniors tend to feel more secure and less anxious when they have a clear routine. Set consistent times for their meals, naps, and bedtime to provide them with a sense of stability.

Create a calming environment. As the evening approaches, dim the lights, reduce noise, and declutter living spaces. This helps create a peaceful atmosphere, reducing agitation. Limiting stimulants like caffeine and sugar, especially in the afternoon and evening, also minimizes undue restlessness and helps maintain a sense of calm.

Engage in Stimulating Activities

Encourage the elderly to engage in regular physical activity. Simple exercises like a short walk or seated yoga can boost mood and improve sleep patterns. Loneliness and isolation can also worsen sundowning. Make arrangements for their visits with friends, family, or group activities to provide companionship.

Arrange fun activities to stimulate their minds. Engage seniors in activities like puzzles, memory games, or simple tasks that challenge cognitive function, promoting mental agility. Find out their interests such as painting, gardening, or playing musical instruments, and organize those activities to keep them active and engaged throughout the day.

Promote Quality Sleep

Create a relaxing bedtime routine, and establish a calming pre-sleep ritual, such as reading a book or listening to soothing music, to signal the body that it’s time to rest.

Consult a healthcare provider to identify and manage any existing sleep disorders like sleep apnea or insomnia, which can intensify sundowning symptoms.

Treatments for Sundowning

Regularly consult a healthcare professional to assess the necessity and effectiveness of medications. Adjust doses or explore alternative treatments if required. It’s important to communicate your concerns about sundowning to a healthcare professional who can offer expert guidance and create a tailored care plan.

Keep a close watch on the impact of medications and check with your healthcare team to ensure they are optimized for the best results. Besides medication, there are many non-drug approaches like light therapy, aromatherapy, or relaxation techniques to alleviate sundowning symptoms.

Role of Caregivers (Both Family and Hired)

Recognize that sundowning behaviors are not deliberate actions; they stem from cognitive changes. Approach your loved one with patience and understanding. Use clear and simple communication to minimize confusion and frustration. Offer reassurance and comfort when needed.

Keep a detailed record of sundowning episodes, including triggers and responses. Share this information with the healthcare team to refine and improve care strategies.

By adopting these holistic strategies and involving caregivers in a proactive and empathetic manner, managing sundowning in seniors can become a more manageable and less distressing aspect of caregiving.

Supporting the Caregiver and the Importance of Self-Care

Sundowning impacts not only the elderly but also their caregivers. Let’s look into some difficulties faced by caregivers and the vital role of self-care in maintaining caregivers’ health.

Impact of Sundowning on Caregivers’ Well-being

  • Emotional strain: Sundowning episodes can be emotionally draining for caregivers. It becomes hard to witness the distress and confusion of your beloved senior. It can leave you feeling exhausted, anxious, and overwhelmed.
  • Physical demands: Older people with sundowning may require constant attention and assistance, which can be physically draining. The physical demands of caregiving, such as helping the elderly move around or ensuring their safety, can lead to fatigue and muscle strain.
  • Sleep disruption: Seniors with sundowners syndrome often experience sleep disturbances, which, in turn, disrupt the caregivers’ sleep patterns. Sleep deprivation can affect your mood, cognitive abilities, and overall health.

Human hand with a watering can put out brain fire - sundowners treatment

Resources for Managing Caregiver Stress

  1. Education and training: Proper education and training are essential for caregivers to understand and effectively manage sundowning behaviors. Learning strategies to manage situations and communicate with the elderly can significantly reduce stress.
  2. Time management: Following structured daily routines can make caregiving more manageable. Consistency helps both the elderly and the caregiver feel more in control, reducing stress and anxiety.
  3. Using technology: In today’s digital age, there are various apps and devices designed to assist caregivers. These tools can help track the elderly’s behavior, set reminders for medications, and ensure their safety, offering peace of mind.
  4. Respite care: Caregivers need regular breaks. Respite care services can provide temporary relief, allowing caregivers to recharge, pursue their own interests, or simply relax.

Seeking Support from Support Groups

Group therapy for senior caregivers - how to deal with sundowners

  1. Local organizations: Many communities have organizations, charities, or non-profits dedicated to supporting caregivers of seniors with sundowning. These groups can provide valuable resources, guidance, and even financial assistance.
  2. Support groups: Joining a caregiver support group can be incredibly beneficial. These groups offer a safe space to share experiences, exchange coping strategies, and receive emotional support from others who understand the challenges you face.
  3. Online forums: The internet has made it easier to connect with caregivers worldwide. Online forums and communities provide a platform to seek advice, vent frustrations, and find camaraderie with people who are going through similar experiences.

Recognizing the Importance of Self-Care

  • Prioritizing self-care: When you’re at your best, you can provide better care for seniors. Think of it as putting on your oxygen mask before assisting others on an airplane.
  • Physical well-being: Regular exercise, a balanced diet, and adequate sleep are your allies in maintaining physical health. These elements contribute to your stamina, energy levels, and overall resilience as a caregiver.
  • Mental health: Don’t hesitate to seek professional help if you’re struggling emotionally. Therapy or counseling can provide tools to manage stress, anxiety, and depression effectively.
  • Respite and breaks: Scheduling regular breaks is not a luxury; it’s a necessity. Arrange respite care for your seniors and use this time to engage in activities you enjoy, spend quality moments with friends and family, or simply unwind.


Remember, caring for individuals with sundowning dementia requires you to show unwavering compassion, patience, and adaptability. You need to understand that every individual’s experience with sundowning is unique. The key is to approach each situation with a willingness to adapt your management plan to their specific needs.

Senior and caregivers holding hands - sundowners in the elderly

If you or someone you know is in need of assistance and care for a loved one with sundowning, reach out to Amy’s Eden. Our dedicated team specializes in providing a nurturing and supportive environment for your loved ones living with sundowning.

Contact us today to learn more about the personalized care and services we offer to help your loved one thrive in a safe and compassionate home-like setting.

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