What is Sundowning Behavior? Understanding Late-Day Confusion

If you are caring for someone living with dementia, you might notice that they become more irritable or confused during the late afternoon or evening. No, you are not imagining it; it’s an actual occurrence called sundowning. 

Sundowning can cause individuals living with dementia to feel more restless, agitated, or confused. These expressions typically coincide with the daylight beginning to fade. These symptoms can sometimes continue throughout the night, making it hard for a person living with dementia (and their care partner) to get a restful night’s sleep. 

Like many aspects of dementia caregiving, sundowning behavior can make you feel like you are in over your head. However, sundowning can be managed with the proper knowledge, preparation, and attitude. 

Understanding Sundowning 

Most adults have a natural circadian rhythm or biological clock. Even without an alarm clock, many of us wake up around the same time, know when it’s time to eat, and know when to go to sleep at night. However, for those living with dementia, changes in the brain can impact these biological clocks and lead to confused sleep-wake cycles, resulting in confusion, restlessness, or disorientation during the evenings. 

Other potential causes of sundowning include:

• Exhaustion
• Boredom
• Depression
• Unmet needs (Hunger, thirst, or an infection like a UTI)

External factors can also contribute to sundowning symptoms, such as background noise and low lighting, which can increase the presence of shadows and lead a person living with dementia to have a difficult time seeing and leads to an increase in anxiety. 

Ways to Minimize Sundowning Behaviors

When managing any symptoms associated with dementia, it’s essential to take a kind, positive approach. Orienting yourself to your family member’s reality can make their expressions easier to understand and manage. 

For example, imagine if you had spent the entire day trying to keep up and make sense of an unfamiliar and confusing environment. By the end of the day, you might be exhausted and irritated too. Or if your body tells you it should be up and pacing at 3:00 a.m., but your caregiver tells you it should be in bed, you would be confused and frustrated. 

These sundowning behaviors, expressions, and actions are all stemming from something, and as a dementia care partner, it’s your job to determine (and prevent, if possible) these triggers. 

Here are some practical tips for managing sundowning expressions: 

Create a routine. Even though changes in the brain can disrupt a person with dementia’s biological clock, establishing a daily routine can help counter this loss and strengthen their sleep-wake cycle. Encourage a regular routine of waking up, eating, doing stimulating activities, and winding down in the evening. 

Plan activities in the morning or early afternoon. If you are going on an outing, going to a doctor’s appointment, or even hosting visitors, try planning these activities for the morning when your family member is more alert.

Try to get enough physical activity and sun exposure during the day. Moving enough during the day can encourage sleepiness at night. Bonus points if you can do some activities outside as exposure to natural light during the day can help restore a person’s biological clock. 

Avoid afternoon naps. If needed, allow your family member to have a quick rest or nap during the day, but (if possible) try to avoid naps later into the afternoon as it can negatively affect their sleep at night.

Establish a calming environment during the evenings. When sundowning is most likely to occur, ensure that you’ve created a soothing atmosphere. Close the blinds and turn on the house lights to avoid shadows, play calming music, and diffuse lavender essential oils. When it comes to activities in the evening, try to avoid stimulating activities like watching television. Instead, try playing a card game, going on a walk, or looking at old photos. 

Observe behaviors and keep notes. Pay close attention to your family member’s behaviors and try to identify triggers.

• What were they doing right before they became agitated? 
• Do they only experience sundowning on certain days, and what is different about those days? 
• Is there any need that could be unmet (for example, when was the last time they ate, drank, went to the bathroom, etc.)? 

Keeping track of these behaviors can help manage sundowning behaviors and can be valuable in dementia care as a whole. After all, you are their biggest advocate, so being as informed as possible can be extremely beneficial. 

Managing Sundowning 

Sometimes, even with the right prevention, your loved one will still experience agitation, confusion, or restlessness during the evening. If your family member is experiencing symptoms of sundowning, you must communicate with them in a positive, soothing manner. Use the following tips: 

• Approach them from the front and if they are sitting down, get on their level 
• Speak to them in a low, calming voice
• Determine if there’s anything that they need right away, such as a glass of water or a blanket 
• Never get frustrated, accusatory, or raise your voice 
• Try to engage them in an activity 

Creating Joyful and Positive Evenings 

Sundowning can make many care partners feel frazzled and exasperated at a time of day when they simply want to relax. However, it’s important to remember that your family member is not choosing to act this way. By putting yourself in their position and ensuring they have sufficient activity during the day and everything they need at night, you can handle sundowning behaviors confidently. 

Of course, if sundowning persists, even after trying the suggested methods, always consult your loved one’s physician. 

At Bella Groves, we are dedicated to helping families to feel confident in their abilities to think through the different scenarios they may experience when caring for a person living with dementia. Our dementia care community in San Antonio offers residential support to those with dementia, while our information and coaching options provide resources, strategies, and encouragement to help all care partners. To discover more about what we do and why, we encourage you to visit our website.