Sundown Syndrome

What is sundowning?

Sundowning is the name for a group of behaviors, feelings and thoughts people who have Alzheimer's or dementia can experience as the sun sets. The behaviors start or get worse around sunset or sundown. However, this delirium can potentially occur at any time, not just at sunset.

Also known as late-day confusion, sundowners syndrome or sundown syndrome, sundowning is most often experienced by people with dementia, a group of symptoms that can affect:

• Memory.
• Thinking.
• Personality.
• Reasoning.
• Behavior.
• Mood.

Around 20% of people diagnosed with Alzheimer’s disease experience sundowning at some point.

What are sundowning behaviors, feelings and thoughts?

Some of the behaviors associated with sundowning are specific to the time of day, while other behaviors can be common at any time for a person with dementia. Behaviors associated with sundowning include:

• Pacing.
• Rocking in a chair.
• Wandering.
• Violence.
• Shadowing. This is when the individual follows their caregiver very closely, everywhere they go.
• Crying.
• Insomnia.
• Yelling.

People who experience sundowning can feel many emotions as a result, including:

• Sadness.
• Anxiety.
• Fear.
• Agitation.
• Restlessness.
• Irritability.

Sundowning can also lead to certain mental states, such as:

• Confusion.
• Paranoia.
• Delusions and hallucinations.

What makes sundowning worse?

Sundowning can get worse when the person with dementia is sleep-deprived. But there are theories about certain triggers that can make sundowning worse, including:

• Disrupted circadian rhythms (sleep-wake cycles).
• Insomnia or other common sleep disorders.
• Infection.
• Dehydration.
• Side effects of medications.
• Problems with seeing the difference between reality and dreams.
• Physical illnesses.
• Pain.
• Fatigue (tiredness).
• Overstimulation from a busy day.
• Low lighting.

How long does sundowning last?

Sundown syndrome begins during the middle and later stages of Alzheimer’s disease and usually continues as long as triggers (listed above) continue.

What is the treatment for sundowner’s syndrome?

Treating the underlying trigger is the most important way to resolve sundowning. But there are other options for treating symptoms of sundowning.

Nonmedication treatments include:

• Light therapy.
• Music therapy.
• Environmental changes. Keep familiar objects (such as family photos) nearby. Ensure your loved one has adequate lighting in their environment during the day and darkness at bedtime. Also if your loved one wears eyeglasses or hearing aids, make sure these are available.

What medications are used for sundowner’s syndrome?

The individual behaviors, feelings and thoughts of people who go through sundowning can sometimes be treated with medications. Examples include:

• Antidepressant medications.
• Antianxiety medications.
• Antipsychotics. (These should be used with caution as they have long-term risks of stroke.)
• Melatonin to help with sleep.

If you’re caring for someone experiencing sundown syndrome, you can take the following steps to help them settle in at bedtime:

• Make their bedroom room quiet. Turn down all noises such as televisions and other electronic devices.
• Play quiet music that’s soothing and gentle.
• Read to the person.
• Do a simple activity — enjoy a snack together, work on an easy puzzle or watch a favorite show.
• Practice sleep hygiene by having your loved one go to bed at the same time, in the same place every night.

Identifying what causes sundowning behaviors, feelings and thoughts is the best way to help your loved one. For example, if they have insomnia, it might be because they had a very busy, overstimulating day. The proper treatment may be to give them a simpler, easier schedule with fewer people, sights and sounds.

How can I prevent sundowning?

There might be some things you can do to prevent sundowning and lessen the severity. Try the following:

• Make sure your loved one gets enough rest at night.
• Avoid caffeinated drinks after the morning.
• Avoid drinking too much alcohol.
• Try to help your loved one get plenty of sunlight during the day by sitting by a window or going out for walks.
• Exercise every day.
• If a nap is necessary, make it short and early in the day.
• Plan some activities throughout the day but not too many.

When should sundowning be treated by a healthcare provider?

Sundowning symptoms should be addressed by a healthcare provider as soon as possible to create a treatment plan. Contact your primary healthcare provider, or talk with a geriatrician (a doctor who cares for people over the age of 65).

Keep in mind that your loved one with sundown syndrome may not understand or be able to communicate that they’re extra agitated because, for example, they’re in pain from a urinary tract infection or other condition. They may need an advocate to prompt a healthcare provider for appropriate tests.

Can sundowning occur when a person doesn’t have Alzheimer’s disease?

Sundowning occurs in people who have Alzheimer's and dementia but also in older people in general.

Can sundowning happen in the morning?

Not everyone who experiences sundowning has the same symptoms or experience. For some people, sundowning may happen in the morning instead of the evening.

A note from Cleveland Clinic

If you're a caregiver for someone with dementia or Alzheimer's, you may feel overwhelmed. These feelings can be magnified if your loved one experiences sundowning. But there are things that can help ease the symptoms of sundowning such as environmental changes and some medications. There are also support groups for people who care for a loved one with Alzheimer's that can help you cope. If you’re a struggling caregiver, reach out for help. You don’t have to cope with sundowning alone.