I've heard that sundowning may happen with dementia. What is sundowning and how is it treated?
Answer From Jonathan Graff-Radford, M.D.
The term "sundowning" refers to a state of confusion occurring in the late afternoon and lasting into the night. Sundowning can cause different behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering.
Sundowning isn't a disease. It's a group of symptoms that occur at a specific time of the day. These symptoms may affect people with Alzheimer's disease and other types of dementia. The exact cause of this behavior is unknown.
Factors that may aggravate late-day confusion
- Spending a day in an unfamiliar place
- Low lighting
- Increased shadows
- Disruption of the body's "internal clock"
- Difficulty separating reality from dreams
- Being hungry or thirsty
- Presence of an infection such as a urinary tract infection
- Being bored or in pain
Tips for reducing sundowning
- Keep a predictable routine for bedtime, waking, meals and activities.
- Plan for activities and exposure to light during the day to encourage nighttime sleepiness.
- Limit daytime napping.
- Limit caffeine and sugar to morning hours.
- Turn on a night light to reduce agitation that occurs when surroundings are dark or unfamiliar.
- In the evening, try to reduce background noise and stimulating activities, including TV viewing, which can sometimes be upsetting.
- In a strange or unfamiliar setting, bring familiar items — such as photographs — to create a more relaxed, familiar setting.
- Play familiar, gentle music in the evening or relaxing sounds of nature, such as the sound of waves.
Some research suggests that a low dose of melatonin — a naturally occurring hormone that induces sleepiness — alone or in combination with exposure to bright light during the day may help ease sundowning.
It's possible that a medication side effect, pain, depression or other medical condition could be contributing to sundowning. Talk with your loved one's health care provider if you suspect that an underlying condition, such as a urinary tract infection or sleep apnea, might be worsening sundowning behavior, especially if sundowning develops quickly.
Jonathan Graff-Radford, M.D.
May 27, 2022
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See more Expert Answers
- Todd WD. Potential pathways for circadian dysfunction and sundowning-related behavioral aggression in Alzheimer's disease and related dementia. Frontiers in Neuroscience. 2020; doi:10.3389/fnins.2020.00910.
- Sleep issues and sundowning. Alzheimer's Association. http://www.alz.org/care/alzheimers-dementia-sleep-issues-sundowning.asp. Accessed April 4, 2022.
- Managing personality and behavior changes in Alzheimer's. National Institute on Aging. https://www.nia.nih.gov/health/managing-personality-and-behavior-changes-alzheimers. Accessed April 4, 2022.
- Francis J. Delirium and confusional states: Prevention, treatment, and prognosis. http://www.uptodate.com/home. Accessed April 4, 2022.
- Graff-Radford J (expert opinion). Mayo Clinic. April 7, 2022.
- Tips for coping with sundowning. National Institute on Aging. https://www.nia.nih.gov/health/tips-coping-sundowning. Accessed April 4, 2022.