Sundowning: Signs, Symptoms, and What to Do Next

If you have a loved one with Alzheimer's, you may notice they become more confused, anxious, or upset at the end of the day. This is called sundowning, a group of symptoms that happen in the late afternoon and evening. It includes confusion, distress, pacing, and hallucinations. About 20% of people with Alzheimer's go through sundowning at some point.

Sundowning causes a range of symptoms. Some of the most common include:

• Change in mood. Someone who is calm during the day can become restless or anxious in the evening.
• Anxiety and agitation. Your loved one feels nervous or upset. 
• Confusion. They don't remember things they knew earlier in the day. You may have a harder time having a conversation with them.
• Delusions and hallucinations. They see or hear something that isn't there.

With sundowning, people act differently than normal. They may do the following:

• Pace, wander, or rock back and forth
• Yell or scream
• Ignore or resist directions
• Become violent or paranoid
• Have trouble sleeping

Doctors don't fully understand why sundowning happens. They think it's related to brain changes and everyday triggers. Alzheimer's affects the parts of the brain that control the internal "body clock," stress, and behavior. Some medications, such as those for depression or Parkinson's, may make you feel confused and anxious. What's more, hunger, exhaustion, stress, and pain can add to sundowning symptoms. 

Some issues and habits can make the symptoms of sundowning worse, such as:

• Sleep problems. Not getting enough sleep can trigger sundowning.
• Dim light. People with Alzheimer's can get anxious or scared when it's harder to see.
• Hunger, thirst, fatigue, or another unmet need can trigger agitation. 
• A busy, noisy, or new environment can cause overstimulation and exhaustion.

Sundowning happens in any stage of dementia and Alzheimer's. But it's more common in the middle and late stages of the disease. As Alzheimer's gets worse, the symptoms of sundowning can become more obvious and difficult to handle. Your loved one may become more upset or aggressive.

You can help avoid or reduce sundowning symptoms. These steps can help:

• Have a regular routine. Wake up, eat meals, and go to sleep at around the same time every day. If you have activities, such as doctor's appointments, schedule them early in the day when your loved one has more energy.
• Identify triggers and avoid them. They may include alcohol, caffeine, upsetting topics, noisy environments, and large meals.
• Keep their home well-lit and uncluttered to reduce confusion.
• Check on their health. They may be upset because they're hungry, thirsty, or sick.

Sundowning symptoms get worse when someone with Alzheimer's doesn't get enough sleep. During the day, encourage your loved one to exercise and get plenty of sunlight. If they have trouble sleeping, avoid long naps late in the day. In the evening, do something soothing, such as listening to calming music, reading a book, or calling a friend.

Caring for someone with sundowning isn't easy. Do your best to be patient. Speak calmly, avoid arguing, and listen to their concerns. Reassure them that they're safe, and you're there to help. You can use gentle touch, such as a pat or hug, to soothe them. If you get frustrated, count to 10 and take deep breaths.

If your loved one becomes upset or agitated, try distracting them. You can suggest getting a drink of water, looking at photos, or watching a favorite television show. Or give them a simple task, like folding towels. As long as they're safe, don't physically restrain them. Let them pace back and forth, or suggest going on a walk together.

Talk to your loved one's health care provider about their sundowning symptoms as soon as you notice them. They can rule out problems that may be behind it, such as a urinary tract infection. People with Alzheimer's can have trouble communicating. Their agitation or anxiety may be because they can't tell you about their discomfort or pain. The doctor can also make a treatment plan.

There's no one remedy for sundowning. But doctors can prescribe medications for specific symptoms. These include antidepressants, and also anti-anxiety and antipsychotic drugs. They may also recommend a melatonin supplement to help improve sleep and sundowning symptoms. Talk to your loved one's health care provider about any treatments.