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    Dementia Symptoms & Caregiver Strategies: Sundowning Syndrome in Cognitively Impaired Adults

    Sundowning, also known as Sundown Syndrome, is a term used to refer to behavioral changes that often occur in the late afternoon or evening in people with Alzheimer's disease and similar conditions. Sundowning affects nearly 20% of people who have progressive cognitive impairment. Individuals with memory loss who "sundown" get confused and agitated in the late afternoon/evening hours -- and occasionally throughout the night. Symptoms generally peak during the middle stages of dementia and then improve as the disease progresses.

    Sundowning syndrome may prevent some sufferers from sleeping well. It may also make them more likely to wander. Due to the stress it puts on caregivers, sundowning is a common cause of caregiver burnout.
    People who sundown may become more:

    • Forgetful
    • Confused
    • Delirious
    • Agitated
    • Anxious
    • Restless
    People with sundowning often have trouble sleeping. They may:
    • Pace the floor
    • Wander
    • Yell
    • Become combative
    Sundowning typically peaks during the middle stages of dementia and symptoms improve as the disease progresses.

    What Causes Sundowning?

    The causes of sundowning are not well understood. Some research suggests that sundowning may be related to changes to the brain's circadian pacemaker, the cluster of nerve cells that keeps the body on a 24-hour clock. Studies in mice suggest that chemical changes in the brain that are characteristic of Alzheimer's disease may play a role as well.

    Several things may increase the risk for sundowning. These include:

    • Pain
    • Severe constipation
    • Poor nourishment
    • Being on too many medications
    • Infection
    • Noisy and disruptive sleeping environment

    Coping Strategies for Sundowning

    Ways to make sundown syndrome less severe include:

    Activity. A person who rests most of the day is likely to be awake at night. Being more active during the day may help cognitively impaired individuals sleep better in the evening hours. Encourage a little healthy (not exhausting) exercise during the day to get the person’s endorphins going and blood flowing. This will promote a relaxing and low-key evening to help switch the body to end-of-day focus. Discourage daytime naps. Only allow cat naps during the day of 20 minutes or less. Hours of sleeping can confuse the body’s circadian rhythms and keep the individual too awake at night.

    • Encourage exercise, like walking, but no later than four hours before bedtime.
    • Plan doctor appointments, trips, and bathing in the morning or early afternoon.
    • Try to keep your loved one engaged in something, whether it’s a specific task or focus like folding laundry, looking at pictures or playing a game.
    • Encourage hobbies that get the person up and moving.
    • Promote evening activities of positive interactions and memories. Whether it’s watching movies, listening to music, looking through photo albums or calling friends and family. Whether it’s watching movies, listening to music, looking through photo albums or calling friends and family.
    Maintain a schedule. As much as possible, encourage the person with cognitive impairment to adhere to a regular routine of meals, waking up and going to bed. This will allow for more restful sleep at night.

    Healthy diet. Caregivers should make sure their loved ones eat properly:
    • Avoid nicotine and alcohol
    • Limit caffeine and sugar to the morning hours.
    • Plan an early dinner.
    • Have a large meal at lunch and keep the evening meal simple.
    • Keep snacks light before bedtime.
    Medical advice. A doctor can look for physical problems like pain, infections, or bladder problems that may be contributing to nighttime confusion and agitation. They should also regularly review prescription medications to make sure they are still needed.

    Light therapy. Turn lights on in the rooms the individual will be occupying during the evening. Adequate lighting may reduce the agitation that occurs when surroundings are dark or unfamiliar. Exposure to bright light, including the sun, during the day may reduce some sundowning symptoms, especially when used in combination with exercise, like walking.

    Good sleeping environment. Allow the person to change bedrooms or to sleep in a favorite chair or couch. Keeping the room partially lit may also help to reduce confusion when he or she wakes during the night. The sleeping area should be at a comfortable temperature. Provide nightlights and other ways to keep the individual safe, such as appropriate door and window locks. Door sensors and motion detectors can be used to alert family members when a person is wandering, as can safety systems.

    Limit environmental distractions. Particularly during the evening hours (TV, children arriving, chores, loud music, etc.) should be avoided. Select one area of a room to become a “quiet place” where there is a bright light and soothing music.

    Calm reassurance. Caregivers should gently help their loved ones remember where they are and what time it is. Avoid arguing and instead offer reassurance that they are OK. If you sense the individual is getting frustrated; hold his or her hand or put your hand on his or her back or knee. Sometimes a soothing hand or shoulder massage can be comforting and can lesson any tension that may be building. Playing calming music in the background can also help. If your loved one paces at night, make sure there’s a clear path and accompany them—to let them know they’re not alone.

    The key to this time of night is helping the person focus on things outside their own thought process, so they do not get upset. Making this time of day easier on them will, in turn, make it easier on you. Having the right balance of tasks, planning and comfort can help to reduce sundowning.

    Cognitive Impairment can have many causes. The patient’s doctor should be consulted to determine a specific diagnosis and treatment options. But whatever the cause, the symptoms are often alike, and the Caregiver Strategies are often similar.

    The information in the resources listed above was compiled by the Ray Dolby Brain Health Center through clinical experience and commonly available published materials. For information on additional Caregiver Strategies, go to: cpmc.org/brainhealth.