Dementia Care: What is sundowning?

Sundowning is a pattern of increased confusion, agitation, and restlessness that occurs in the late afternoon or evening in people living with dementia. It is one of the most common and challenging behavioural symptoms families encounter, and while it cannot be prevented entirely, it can be managed effectively with the right routines and support in place.

If you are starting to notice changes in behaviour alongside evening agitation, it may be worth reading about the early signs that professional dementia care may be needed.

What is sundowning?

Sundowning describes a pattern of increased confusion, agitation or anxiety that occurs in the late afternoon or early evening. According to the Alzheimer’s Society, sundowning is thought to affect approximately 20% of people living with dementia in the community, rising to around 80% of those in residential care settings.

People living with dementia may become restless, irritable, or emotionally distressed as light fades, with symptoms typically easing by morning. Specialist dementia care at home can provide the consistent routine and familiar environment that helps reduce the severity of these episodes.

Understanding why this happens can help you support the person you care for through these challenging periods and reduce the frequency of distressing episodes.

What causes sundowning in dementia?

While the exact cause isn’t fully understood, researchers believe a combination of biological and environmental factors may be involved.

• Disrupted circadian rhythm – Dementia can affect the brain’s internal clock that regulates sleep, wakefulness, and mood. As natural light diminishes, this disruption can trigger confusion or agitation. Dementia UK notes that sleep and circadian rhythm disruption are among the most common and least addressed challenges in dementia care.
• Mental and physical exhaustion – By late afternoon, someone with dementia may have depleted their energy reserves. When communication is impaired, agitation becomes their way of expressing discomfort, thirst, or fatigue. NICE guidance NG97 recommends assessing for unmet physical needs – including pain, hunger, and dehydration – as a first step when behavioural symptoms escalate
• Environmental factors – Poor lighting, background noise, unfamiliar routines, or overstimulation can all contribute to evening confusion.
• Sensory difficulties – Changes in vision or hearing can make environments feel more confusing as darkness approaches.

Recognising these triggers allows you to create calmer evenings and prevent distress before it escalates.

Recognising the signs of sundowning

Sundowning symptoms vary between individuals and often become more noticeable as dementia progresses. Episodes typically begin around sunset and may continue into the night, disrupting sleep for both the person living with dementia and the family supporting them.

Common signs of sundowning include confusion, emotional outbursts, pacing, restlessness, paranoia, hallucinations, and disrupted sleep. The Alzheimer’s Society notes that these symptoms can overlap with other behavioural changes in dementia, making it important to discuss new or worsening episodes with a GP or clinical care team.

Families managing hallucinations alongside sundowning may also find it helpful to read about aggressive behaviour in dementia, as the two symptoms frequently occur together.

Specific symptoms include:

• Confusion or disorientation
• Increased agitation or emotional outbursts
• Pacing or wandering
• Restlessness or anxiety
• Paranoia, such as hiding possessions or mistrusting familiar people
• Hallucinations
• Difficulty sleeping or reversed sleep patterns

As dementia advances, sundowning symptoms may blend with other behavioural changes. Discuss any new or worsening symptoms with your GP or clinical care team, so support can be adjusted appropriately.

When does sundowning occur in dementia?

Sundowning is most common in the middle to late stages of dementia. It affects people with all types of dementia – including Alzheimer’s disease, vascular dementia, frontotemporal dementia, and Lewy body dementia. According to Dementia UK, episodes tend to become more frequent and prolonged as the condition advances, and are closely associated with deteriorating sleep quality.

Once episodes begin, they may lengthen and interfere with normal sleep patterns, creating a cycle of fatigue and worsening confusion. While sundowning cannot be prevented entirely, symptoms can be managed through consistent routines, a calm environment, and professional support. Families navigating the middle to later stages of dementia may find it useful to read about what the later stages of dementia involve and how care needs typically shift over time.

Professional live-in carers trained in dementia care can help establish patterns that reduce late-day stress and provide reassurance during difficult periods.

Can sundowning happen without dementia?

Yes. Although sundowning is most closely associated with dementia, sundowning-like symptoms can occur in older adults without a dementia diagnosis, as well as in people recovering from illness, surgery, or a period of acute stress.

Age-related changes in the brain

As the brain ages, its ability to regulate the sleep-wake cycle and manage stress weakens. Evening irritability, anxiety, or low-level confusion can occur in otherwise healthy older adults, particularly when sleep quality is poor or daily routine is disrupted.

Delirium

Delirium is a state of acute confusion that can develop rapidly in older adults, often triggered by infection, surgery, medication changes, or dehydration. It frequently worsens in the evening and can closely resemble sundowning. Unlike sundowning, delirium typically has a sudden onset and a reversible cause. The NHS recommends urgent medical assessment if delirium is suspected, as prompt treatment of the underlying cause is essential.

Anxiety and mood disorders

People living with anxiety or depression may experience a peak in psychological distress in the late afternoon or early evening, sometimes described as the “late-day crash”. This can include restlessness, low mood, and difficulty settling – symptoms that mirror sundowning without any neurological cause.

Medication side effects

Certain medications, including some sedatives, antihistamines, and bladder medications, can cause confusion or agitation that is more pronounced in the evening. A GP or pharmacist can review the medication list if evening symptoms are a concern.

Urinary tract infections

UTIs are a common and frequently overlooked cause of acute confusion in older adults, and symptoms often worsen at night. If evening confusion appears suddenly or is accompanied by changes in continence or behaviour, a UTI should be ruled out before assuming a neurological cause.

In our experience at Hometouch, families sometimes mistake early delirium or medication side effects for sundowning – particularly when a dementia diagnosis is already in place. A sudden or significant change in evening behaviour always warrants a GP assessment to rule out a reversible cause before adjusting the care approach.

If you notice sundowning-like symptoms in someone without a dementia diagnosis, speak with their GP. Early assessment can identify treatable causes and prevent unnecessary distress.

Managing sundowning: practical strategies

There is no single treatment for sundowning, but a structured and reassuring approach can significantly reduce the frequency and intensity of episodes. The strategies below are recommended by Hometouch’s clinical team and align with NICE guidance NG97 on non-pharmacological approaches to behavioural symptoms in dementia.

Maintain a consistent daily routine

Predictability is one of the most effective tools for reducing sundowning. A regular pattern of waking, meals, activity, and rest helps regulate the body’s internal clock and reduces the disorientation that drives late-afternoon agitation. Where possible, keep mealtimes, activity sessions, and bedtime at the same time each day.

Manage light exposure

Natural light in the morning helps reinforce the circadian rhythm and can reduce the severity of evening confusion. Encourage time outdoors or near a window during daylight hours. As evening approaches, switch to warm, consistent indoor lighting – avoiding bright overhead lights that cast shadows, which can cause disorientation or distress.

Reduce evening stimulation

Background noise from television, radio, or household activity can overstimulate a person with dementia as their cognitive reserves deplete through the day. Aim for a quieter, calmer environment from mid-afternoon onwards. Reduce visual clutter and remove mirrors where they confuse.

Use familiar music and sensory comfort

Meaningful music can reduce agitation and provide reassurance during sundowning episodes. Play familiar songs at a low volume during the late afternoon as part of a winding-down routine. Gentle touch, a familiar blanket, or a warm drink can also help ground a person who is becoming distressed.

Support healthy sleep patterns

Limit caffeine after midday and avoid lengthy daytime naps where possible, as these can disrupt nighttime sleep and worsen the cycle of fatigue that contributes to sundowning. Dementia UK recommends keeping the bedroom environment dark, cool, and quiet, and establishing a consistent pre-sleep routine.

Respond calmly during episodes

During a sundowning episode, a calm and reassuring presence is more effective than attempting to reorient the person to reality. Speak slowly and clearly, use the person’s name, and avoid challenging or correcting confused beliefs. If the person is distressed, gentle redirection – moving to a different room, offering a drink, or introducing a familiar activity – can help break the cycle of agitation.

In our experience at Hometouch, carers who establish a consistent late-afternoon routine within the first two weeks of a placement report a measurable reduction in sundowning episodes. The predictability of a live-in carer’s presence – the same face, the same voice, the same routine – is itself a calming influence that visiting or hourly care cannot replicate.

When to consider medication

Medication is not a first-line treatment for sundowning. Non-pharmacological approaches should always be tried first. Where symptoms are severe and significantly disrupting sleep or safety, a GP may consider low-dose melatonin or other options – but these should only be used following a professional assessment and should be reviewed regularly. Always discuss any medication changes with a qualified healthcare professional before proceeding.

If sundowning episodes are becoming unpredictable or unsafe, specialist dementia care at home can provide the consistent support and trained oversight that reduces risk and restores routine. Families managing both sundowning and episodes of aggressive behaviour in dementia may find that addressing the sundowning pattern first has a positive effect on daytime behaviour overall.

Frequently asked questions

What is sundowning in dementia?

Sundowning is a pattern of increased confusion, agitation, and restlessness that occurs in the late afternoon or evening in people living with dementia. It is thought to affect around 20% of people with dementia living at home, rising to approximately 80% of those in residential care settings. Symptoms typically ease by morning but can worsen as dementia progresses.

What causes sundowning in dementia?

Sundowning is caused by a combination of biological and environmental factors. Dementia disrupts the brain’s internal clock, making it harder to regulate sleep, wakefulness, and mood as daylight fades. Fatigue, dehydration, pain, poor lighting, and changes in routine can all contribute to or worsen episodes. Identifying and addressing individual triggers is the most effective way to reduce their frequency.

Can sundowning happen without dementia?

Yes. Sundowning-like symptoms can occur in older adults without a dementia diagnosis, as well as in people experiencing delirium, anxiety, depression, or medication side effects. A sudden onset of evening confusion in someone without a dementia diagnosis – or a significant change in an existing pattern -always warrants a GP assessment to rule out a reversible cause.

How do you manage sundowning at home?

The most effective approach combines a consistent daily routine, managed light exposure, reduced evening stimulation, and a calm, reassuring presence during episodes. Familiar music, sensory comfort, and a structured pre-sleep routine can all help. Medication is not a first-line treatment and should only be considered following a professional assessment when non-pharmacological approaches have not provided sufficient relief.

When should I consider professional care for sundowning?

Professional care is worth considering when sundowning episodes are becoming unpredictable or unsafe, when sleep disruption is affecting the health of the family carer, or when the consistency of routine needed to manage symptoms is difficult to maintain at home. A live-in dementia carer provides the same face, the same voice, and the same routine every day – the single most effective environmental intervention for reducing sundowning frequency.

Does sundowning get worse as dementia progresses?

In most cases, yes. Sundowning tends to become more frequent and prolonged as dementia advances, particularly in the middle to later stages. Episodes may begin to overlap with other behavioural changes, including agitation and sleep reversal. Families navigating this stage may find it helpful to read about the later stages of dementia and what to expect as care needs increase.

How can professional care help with sundowning?

Sundowning can be distressing for both the person living with dementia and the family supporting them, but understanding its causes and recognising the signs allows you to respond with confidence. Establishing calm routines, managing the environment, and having a consistent, trained carer in place are the most effective tools available.

Hometouch’s specialist dementia carers are matched to each person’s clinical profile and experienced in managing sundowning as part of a structured daily routine. Every placement is supported by a Clinical Manager, with care plans reviewed regularly as the condition develops.

If you need additional support managing sundowning or other aspects of dementia care, our clinical team is here to provide guidance tailored to your family’s situation.