What to Know About Sundowning In Alzheimer's

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Individuals living with Alzheimer’s can experience sundowning. This phenomenon manifests at dusk and can lead to increased anxiety, pacing, confusion, disorientation, or agitation. Those experiencing sundowning may also have problems sleeping.

According to Dr. Kuljit Kapur, Chief Medical Officer at Transitions Care, sundowning can burden caregivers of Alzheimer’s patients.

Dr. Kuljit Kapur

Since these symptoms arise at the end of the day, it may be more difficult for caregivers to provide proper care.

— Dr. Kuljit Kapur

That’s why it’s essential to look for signs of sundowning and be prepared to handle situations in which a loved one might be dealing with it.

Causes of Sundowning

Not all individuals living with Alzheimer’s will experience sundowning. “It most commonly occurs in patients during the middle and later stages of their disease process,” Dr. Kapur says.

Why Sundowning Occurs

The reasons why sundowning occurs are not well understood. But, according to Dr. Kapur, many factors can make it more likely. These include:

Dr. Christopher Dennis, Chief Behavior Health Officer of Landmark Health, says sundowning may also occur due to changes in a person’s circadian rhythm, thereby impacting sleep-wake cycles. 

“This may result in agitation and other sundowning behaviors, generally beginning around dusk,” Dr. Dennis says.

Additionally, those experiencing sundowning may also be unable to describe being tired, hungry, thirsty, bored, or in pain. This can make it confusing for caregivers to determine their loved one’s problem. 

How to Cope With Sundowning

While sundowning can be a huge challenge for individuals living with Alzheimer’s and their loved ones, there are many ways to cope.

Look Out for Triggers

According to Adria Thompson, MA CCC-SLP, a certified dementia practitioner, caregivers can examine whether certain triggers lead to sundowning behavior.

For instance, if one caregiver leaves home at 3 P.M. and another takes their place, an individual with Alzheimer’s may think they need to leave, too. “This triggers confusion, disorientation, and agitation for the next [caregiver],” Thompson says.

Moving forward, caregivers can be more discrete when leaving to not trigger sundowning symptoms in individuals with Alzheimer’s.

Identify Patterns

Furthermore, Thompson points out that caregivers can use patterns in sundowning to their advantage.

For instance, if your parent with Alzheimer’s begins exhibiting symptoms around 3:30 P.M. each day, you can start giving them a task at 3 P.M., like sweeping the floors. This can help minimize or delay the onset of sundowning symptoms. 

Maintain Regular Routines

Thompson also says it’s important to stick to routines. “Keep the environment calm in the late afternoon with predictable routines,” she states.

This can mitigate unnecessary confusion or disorientation. For an individual living with Alzheimer’s, this can mean set mealtimes and after-dinner rituals—anything to provide a sense of familiarity.  

Support Sleep-Wake Cycles

Furthermore, Thompson says those living with Alzheimer’s should limit alcohol, caffeine, nicotine, and naps.

Stimulating substances and sleeping during the day can interfere with the body’s natural sleep-wake cycles. Sun exposure can help maintain that internal rhythm, as well, especially in the winter, when the daylight hours are shorter. 

Decrease Cognitive Load

You can decrease the cognitive load individuals with Alzheimer’s experience throughout the day. This means limiting the amount of cognitively challenging situations they experience. 

Example Scenario

Thompson provides an example of Jill, an Alzheimer’s patient whose family decides to visit her nursing home on her birthday. “Staff woke her up an hour earlier, helped her shower, and sent her to lunch with 15 family members. By 2 P.M., Jill was anxious and crying,” Thompson says. This was two hours earlier than Jill typically sundowns. 

Jill’s sundowning symptoms can be explained by her being overwhelmed with new situations. “Next time, Jill should keep her morning routine, and family can visit in small shifts over the next three days,” Thompson says.  

Incorporate Daily Exercise

Exercise is important for individuals living with Alzheimer’s, as it can help mitigate sundowning symptoms. Walking, especially in the afternoon, can be especially beneficial.

One study split participants into three groups—one took morning walks, another took afternoon walks, and another was the control. Each participant had Alzheimer’s or another form of dementia and struggled with sundowning symptoms. Those in the afternoon walking group had a significant decrease in sundowning symptoms after walking for 120 minutes per week over 16 weeks. Furthermore, after 24 weeks, those in the morning and afternoon groups showed a similar level of improvement.

Avoid Physical Restraint

While it may seem like physical restraint may be the only option at times, Dr. Dennis says it will only make agitation worse. 

“Involving members of your loved one’s home-based medical care team may help to ease the challenges,” he says. It can also help identify treatment and management strategies that can improve your loved one’s quality of life. 

A Word From Verywell

Sundowning can be an immense challenge in Alzheimer’s disease—both for those affected and their caretakers. Not only does it present later in the day, but those experiencing it are often unable to explain what is bothering them, whether that’s hunger, pain, or boredom. 

However, several coping strategies—from identifying triggers, maintaining regular routines, and engaging in exercise—can help alleviate sundowning symptoms. If your loved one is beginning to exhibit sundowning symptoms, it’s important to discuss their challenges with a physician. 

2 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Alzheimer's Association. Sleep Issues and Sundowning

  2. Shih YH, Pai MC, Lin HS, Sung PS, Wang JJ. Effects of walking on sundown syndrome in community-dwelling people with Alzheimer's disease. Int J Older People Nurs. 2020 Jun;15(2):e12292. doi: 10.1111/opn.12292.

By Brina Patel
Brina Patel is a freelance writer from Sacramento, California. Prior to writing full-time, she worked as an applied behavior analysis therapist for children on the autism spectrum. She leverages her own experiences researching emotions, as well as her personal challenges with chronic illness and anxiety, in her storytelling, with the hope of inspiring others to take better charge of their overall wellness and understand themselves on a deeper level.