Sundowning is a temporary state of confusion triggered in the late afternoon or evening. Up to 66% of people with dementia may experience sundowning. Sundowning may lead to faster cognitive decline, recurrent hospitalizations, and increased stress for caregivers. A treatment plan to manage symptoms can help reduce complications.
Sundowning may be caused by changes in circadian rhythm (your body’s internal clock). Sleeping can become more difficult as you get older. This disruption to your typical sleep pattern may cause psychiatric symptoms that improve during the day. It’s not uncommon for people with Alzheimer’s disease (AD) to feel tired during the day but more alert at night.
Symptoms are chronic (long-lasting) and usually become more pronounced with time. Some people with dementia may have symptoms all day that worsen during the evening. They may experience mood changes, hallucinations, or wandering.
Sundowning includes a variety of behavioral and psychiatric symptoms. They vary from person to person but can include:
Wandering
Wandering is a common symptom for people with Alzheimer’s disease, but it can become more frequent when the sun goes down. During this time, they may try to return to a familiar place or continuously pace around.
People who are sundowning may wander to:
- Former jobs or homes
- Favorite restaurants
- Other familiar places
This might be more pronounced if they’re away from home.
Mood Changes
Your mood may change during sundowning. It’s not uncommon to feel anxious, tense, or fearful. People who are sundowning may ask the same question repeatedly. Their behaviors can also become repetitive. They may rummage around their room or belongings without a purpose.
People who are sundowning can also become aggressive. They may:
They may direct their aggression toward other people.
Hallucinations and Delusions
People with sundowning may experience hallucinations—seeing or hearing something that isn’t really there. Dim lighting or shadows at night can make hallucinations worse.
Delusions can occur during the day, but sundowning may make them worse. A delusion is a false belief or idea. Most commonly, the person sundowning believes something has been stolen or that they are being targeted.
Other common delusions or hallucinations include:
- Their purse being stolen
- Thinking their reflection is an intruder
- Misinterpreting sounds from a television
Delusions and hallucinations may be a person’s way of making sense of their surroundings.
There is no single cause of sundowning. It’s typically caused by an interaction of multiple factors, including biological changes and environmental factors.
Biological Changes
Sundowning may be caused primarily by biological changes that interfere with your circadian rhythm, or internal clock. Melatonin is a hormone released during darkness, and it plays a major role in regulating your ability to distinguish day from night. Melatonin signals when it’s time to go to sleep and wake up.
Melatonin levels naturally decline as you age. People with Alzheimer’s disease seem to have even lower levels of melatonin. This may dysregulate (confuse) their internal clocks, causing them to feel more awake at night.
Environmental Causes
A person’s environment can worsen their symptoms if they’re already predisposed to sundowning. Regularly seeing light and darkness regulates your biological clock. Seeing less natural light during the day, like in the winter, may further confuse the internal clock and trigger nighttime symptoms.
Not having a reliable daily schedule can also confuse your sense of time. Most people, especially those with dementia, thrive on a clear schedule. It’s another way of offering cues to your internal clock. Without a clear schedule, some people may stay awake for longer.
Vision or Hearing Impairments
People with vision or hearing impairments may be more prone to sundowning. They may have a more difficult time recognizing and understanding their environment if they can’t see or hear clearly. This is particularly true for people with cognitive symptoms, such as impaired memory.
Hallucinating may serve as a coping mechanism for not seeing or hearing clearly. For example, someone who doesn’t recognize a pile of clothes in the corner may perceive it as their childhood dog. In other words, they’re shifting an unfamiliar scenario into something they can understand.
Urinary Tract Infections (UTIs)
There is a strong connection between delirium and urinary tract infections (UTIs) in older adults. UTIs can cause dementia, and dementia can increase the risk of UTIs.
According to one analysis of about 380,000 adults over the age of 65 with Medicare, up to one-third of people with dementia who visited the emergency department received a UTI diagnosis. However, the researchers questioned the potential of overdiagnosis.
UTI risk factors include poor personal hygiene, difficulty going to the bathroom, and use of catheters. Older adults may be more prone to all of these. Changes in the brain that occur with age can cause people to be prone to experiencing confusion when they have a UTI. This can make sundowning symptoms worse.
The brain shrinks with age, which makes it more vulnerable to delirium in general. Neurotransmitters become unbalanced, and the blood-brain barrier becomes more permeable. These changes make it more challenging for your brain to manage stress caused by infection. This may increase the likelihood of developing psychiatric symptoms.
Medications
Some medications may increase your likelihood of sundowning by increasing confusion, disrupting sleep patterns, or altering mood. This may contribute to night behaviors if you have dementia.
Medications that may worsen sundowning include:
- Benzodiazepines for conditions like anxiety and insomnia
- Opiates to reduce pain or promote sleep
- Anticholinergic agents for conditions like Parkinson’s disease (PD), bradycardia (low heart rate), and asthma or chronic obstructive pulmonary disease (COPD)
- Some corticosteroids for conditions like rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and asthma
These medications may make sundowning worse by interfering with certain neurotransmitters, like dopamine and serotonin. An imbalance of neurotransmitters can cause delirium in some people. The risk of sundowning might be higher with higher medication doses.
See a healthcare provider if you notice worsening behavioral or psychiatric symptoms that haven’t been addressed. Your healthcare provider may recommend non-medication approaches to manage some symptoms. In some cases, they may recommend antipsychotic medication or even an eye exam.
Other reasons to visit your emergency department include:
- A fall while wandering, especially if no one witnessed the fall
- Increased pain
- Hallucinations
- Changes in breathing or digestion
- Significant changes in mental status that may cause harm
Infections, particularly UTIs, can worsen psychiatric symptoms in older adults. If you suspect an infection or notice a rapid change in mood, see a healthcare provider immediately for evaluation and treatment.
The goal of treating sundowning is to manage symptoms. There are no set guidelines for treating sundowning, and no medication is approved to manage these symptoms.
Treatment options include the following:
- Reorient frequently: Have a caretaker or staff member nearby to empathetically explain to the person where they are and what is happening
- Remove medications: Review medication history and stop or replace any therapies that may cause delirium
- Treat infection: Manage any infections that may be contributing to sundown symptoms
- Use light therapy: Include bright light exposure throughout the afternoon
- Promote schedules: Implement daily schedules to train the internal clock
- Try melatonin supplements: Address possible melatonin deficiency
Treatment plans are highly individualized for each person experiencing sundowning symptoms. Managing the underlying cause (if there is one) may help reduce some of the behavioral symptoms.
Sundowning can be difficult to prevent. Some people are more prone to developing sundowning due to biological changes. However, environmental factors can be altered to help prevent symptoms from appearing.
The following strategies can promote a healthy sleep environment at bedtime:
- Reduce noise
- Minimize nighttime disruptions
- Keep the bedroom dark
Make sure the person with sundowning symptoms is comfortable and ready for bed. If they’re in pain, they’re more likely to wander. Manage any pain symptoms earlier in the afternoon to prepare for the evening.
If a person is awake during the evening, make sure they have their appropriate aids. If they need glasses, have them at the bedside table. If they wear hearing aids, make sure they are within reach. This will help them understand their surroundings and help prevent hallucinations.
Sundowning is a group of behavioral symptoms that worsen from dusk to dawn. It’s commonly seen in people with dementia and Alzheimer’s disease. It’s primarily caused by changes to the body as you age, including low levels of melatonin that alter your internal clock.
People who sundown may hallucinate or have delusions about experiences from their past. They may pace or wander around during the night. It’s not uncommon for their mood to change.
Talk to your doctor if you think you or someone you love may be experiencing sundowning. They can offer a supportive treatment plan.