How to Cope with Sundowning: Tips from Family Caregivers
Sundowning is a phenomenon in which individuals with Alzheimer’s and other types of dementia experience increased confusion and behavioral problems during the late afternoon and evening due to a disruption in their sleep-wake cycle. Not all patients suffer from sundowner’s syndrome, but it is estimated that around 20 percent of people with Alzheimer’s are affected. These troublesome symptoms typically present in the middle and late stages of the disease.
This nighttime agitation and confusion can be hard on a loved one, but it can be especially draining for their caregiver as well. It is important to minimize these frustrations for all involved since sundowning commonly affects an entire household’s ability to get quality sleep.
Furthermore, since these progressive diseases affect a person’s circadian rhythms, patients may also be disoriented upon waking early in the morning or even after the sun has been down for some time. The exact nature of a person’s sundowning or “sunrising” is highly variable.
We have collected a list of caregiver tips and advice from members of AgingCare.com's Support Groups that caregivers can try to help keep their loved ones calm in the evenings. As with most things pertaining to these conditions, no patient, routine or caregiving situation is exactly the same. Finding solutions will likely involve some amount of trial and error. (For example, some caregivers below found that naps significantly improved their loved ones’ mood and behavior at night, while others found their loved ones were more disoriented after waking up from a nap.) The key is to remain as open-minded and flexible as possible when trying to find a remedy for these frustrating dementia symptoms.
Care Routine Tips
“I found that music calmed my husband when he began sundowning. I would sometimes sit and pat his hand and just be there beside him for a while. It would often help. I always went along with whatever thing he thought he saw, such as a nonexistent dog in the yard.” –shorty4631
“Try to keep the patient from becoming over-stimulated. This can be from watching crime shows on TV at night or even scheduling bathing in the evenings. Try to keep the room they're in well lit to prevent shadows, which often confuse a person with AD. The less agitation and the more familiarity they have, the better.” –virtualhorizon
“My Mom had sundowner's and I found that a sleep machine (playing nature noises) worked well to calm her. Also, I put the shades down BEFORE sundown and that seemed to help.” –dogloving1
“My mom gets all messed up after her afternoon nap. She can’t distinguish dreams from reality, gets a second wind and spends the afternoon calling me over and over again. I have definitely found that the afternoon naps seem to cause more harm than good, especially for a patient prone to sundowning.” –TSM1013
“Naps can be incredibly disorientating for someone with dementia... Especially if the person sleeps deeply! My mum has the most bizarre delusions (and paranoia) just after waking up in the afternoon.” –JGWBRG
“Turn on lots of lights in the house and change bulbs to higher wattage (appropriate for each fixture). Seniors tend to walk around and turn off the lights or have dim bulbs as part of their "energy saving" mentality, but the more lights on the better. Also, try to go for a walk even if just around the yard before it gets dark. This is not possible every day, but going to a brightly lit store (Target, Walmart, etc.) might help in the early evenings before or after dinner. When I'm visiting Mom, we try to have a routine like a small glass of wine and a light snack at that time to cut down on the wandering, fidgeting or constant circling in the kitchen. It’s tough, but if you can do some more physical activity (walks, light exercise like chair yoga, etc.) to wear them out late in the afternoon, they tend to be more settled in the evening. I've also moved dinner time up in the winter (short days) from a normal 6 PM to more like 4:30 or 5 PM just for a change of pace.” –sinflo2
“Sundowning, in my opinion, is the brain's inability to process what's happening in real time due to changes in neuro-chemistry, which are affected by metabolism, physiology and usually is triggered by fractured light sources. When your loved one gets to this point, and is safely diagnosed with intermittent confusion or sundowning, and not something more serious like a urinary tract infection (please have this ruled out first), I like to use distraction in the form of music. Out of the five senses, I believe listening to be most useful to calm an anxious mind. Sounds of ocean breezes or bird noises are all so very calming. People have used herbs and teas for relaxation with scents as well. Going to sleep with a recording of a narrated book is a helpful tool. A monotone voice reading of a novel perhaps. If your loved one is to the point where you are so frustrated you want to pull your hair out, they are out of control, constantly standing at the door trying to escape, or yelling and screaming obscenities at you, or just somewhere in between, then don't worry. You’re just like every other hardworking care giver. Hang in there, join a support group, and pat yourself on the back. No one else will touch this job with a ten foot bed pan!” –anonymous122086
“Some get it worse than others. The days are shorter during winter in the northern hemisphere, so the evenings are longer. You may find things that help, such as having lights on and blinds drawn. I would focus on making your loved one feel as safe and secure as possible. You know them, so you may be able to figure out some good things, e.g. familiar movies, music, or old TV shows that help.” –JessieBelle
“Sundowning is a curious thing; you never know what is coming and when. I had the freedom to sit with my husband and just talk and hold his hand. I will tell you this, you will become an "accomplished liar," as someone in my Alzheimer’s support group once said. And that is okay. You have to agree with whatever they say no matter how off the wall it is. Correcting them does not help. I went through all of this with my dear deceased husband. Engaging him in conversation and changing the subject worked wonders. Sometimes we were holding hands and he was only in his underwear. You do whatever it takes to calm them. Imagine, if you can, what they are thinking about (not being able to think at all) and what their disconnected brain wires are causing him to think and do. It is a horrible disease. Some medications work, but take time to be effective. Others make things worse.” –butterflykisses
“As a geriatrician, I tell families that sundowning in people with dementia is a little similar to the 5pm "witching hour" that parents often see with babies & young children. It's probably a combination of long shadows, being tired at the end of the day, and who knows what else. Every family has to do some trial-and-error to figure out a way to manage it. Try using routine, creative redirection, and minimizing stressors during this time of day if possible. Medications can be tricky. But at the end of the day, it's very important to keep things manageable for the family caregivers. Sometimes a little medication seems to offer a reasonable balance of benefits and risks.” –drkernisan
“You may not be able to avoid it altogether, but there are things you can do that might make things easier for you and for your parents. Have a routine and stick to it. No caffeine after 12 PM. Arrange the schedule so that you're not asking or expecting anything of your parents when they begin to sundown. For example, make sure they've had their medications and provide them with snacks and drinks. Cut down or alleviate activity around your parents. Increased stimulation can cause increased agitation.” –Eyerishlass
“My late husband began sundowning towards the end of his life. I called the Alzheimer's 800 number for suggestions. They said to provide a snack and get him involved in older TV programs and movies—quiet and nostalgic ones. To just put in a tape and, if necessary, sit and watch it with him instead of rushing about and taking care of dinner or the dogs as my usual routine would go. I had to change, slow down and just "be" with him. I took up crocheting, which fascinated him to no end, and a nap worked well for him too. Our afternoons went something like this: he took a nap when he would start getting fidgety from about 2-3 PM until around 4-5 PM. I gave him a snack with carbs and sugar that was easy to eat, and he enjoyed it (comfort food like pudding or an egg custard like his mom used to make). I would have dinner premade and ready to microwave. I would give him a small task to do like putting the utensils on the table or putting the food down for the dogs. He loved feeding the dogs! They gave him so much love right back that it diffused the situation. Try to stay calm at all costs. Keep the atmosphere as soothing as possible. Diffusing lavender oil into the air or some other soothing scent might help.” –muddiggermom
“Lighting and napping help us. My mom doesn't like to nap, so sometimes I have to lie down too just so she will. Another thing that works most of the time is to refocus them. Get them engaged in an activity that draws their attention away from the things that sundowner's brings out. Try dusting furniture or just sitting down with them and engaging in conversation where they have to help you with a problem you have (wink wink). I've been known to sit and listen to my mom chatter on for over an hour about things that aren't really happening. But if I can say things like, "How did you handle that?" or "That must have been challenging, what do you do if it happens again?" it really refocuses her and she bounces out of it more often than not.” –dianestark
“You might try a walk in natural lighting in the late afternoon. Perhaps a routine of lunch, a nap, a little snack, and then a walk in natural lighting followed by calming activity.” –momsie
“At home, we planned casual relaxing activities to begin in the later afternoon and transition through and past sundown. And we tried to be with Mom during the sundowning period so she wouldn't be alone while in the SNF. Don't plan any excursions, visits, appointments, etc. later in the afternoon. Make them in the morning so you can both return home and your loved one can adjust without coming home in the evening. Try playing their favorite TV programs in the early evening. Listening to music could help them relax; put on their favorite songs, or tune into one of the calming music channels on TV. Keep visitors to a minimum in the afternoon as well. Too much activity could aggravate the confusion.” –GardenArtist
“My cousin used to have some episodes of getting quite confused, agitated and anxious in the late afternoon. It would happen rather suddenly. However, that got much better when she went on Cymbalta (antidepressant). I don't know if it's coincidental or not, but she doesn't seem to be bothered as much. Before she went on the antidepressants, she would sometimes tell me that she was scared, she didn't know what was happening, or that she thought she was in a dream. She would ask me if things were real or not. She doesn't say those things anymore. I would discuss medications with your loved one’s doctor and see if there might be something that could help.” –SunnyGirl1
“My Mom takes Seroquel, which has helped a lot. She started with 12.5 mg two and a half years ago. She is now up to 75 mg. I give it to her about 4 PM and it helps until she goes to bed at 6:30 PM. I also try to keep her away from the evening news, NCIS, and Law and Order. She completely misinterprets shows like this and thinks her children, who are now old women, are somehow in danger. I even stopped phone calls after 5:30 because they seemed to set off her delusions.” –gladimhere
“Sundowning can go on all night and it's not just a matter of wanting to go to bed early. It's seeing people who aren't there, sometimes yelling and screaming, anxiety and fear ("I know there's someone outside my window!"). Medication is the best bet to ensure the whole household gets a good night's sleep.” –4thdaughter
“Ask your doctor. We've found that Haldol (a very strong anti-psychotic drug) was needed for my husband. Otherwise he gets very agitated and has even tried to hit people. Then the next day he is so remorseful that he cries all day.” –Corrine
“My wife becomes like an over-caffeinated road runner in the late afternoon, rummaging incessantly, dressing and undressing, totally unable to sit still. Our PCP has prescribed generic Ativan (Lorazepam) and has given me a great deal of leeway to titrate the dose from 0.5mg to 2mg to deal with her symptoms, which vary in intensity. It has been very effective for the 9 months she’s been on it. I give her the initial dose in the early afternoon.” –martydotcom
“Sunrising” and Behaviors at Other Times of Day
“I'm not a doctor, but I have a theory about "sunrise" syndrome, because my mother does it too. I think, because her brain has been able to "run wild" while sleeping, when she awakes and opens her eyes and takes in her surroundings, she must determine what is real, what is new and what is a dream from the night before. She takes a little while to get her "land legs" as I call it, and then she does better by about 10 AM. Her mood is definitely different for sunrising compared to sundowning. She experiences confusion and re-figuring out her world, without the irritation or perseverance she experiences during the evening.” –EdithFrances
“Sundowner's is really collection of behaviors that tend to happen later in the day but don't have to be isolated to that time. It can happen at any time of day. Make sure you are keeping a journal each day of what you see, hear, and sense. Especially if something strikes you as new/different/or super strange. The doctor is going to want to know how long something has been going on, and it's too hard to remember the details when you are up to your eyeballs in caregiving. Make sure to note the sundowner behaviors to the doctor, as there may be medication that can help turn down the severity of symptoms without making them sleepy all the time.” –sandwich42plus
“Sundowning happens during all parts of the day and night when the light outside is dark or fading. It does not just happen at the time of day that the rest of us call sundown (i.e. sometime between 6:00 PM and 9:30 PM, depending of the season). As a 28-year night shift RN, I dealt with one heck of a lot of sundowning, and I never arrived at work earlier than 10:00 PM. There is no "getting through" sundowning. It's not over till they fall asleep, either on their own (likely in the early morning), or via the use of medication.” –DoingbestIcan
“I think that the reason "sundowning" is thought to be only at night is because most people indeed sundown about this time. But I believe that sundowning occurs at the time of day when a demented individual is accustomed to (or wired for) something of importance happening. It is usually about sundown when most traditional families sat down to dinner, the kids were home from school, hubby was home from work, it was family time. This was a pattern that was repeated for many years in their earlier lives (both as children and as adults), therefore it is a deeply ingrained pattern. Can you identify something that will occupy your loved one during the time they are sundowning? In my experience, sundowning is best addressed not by medication but by activity during those hours when it occurs depending on their level of ability. For some of my clients a car ride works, cooking or another complex task (with assistance of course), a nap that begins 1/2 hour before the typical agitation begins (not such a great idea in the morning, though), or visits with/from others during that time.” –cindybrownlbsw