Tips to Manage Sundowners Syndrome

Understanding and Managing Sundowning (Sundowners Syndrome) in Dementia Care

Evenings can be one of the most challenging times of day for people living with dementia and the families who care for them. As the sun sets, some individuals experience sudden increases in confusion, agitation, restlessness, or anxiety,  a condition known as Sundowners Syndrome or sundowning.

This behaviour can be distressing for both the person with dementia and their carers, as familiar routines and environments suddenly feel unfamiliar or frightening. While this is a common symptom in people with Alzheimer’s disease and other forms of dementia, it is not well understood outside clinical circles, leaving families feeling worried and often isolated.

At Independent People Homecare, we have over a decade of experience providing live-in dementia care across the UK. Our approach is informed by clinical best practice, academic research, and hands-on experience, ensuring that people living with sundowning receive safe, compassionate, and person-centred support.

What Causes Sundowning in Dementia?

The exact causes of Sundowners Syndrome are complex and multifactorial. Research and clinical observation point to a combination of neurological changes, environmental factors, and lifestyle triggers. Understanding these triggers allows carers and family members to anticipate behaviours and adapt care strategies accordingly.

Key Contributing Factors:

1. Fatigue and Mental Exhaustion
   As the day progresses, mental fatigue can make it harder for the brain to process information, increasing disorientation and anxiety. Carers often notice that small frustrations or changes in routine are magnified in the evening.
2. Reduced Light and Shadows
   Dim or fading light can make familiar surroundings appear unfamiliar. Shadows and poor illumination may trigger visual confusion, making ordinary objects seem threatening or strange.
3. Disrupted Circadian Rhythms
   Many people with dementia experience disturbed sleep-wake cycles, making it difficult to distinguish day from night. This disruption can exacerbate evening agitation and restlessness.
4. Environmental Changes and Overstimulation
   Noise, unexpected visitors, or changes to familiar routines can be overwhelming. Even small changes in the household environment can trigger fear, pacing, or agitation, especially in the late afternoon.
5. Seasonal and Hormonal Influences
   Shorter days, reduced natural light, and seasonal factors such as Seasonal Affective Disorder (SAD) can worsen mood changes, compounding sundowning symptoms.

Clinical insight: Studies suggest that a person’s neurological sensitivity to light and fatigue plays a major role, meaning that small, targeted interventions (like lighting adjustments, routine planning, and calm evening activities) can make a significant difference in outcomes.

Real-Life Example of Sundowners Syndrome

Take Margaret, a 72-year-old woman in the early stages of Alzheimer’s disease. Her mornings are calm and pleasant, she enjoys a leisurely breakfast, chats warmly with carers, and participates in familiar routines. But as the day progresses and evening approaches, Margaret begins to experience heightened confusion and agitation. She may accuse carers of stealing, pace restlessly, or struggle to settle for the night.

This stark change is a clear example of Sundowners Syndrome, where the late afternoon and evening trigger disorientation, anxiety, and emotional distress. For Margaret, these episodes can be frightening and upsetting. For her carers and family, the emotional toll can be equally heavy, as they strive to provide reassurance, maintain calm, and ensure her safety.

Real-life cases like Margaret’s highlight the importance of understanding sundowning triggers, recognising early warning signs, and implementing gentle, supportive strategies to ease transitions and improve quality of life.

Common Symptoms of Sundowners Syndrome

Sundowners Syndrome can manifest in a variety of ways, and symptoms often intensify in the late afternoon and evening, when fatigue and environmental changes can heighten confusion. Recognising these signs early can help carers respond with compassionate, effective support. Common indicators include:

• Rapid Mood Changes or Emotional Outbursts: Sudden shifts from calm to distress, frustration, or tearfulness.
• Increased Confusion or Disorientation: Difficulty recognising familiar people, places, or objects, sometimes leading to fear or anxiety.
• Agitation, Pacing, or Restlessness: Repetitive movements, wandering, or inability to settle comfortably.
• Paranoia, Delusions, or Hallucinations: Unfounded fears, seeing or hearing things that aren’t there, or believing others are acting against them.
• Verbal Aggression or Crying Spells: Sudden shouting, blaming, or emotional breakdowns, often triggered by frustration or misunderstanding.
• “Shadowing” a Carer or Following Them Room to Room: Seeking reassurance and safety through constant presence and attention.
• Night Waking or Difficulty Falling Asleep: Restlessness and insomnia disrupt natural sleep cycles, which can worsen symptoms over time.

Recognising these behaviours as part of Sundowners Syndrome, not intentional misbehaviour, can help carers respond with patience, empathy, and structured support, reducing distress for both the person with dementia and those caring for them.

Practical Tips for Managing Sundowners Syndrome

Managing Sundowners Syndrome can be challenging, but structured routines, a calm environment, and gentle support can make evenings less stressful for both the person with dementia and their carers. For those considering additional support, live-in care can provide invaluable continuity, reassurance, and safety around the clock.

1. Maintain a Regular Daily Routine

Consistency and predictability are crucial for people with dementia, especially during vulnerable evening hours. A structured routine helps the brain anticipate what will happen next, reducing confusion and anxiety.

• Set regular mealtimes and snack times to maintain energy levels and stabilise blood sugar, which can influence mood.
• Keep activity schedules consistent: gentle exercise or cognitive stimulation in the morning and early afternoon helps expend energy constructively and reduces restlessness later in the day.
• Bedtime rituals: A calming evening routine, such as washing hands and face, changing into nightwear, or listening to soft music, can signal the body and mind that it’s time to wind down.
• Avoid stimulating tasks late in the afternoon, including intense conversations, challenging puzzles, or unfamiliar visitors, as these can exacerbate confusion and agitation.

Expert insight: Even small deviations in routine can trigger heightened anxiety, so minor adjustments should be introduced gradually and explained clearly to the person where possible.

2. Keep the Environment Calm and Consistent

The environment can greatly influence Sundowning behaviours. People with dementia are highly sensitive to sensory input, and overstimulation or unfamiliar surroundings can trigger agitation.

• Lighting: Use soft, warm lighting in the evening to reduce shadows and prevent visual misperceptions. Motion-sensor night lights in hallways and bathrooms can prevent sudden fright or confusion if the person wakes during the night.
• Noise reduction: Minimise background noise from televisions, radios, or household appliances during late afternoon and evening.
• Consistency: Keep furniture, personal belongings, and daily objects in familiar locations to reduce disorientation. Avoid moving or rearranging items during the evening.
• Calm household activity: Encourage family members to speak softly, avoid arguments in the presence of the person with dementia, and keep visitors limited during the late afternoon if possible.

3. Encourage Soothing Activities

Engaging in familiar, low-stress activities can redirect attention and provide comfort, reducing anxiety and frustration.

• Music therapy: Playing favourite songs or gentle classical music can lower stress hormones and promote relaxation.
• Memory activities: Looking through photo albums, scrapbooks, or personal mementos encourages reminiscence, helping the person reconnect with positive memories.
• Simple cognitive or manual tasks: Low-pressure puzzles, crafts, or sorting objects can occupy the mind constructively without causing frustration.
• Gentle conversation and storytelling: Talking about familiar topics, family stories, or even reading aloud can reassure and provide emotional connection.

Tip for carers: These activities should be predictable, brief, and positive. Overly long or challenging tasks can backfire and increase agitation.

4. Use Light Therapy

Disruption of circadian rhythms is a key contributor to Sundowning. Supporting natural sleep-wake patterns can reduce evening confusion and night-time waking.

• Daytime light exposure: Encourage outdoor activity or sit near bright windows during the day. Sunlight helps regulate melatonin production, improving night-time sleep.
• Light therapy lamps: In the UK, shorter winter days can disrupt sleep patterns. Clinically approved light therapy lamps can supplement natural light exposure.
• Avoid late-day naps: While short naps may be fine, long or late-afternoon naps can interfere with the ability to fall asleep at night.
• Consistent bedtime: Going to bed at roughly the same time each night signals the body that it’s time to rest.

5. Adjust Diet and Hydration

Nutrition and hydration directly affect mood, cognition, and energy levels, making them important for managing sundowning:

• Limit stimulants: Avoid caffeine, chocolate, and sugary snacks in the afternoon and evening, which can increase restlessness or insomnia.
• Hydration: Dehydration can exacerbate confusion and irritability. Encourage small, frequent drinks throughout the day.
• Balanced diet: Ensure meals contain adequate protein, fibre, and vitamins to maintain energy and mood stability.
• Gentle reminders: People with dementia may forget to eat or drink; carers should offer discreet reminders or assistance.

6. Use Melatonin with Caution

Melatonin is a hormone that regulates sleep-wake cycles and may support better sleep for people with dementia.

• Medical supervision is essential: Only use melatonin if recommended and monitored by a GP or specialist.
• Personalised dosing: Incorrect timing or dosage can cause over-sedation or interfere with natural sleep patterns.
• Complementary strategies: Melatonin is most effective when combined with light exposure, routine, and environmental adjustments.

Warning: Never self-prescribe supplements for dementia-related sleep disturbances.

7. Create a Safe and Secure Environment

Safety is a critical consideration, particularly during evening hours when agitation and restlessness peak.

• Motion-sensitive lighting: Prevent falls and reduce sudden disorientation during night-time wandering.
• Door alarms and secure access: Prevent wandering outside or into unsafe areas.
• Identification aids: ID bracelets or necklaces can provide peace of mind if the person leaves the home.
• Live-in carers: Continuous presence allows immediate reassurance, guidance, and intervention in moments of distress, reducing risk and increasing emotional comfort.

Expert tip: Even small adjustments, such as decluttering walkways and removing tripping hazards, can significantly reduce anxiety and physical risk.

Managing Sundowning is not about eliminating all challenging behaviours, it’s about anticipation, structure, and emotional reassurance. By combining consistent routines, a calm environment, personalised activities, support for sleep, proper nutrition, and safety measures, carers can significantly reduce evening agitation while promoting dignity, comfort, and peace of mind.

For families struggling with Sundowning, live-in care provides continuity, reassurance, and expertise, ensuring that evenings, once stressful, can become calmer and safer for everyone involved.

Benefits of Live-In Care for Sundowners Syndrome:

• 24/7 Presence: Constant supervision reduces risk of wandering, falls, and late-evening agitation.
• Consistency and Familiarity: A dedicated carer helps maintain routines, calm environments, and personalised strategies.
• Emotional Support: Continuous companionship provides reassurance and reduces feelings of isolation or fear.
• Relief for Family Carers: Families can feel confident their loved one is safe and supported, reducing stress and exhaustion.

New Research and Approaches to Sundowners Syndrome

• Personalised Music Therapy: Familiar music can reduce anxiety and even boost memory.
• Virtual Reality: Calming VR experiences have been shown to reduce evening agitation in some care settings.
• Sensory Rooms: Dimly lit rooms with soft music and textures can provide refuge from overstimulation.
• Visual Aids: High-contrast colours and signage can reduce confusion around sunset and at night.

When to Seek Further Help

If symptoms escalate or affect quality of life, consult a GP or specialist. Medication reviews, environmental changes, and dementia-trained live-in care can provide consistent relief and support.

Support for Carers

Supporting someone with Sundowners Syndrome is demanding. Seek help from respite services, live-in care, or charities like Alzheimer’s Society and Dementia UK. Your wellbeing matters too.

Conclusion

Sundowners Syndrome can be distressing, but with structure, understanding, and targeted care, its effects can be reduced. The goal is not perfection, but comfort, safety, and dignity — especially in the evening hours when vulnerability increases.

Last Updated: 16 June 2025

Authored by Paul Austin, CEO of Independent People, who brings extensive experience in dementia care and senior wellbeing.