Understanding Sundowner’s Syndrome and Dementia Symptoms

Sundowner’s syndrome is a pattern of recurrent irritability, anxiety, and restlessness during the evening and at night that is often described as sundowning. These symptoms can affect people living with Alzheimer’s disease and other types of dementia. It can cause distress for caregivers, primarily due to worry about a loved one getting injured or lost at night.

This article describes the symptoms of sundowning syndrome, what you can expect, and ways to cope.

Sundowner’s Syndrome Symptoms in the Evening 

Symptoms of sundowning are generally associated with feeling scared, confused, or agitated. Most people who experience sundowning have difficulty falling asleep, and sundowning can make it even harder to rest and sleep. Many people with sundowning resist or refuse nighttime sleep. 

Symptoms include:

• Confusion
• Anxiety 
• Sadness 
• Agitation
• Irritability
• Not recognizing familiar things
• Feeling helpless
• Acting suspicious
• Fear
• Hostility
• Fighting
• Refusing to cooperate 
• Hallucinations
• Running away

A person may have consistent symptoms every time they experience sundowning or have different symptoms during different episodes. 

Timing and Frequency 

Sundowning can begin anytime from early evening to late evening to the middle of the night. It can start before bedtime, or a sleeping person can wake up in the middle of the night with symptoms of sundowning.

The symptoms can last from a few minutes to all night long. Sundowning can occur occasionally or almost every evening. 

In general, the symptoms of sundowning are more severe for people with dementia who still have a moderate level of independence. The timing, duration, and severity can vary for different individuals—and one person may even have variable symptoms that are not the same every time. 

Link Between Dementia and Sundowner’s Syndrome 

Sundowning is related to dementia for many reasons. Dementia is known to be associated with changes in areas of the brain that control memory, reasoning, behavior, and mood. For many people with dementia, the area of the brain that controls the circadian rhythm, which is the 24-hour body cycle, is also affected. 

People with a disordered circadian rhythm usually experience inconsistencies in wakefulness, sleep, and eating that do not correlate with light and dark. When the body doesn’t experience the normal drive to sleep or wake up in response to light and dark, people can have disruptions in their sleep patterns.

People with dementia can become more confused when it gets dark, when they are tired, when they are asked to get ready for bed, or when caregivers go to bed. Sundowning is believed to occur due to disruption of the circadian rhythm, and with thinking and behavioral changes of dementia.

Triggers

A person who has dementia can experience symptoms of sundowning even in the most comfortable and familiar conditions. However, some triggers can make the symptoms more likely or could make them worse.

Triggers may include:

• Being in an unfamiliar environment
• Being around unfamiliar people
• A change to the routine
• Feeling physically uncomfortable, hungry, thirsty, or sick
• Having had a long nap earlier in the day
• Being more tired than usual
• Changing the surroundings, such as furniture, blankets, decorations, food, or the season
• Certain medications

Since the regular day and night pattern regulates the circadian rhythm, sundowning symptoms can worsen during the winter months or when there is less exposure to daylight.

Sometimes, the symptoms can worsen on weekends or when professional caregivers are not visiting the home due to changes in routine.

Effect on Family and Need for Caregiving

If your loved one with dementia has been having symptoms of sundowning syndrome, it can add a significant amount of stress to your life, as well as worry, concern, and your own sleep deprivation. 

You may feel tired and burned out due to:

• Your loved one might refuse to sleep when you want to get some rest, which could prevent you from getting to bed.
• If they get up after you think they’re sleeping, they could become injured. You may have to treat their injuries or get them medical attention.
• You may feel distress and guilt if they’ve become injured.
• You may have anxiety or feel constantly on guard while you’re trying to sleep, with restless nights as you don’t allow yourself to sleep fully.

Getting Help

Some families may decide to share caregiving responsibilities with a shift schedule so that caregivers can alternate sleeping times. But for many families, this can be exhausting and unsustainable. You may opt to seek the help of a professional caregiver who can come and watch your loved one while you are sleeping.

Getting help can potentially give your loved one the flexibility to sleep when they feel tired and stay awake when they aren’t, relieving some of your anxiety about their sleeping hours. However, it’s important to know that people who have sundowning may exhibit symptoms of agitation during the evening hours, even when they are not asked to sleep.

For some families, it is safer to consider moving a loved one who is living with dementia to a facility where they can receive professional management. 

Treatment to Manage Sundowning Episodes 

Treatments for managing sundowning episodes generally focus on prevention, avoiding triggers, and maintaining predictability. Additionally, some medications have been used with varying levels of success. Medication is not considered the first-line therapy for managing sundowning syndrome, but it has been incorporated into some treatment plans.

Treatment approaches with varying levels of success for sundowning include:

• Medications used to treat Alzheimer's disease: These medications may help alleviate or delay some symptoms of dementia for some people. 
• Antipsychotics: Sundowners syndrome is not a type of psychosis, but sometimes antipsychotics have been used to help alleviate some of the more distressing symptoms, especially if hallucinations are occurring.
• Melatonin: This over-the-counter medication is sometimes used as a sleep aid for people with or without sundowning syndrome. It can work like the body's natural melatonin, a hormone that helps regulate sleep.
• Light therapy: Exposure to light at certain times of day may help regulate the circadian rhythm.

The treatments could help reduce symptoms of sundowning, but be sure to discuss your options with a healthcare provider. These therapies can interact with other medications or could cause significant side effects.

Prevention 

It is important to follow a routine that includes quiet time before bed. You might consider activities such as reading out loud, asking your loved one to talk about their day, preparing a light snack, or looking at family photos together.

Additionally, a sense of predictability throughout the day can help people with dementia learn to anticipate what activities will be next.  

How to Soothe Someone With Sundowner’s Syndrome 

If your loved one has been experiencing sundowning, you can do some things to help ease the symptoms. This starts with knowing what makes them comfortable.

Tips include:

• Asking what they want to do or what they want to talk about
• Avoiding exposure to unexpected people, sounds, or other surprises, especially in the evening
• Using room lighting that makes them comfortable
• Asking if they want their windows open or closed
• Playing music that they like at the volume they like (and from a source they can see)
• Offering food or a drink, such as warm tea, crackers, or whatever they ask for
• Making sure they have a comfortable bed, blankets, and pillows
• Showing them things that make them feel in control—like the light switch or their phone

You and your family can decide which of these things is most suitable for your loved one. Some people with dementia like to maintain a sense of control and also want to feel safe and taken care of.

How to Support Yourself as a Caregiver 

As a caregiver, you must also care for yourself and maintain your health and well-being. Taking care of your loved one who has dementia can feel rewarding for you, but it can also be exhausting.

You will be able to provide more care for your loved one if you get enough rest and self-care. This usually includes asking for help so you can take some time off. It is impossible to be on call to take care of your loved one 24 hours a day while also taking care of yourself, especially with their unpredictable sleeping schedule.

Support Groups and Resources

You can learn to lean on others who have gone through similar caregiving experiences by joining a support group for people who have loved ones with dementia. You could ask your loved one’s healthcare providers if there is a local support group near the clinic or hospital where you take them for care. You may also find a group in your community.

Dementia is very common, and you may also have friends or acquaintances who have had similar experiences and who can provide you with a listening ear, compassion, and practical tips based on what they have experienced—even outside of the formal definition of a support group.

Some organizations you may consider as a step to find support include:

• Alzheimer's Association
• Alzheimer's Foundation of America
• AARP
• The Association for Frontotemporal Degeneration
• Lewy Body Dementia Association

Summary 

Sundowning syndrome can be stressful for you and for your loved ones. The symptoms can include agitation and confusion in the evening or at night that might not occur at other times during the day.

Ways to help manage sundowning syndrome include avoiding triggers, maintaining a consistent schedule, trying to keep a familiar environment, scheduling shifts with family or other caregivers, and medication.

It’s also important that you maintain self-care because sundowning syndrome can be exhausting for caregivers. Get support from family and friends, from professional caregivers who can come to your home, and from your loved one’s healthcare provider

If necessary for their safety, your loved one may need to live where other people can professionally direct their 24-hour care. No matter where your loved one lives, you can still be a loving and present part of their lives.

Make sure you take care of yourself and get the support and help you need—which may include talking with a therapist, spending time with friends and family, joining a support group, and taking time for yourself to recharge.