What Stage of Dementia Is Sundowning? (and How to Manage It)

Sundowning—also known as sundowner's syndrome—occurs when dementia symptoms like confusion, agitation, distress, and confusion occur or worsen in the later afternoon or evening. While anyone with dementia can exhibit sundowning, it’s most often seen in the middle or late stages of the condition.

What Does Sundowning in Dementia Feel and Look Like?

Sundowning is characterized by worsening dementia symptoms. It occurs around the time the sun goes down, in the late afternoon or evening.

Research shows that neurodegenerative disorders, like dementia, affect the circadian rhythm (your body’s biological clock). Disruptions in the sleep-wake cycle can also affect emotional processing and aggression. Researchers believe this relationship contributes to sundowner's syndrome.

Sundowning episodes can vary from case to case, lasting anywhere from a few minutes to several hours, sometimes continuing through the night. Someone experiencing an episode may feel:

• Agitation or anxiousness and nervous excitement
• Anxiety, irrational fear, paranoia
• Apathy (a loss of desire to do things or take part in activities)
• Confusion (e.g., forgetting where you are, what you are doing, getting lost in your own neighborhood)
• Delusions (false beliefs or perceptions about reality)
• Difficulty forming or understanding sentences
• Forgetting familiar names and names of loved ones
• Irritability, irrational anger or rage, aggression
• Motor tics or uncontrolled movements
• Restlessness, feeling unable to settle down
  
• Visual or auditory hallucinations (seeing or hearing things that aren’t there)
  

Some people with dementia experience daily attacks, while for others, sundowning may be more sporadic. However, once episodes start, they’re likely to recur.

Signs of Sundowning in Others

It’s essential to recognize the symptoms of sundowning when caring for or living with someone with dementia. Typical signs associated with sundowning include:

• Aggressive behavior, lashing out verbally or physically
• Changes in how they walk or move, unusual movements
• Difficulty understanding or comprehending their speech
• Loss of interest in activities they enjoy
• Pacing or wandering around, not being able to sit still
• Yelling, screaming, or other erratic behaviors
  

What Stage of Dementia Is Sundowning?

Though it can arise in the early stages, sundowning is typically a sign that the dementia is more advanced; sundowning in early dementia is rare. As such, this issue generally arises once other symptoms, such as confusion and memory lapses, are more pronounced.

Since fatigue triggers sundowning, this condition is more common and severe in people with dementia who are more independent and active, primarily occurring in those with moderate-stage dementia. People in later stages of dementia tend to be less active, and sundowning is rarer and less severe in this population.

Dementia Stages: What to Expect

Dementia is a progressive condition that gradually worsens over time. Clinically, healthcare providers break dementia into seven stages, as follows:

• Stage 1: The appearance of being cognitively normal (though brain changes occur)
• Stage 2: Mild memory loss appearing similar to forgetfulness from normal aging
• Stage 3: Mild cognitive impairment; people get lost or struggle to find words
• Stage 4: Moderate dementia: limited short-term memory; people begin to forget their personal history
• Stage 5: Continued cognitive decline; people need assistance in their day-to-day lives and are often confused or forget personal details
• Stage 6: Severe dementia; people require ongoing personal care and don't recognize close family members and friends
• Stage 7: Final stage, nearing the end of life; people show motor symptoms and struggle to communicate, are incontinent, and need feeding assistance

These stages are categorized as "early," "moderate," or "severe" dementia, as described below.

Early Dementia

Early dementia comprises stages 1 through 3. Healthcare providers can see evidence of cognitive decline in imaging in the earliest stages, but people in these stages show mild or no symptoms. The earliest signs are memory lapses that may be mistaken for age-related memory decline. As dementia progresses, it leads to more pronounced memory and cognitive problems and mild cognitive impairment.

Signs in someone with early-stage dementia may include:

• Declines in work performance
• Denial or anxiety surrounding memory problems
• Difficulty with remembering plans, forgetting plans
• Not remembering something they just read
• Problems remembering names of acquaintances or friends
• Reduced ability or an inability to remember names of new acquaintances
• Taking longer to complete tasks
  
• Wandering off
  

Moderate Dementia

Stages 4 and 5—moderate and moderately severe cognitive decline—make up moderate dementia. In moderate dementia, people start to need assistance with daily living. Symptoms become more severe as the damage spreads to parts of the brain involving consciousness, language, memory, senses, and perception. Signs of this stage can include:

• Difficulty with dressing or other daily tasks
• Forgetting the names of loved ones, family, or friends
• Hallucinations, delusions, and paranoia
• Impulsive or erratic behaviors
• Inability to learn new tasks
• Severe confusion, disorientation

Severe Dementia

In stages 6 and 7, memory, cognition, and language deficits are so severe that someone with severe dementia can’t live independently. Over time, people lose the ability to talk, move, and respond to the outside environment. In the final stages of Alzheimer’s disease or other progressive brain diseases, people need help eating, dressing, and going to the bathroom.

Factors That Can Worsen Sundowning

Researchers are still working to understand what triggers sundowning. They believe it arises due to a combination of factors, including changes in brain structure and function and problems with the circadian rhythm. Several health factors can trigger or worsen sundowning, including:

• Chaotic environments: Too many people visiting, messiness or cluttered environments, and loud noises can trigger sundowning episodes.
• Consumption habits: Alcohol and caffeine use can interrupt circadian rhythms and trigger sundowning, especially when consumed later in the day.  
• Fatigue: Being tired can also contribute to or worsen sundowning; fatigue can be especially intense in the afternoon after an active day, setting off episodes.   
• Lack of routine: Days that lack structure can also worsen sundowning, as can sudden sleep cycle changes.
• Medications: Certain classes of drugs, including certain antipsychotics, hypnotics, antidepressants, and anticholinergic medications, can trigger sundowning.
• Reduced light exposure: Not getting enough natural light throughout the day can contribute to sundowning and disrupt sleep.  
• Sleep disruption: Disruptions or problems with the circadian rhythm, or daily sleep-wake cycle, can trigger episodes and are thought to contribute to their formation.
  

Methods to Reduce Sundowning

There’s no cure for dementia, but there are ways to manage sundowning and other symptoms. Support your loved one in adopting lifestyle habits to reduce the chance of episodes and try methods to manage irritation and aggression. Steps you can take include:

• Avoid alcohol and coffee: In the evening, minimize or completely eliminate alcohol and caffeinated beverages like coffee or black tea.
• Avoid naps: Long naps in the day can disrupt the circadian rhythm and trigger sundowning and dementia symptoms.
• Create a soothing environment: Reduce the clutter in your home; let natural light in during the day, and use soft lights at night.
• Get sleep: Poor sleep can trigger episodes. Aim to get seven to eight hours of sleep a night—go to bed and get up at consistent times.
• Keep a schedule: Maintain a regular daily schedule, eat at regular times, plan activities earlier in the day, and avoid stressful or demanding activities in the afternoons or evenings.
• Light exposure: Plan a time to get sunlight every day by going outside or sitting by a window.
• Stay active: Get physical activity earlier in the day to promote better sleep—but don’t overdo it as fatigue can trigger sundowning.
  

How to Manage Sundowning: Tips for Caregivers

There’s no doubt that dementia can be challenging, not only for the person with the condition but also for the caregiver. Caring for someone who is experiencing sundowning means coping with symptoms like aggressiveness and irritation while providing support and comfort. In doing so, thinking about communication, environment, activities, and safety is essential.

Communication

If someone is irritable, angry, or displaying other symptoms, try to be patient and avoid displaying frustration. Methods to promote good communication with someone with dementia include:

• Deep breathing—inhale and exhale slowly to ease frustration
• Explaining what you’re doing before touching the person with dementia, as when bathing or dressing them
• Listening to the person experiencing symptoms; don’t try to argue or reason with them
• Providing reassurance that you’re there to help and provide support
• Trying to use humor
  
• Using a calm voice, speaking slowly and clearly
• Using touch, such as hugs or stroking hair, instead of speaking
  
• Validating their feelings, showing empathy when they feel upset
  

Environment

You can support people with dementia by creating a comfortable home environment. There are several steps you can take, including:

• Create a space with natural light during the day and soothing light in the evenings.
• Decorate the home with cherished objects, like pictures, photographs, or other keepsakes.
• Plan regular meal and bathing times, as well as other activities like walks.
• Reduce household clutter and work to prevent excessive noise.
• Take breaks and slow down your life if you’re feeling overwhelmed.

Activities

Certain activities or objects can help someone with dementia as they experience symptoms, changing their focus. Here’s what you can try:

• Do simple tasks together, such as folding laundry.
• Enjoy a flavored, nonalcoholic beverage, such as an herbal tea.
• Play music, sing, or dance.
• Read them a book that they enjoy.
• Watch a TV show or movie that they enjoy.
  

Safety

As a caregiver for someone with dementia and sundowning, it’s essential to consider safety, which can involve:

• Hiding or locking away any guns, knives, keys, or other objects that could be weapons
• Keeping at a safe distance when the person with dementia is becoming aggressive
• Seeking medical help if they’re hallucinating or experiencing delusions
  
• Seeking out counseling or support from family to cope with mental health effects
• Staying attentive to your feelings

Summary

Sundowning occurs when dementia symptoms like confusion and irritability worsen in the late afternoon or evening. Dementia progresses through stages of severity, and sundowning is most prevalent in the moderate stages of the condition. Sleep disruptions, noisy or chaotic environments, and insufficient natural light are among the factors that worsen sundowning. Make lifestyle adjustments to address these factors to help prevent episodes and manage symptoms.