Sundowners Syndrome: Signs, Triggers and Caregiver Support

Sudden confusion needs emergency assessment

Delirium is an acute change in attention and awareness that can develop over hours or days and fluctuate. It may involve agitation, but it can also make someone unusually quiet, withdrawn, slow to respond or less interested in eating. This quieter form is easily missed. Dementia and delirium can occur together; a dementia diagnosis does not explain away a sudden deterioration. Tell the healthcare team exactly how today differs from the person’s usual abilities. NICE advises clinicians to manage delirium first when it is difficult to distinguish delirium, dementia and delirium superimposed on dementia. [4]

Call emergency services for new facial drooping, weakness or numbness on one side, or trouble speaking. Sudden vision loss, marked dizziness or falling, and a severe headache can also be stroke symptoms. Act even if the symptoms improve or disappear; improvement does not make the episode safe to ignore. Explain that the change was sudden and describe what you observed. Our guide to transient ischemic attack, sometimes called a mini-stroke, explains why brief symptoms still matter. Reading it should never delay an emergency call. A familiar evening pattern is not a reason to attribute new neurological symptoms to sundowning. [5]

What sundowning can look like

A person may become more anxious, irritable or disoriented, repeatedly ask to leave, or have difficulty settling. Some people experience hallucinations or strongly held beliefs that others do not share. These changes may continue into the night. Despite its name, sundowning is not tied precisely to sunset, and distress can occur at other times too. It can happen at different stages of dementia, although it is more common in the middle and later stages. There is no single established explanation. Fatigue, unmet physical needs, disrupted body-clock signals, sensory difficulties, changes in surroundings and medicine effects may contribute in different combinations. The person’s individual pattern is more useful than assuming everyone will become distressed at the same hour. [2]

Sundowning is a description of symptoms and behavior, not a separate disease. It is therefore not a sufficient explanation for every sleep problem or difficult evening. A person may be tired after too much activity, unsettled in an unfamiliar room, or distressed by shadows that are hard to interpret. Schedule demanding tasks, such as appointments or bathing, for the part of the day when that particular person is most alert. If they are awake and pacing, a calm approach and supervised movement may be more helpful than insisting that they sit still. Do not use physical restraints to make someone settle. [6]

Look for discomfort and unmet physical needs

Pain may appear as a change in behavior

Someone who struggles to find words may still communicate pain through facial expression, movement or sound. Watch for grimacing, guarding or rubbing a body part, calling out during care, refusing food, or becoming reluctant to stand or move. Ask simply whether something hurts, aches or feels sore, and give them time to respond. Notice whether a particular movement brings on the reaction. These observations help a clinician assess possible pain; they do not prove its cause. Record new symptoms and seek advice about assessment and treatment. Follow an existing pain-management plan as prescribed rather than adding a sedating medicine because the person seems restless. Comfort includes positioning, suitable seating and care that does not rush a painful movement. [7]

Offer practical help with drinking

Dementia can make it harder to notice thirst, remember to drink, obtain a drink or explain what is wanted. Offer familiar drinks regularly through the day and during meals, using a cup the person can see, recognize and hold comfortably. Sit with them when encouragement helps. Simply leaving a glass nearby may not be enough, and an empty glass does not necessarily mean its contents were drunk. Notice actual intake without turning every drink into a confrontation. Alcohol can worsen confusion, contribute to dehydration and interact with medicines, so it is a poor choice for trying to calm someone or make them sleep. Ask the care team how to adapt drinking support if the usual approach is not working. [8]

Follow any existing swallowing plan or prescribed fluid restriction, including advice for heart or kidney disease. New difficulty swallowing, repeated coughing or a wet-sounding voice with drinks needs urgent clinical advice. Do not force drinks or improvise their thickness; ask the healthcare team how to support drinking safely for this person. [4, 38]

Much less urine, persistent dizziness on standing, unusual tiredness or rapid breathing can indicate dehydration needing urgent care. Confusion, difficulty waking, breathing difficulty or cold, pale or blotchy skin in someone who is dehydrated require emergency help. Do not assume that severe sleepiness is simply the welcome end of a restless evening. Older adults and people who depend on others for drinks are especially vulnerable. When seeking help, explain recent intake, vomiting or diarrhea, and the change in urine and alertness. [36]

Do not diagnose a urinary infection from confusion alone

A urinary tract infection can be one possible contributor to acute illness, but confusion alone does not establish a UTI. Many older adults have bacteria in their urine without a symptomatic infection. UKHSA guidance advises checking other causes when delirium is present but symptoms do not suggest a urinary infection. Tell the clinician about pain or burning with urination, changes in urinary frequency, bladder discomfort, fever and other new symptoms, including when the person cannot describe them clearly. Do not start leftover antibiotics or assume a positive urine result explains the entire problem. Assessment needs to consider pain, constipation, dehydration, medicines and the environment as well. [9]

The emergency advice above still applies: seek help immediately for sudden new confusion. [3]

Make toileting easier without sacrificing dignity

A person may need help locating the bathroom, recognizing the toilet or undoing clothing. Make the route easy to navigate and well lit, including at night. A clear sign with words and a picture may work better than repeated directions from across the room. Offer a discreet reminder and enough time, using clothing that is manageable for the person. Check whether a mirror makes them think someone else is in the bathroom. Preserve privacy while ensuring they will not accidentally lock themselves in without help. If mobility makes the journey difficult, ask an occupational therapist or the care team about suitable aids. A device is useful only if the person can recognize and safely use it. [11]

Remember teeth, dentures and the evening meal

Refusing dinner, wincing when chewing or appearing uncomfortable at the table may signal tooth or mouth pain, including poorly fitting dentures. Arrange dental advice rather than treating repeated mealtime distress solely as a dementia behavior. Oral care may also be frightening if the person does not understand what you are about to do. Explain one step at a time, demonstrate brushing when helpful, and allow the person to do as much as they comfortably can. If they are upset or resist help, pause and try a calmer approach later instead of forcing the task. Tell the dentist about the dementia and any difficulties with care so the visit and home routine can be adapted. [12]

How to respond during a difficult evening

Use fewer words and give more time

Approach from the front, introduce yourself if needed and speak to the person directly. A quiet, one-to-one exchange is often easier to follow than several people explaining at once. Use a calm adult tone, one short question or instruction at a time, and a pause long enough for a response. A simple choice can be easier than an open-ended question. If words are difficult, offer a visual cue or invite the person to point. Listen for the feeling behind an unfinished sentence. Correcting every mistaken detail can distract from the immediate need for reassurance. Avoid talking about the person as though they are absent, even if their spoken responses are limited. Their preferences and dignity still belong at the center of the conversation. [13]

If anger rises, consider what happened just before it: an unexpected touch, a complicated request, noise, discomfort or a task the person did not understand. Stop a nonessential task that is escalating distress and give the person some space. Speak slowly and softly rather than matching their volume. If it is safe, another trusted caregiver may be able to take over while you regain composure. Keep yourself and others safe, and seek assistance if the situation cannot be settled. Call emergency services when there is immediate danger, explaining that the person has dementia. Compassion does not require staying within reach of someone who is hitting, or trying to manage a dangerous episode alone. [14]

Respond to frightening perceptions without arguing

If the person sees or hears something you do not, first consider whether they are frightened or at risk. A calm statement such as “That sounds frightening; I’m here with you” acknowledges their experience without confirming that an imagined threat is real. If asked what you see, respond honestly and gently. A quieter or better-lit room may help, as can checking for shadows, reflections or noises being misinterpreted. Harmless experiences do not always need to be challenged or interrupted. New hallucinations deserve medical assessment because medicines, physical illness and sensory problems can contribute. Tell the clinician whether the experience is new, how distressing it is and whether it leads to unsafe actions. [15]

When the person asks to go home

“Home” may mean a previous house, a familiar period of life or a place where the person felt secure. Repeatedly proving that they already live here may not meet that need. Reassure them, listen to what they associate with home, and look for ways to make the current setting feel familiar. A photograph, a well-known object or a comfortable place to sit may help more than a long explanation. If conversation is possible, asking what they liked about that home can reveal what feels missing now. Use signs or other recognizable cues if they are having trouble finding rooms. The aim is to understand and support the person’s sense of safety while responding to their actual surroundings. [16]

Repeated questions can reflect a forgotten answer, but they can also express worry, boredom or a wish for reassurance. Try answering the underlying concern as well as the words. For example, repeated questions about a family member’s arrival may call for reassurance that the person will have company. A written reminder can help if reading and understanding it remain comfortable; otherwise it may become another confusing object. Observe whether repetition is linked to a particular time, visitor or activity. A harmless repetitive action can sometimes become a familiar task, such as smoothing a cloth becoming folding laundry. There is no need to stop every repetition when it is safe and the person is content. [17]

Build a daytime routine that supports the evening

Start with the person’s existing rhythms, interests and abilities. A useful day plan includes meals, personal care, movement, company, enjoyable activities and rest, with room for flexibility. Put more demanding activities at a time when the person usually manages them best. Do not fill every minute in an effort to prevent symptoms; too much activity can be as unhelpful as having nothing meaningful to do. Regular waking and bedtime cues can support a recognizable day. When an activity stops being enjoyable, simplify it or take a break. Review the plan as abilities change, because a routine that suited someone six months ago may now involve too many steps or too little help. [18]

Offer opportunities for natural daylight, such as time outside with appropriate support or sitting near a window during the day. Aim for activity that suits the person without packing the schedule. Long naps or dozing late in the day can make nighttime sleep more difficult, so discuss a manageable balance of rest and daytime engagement. Avoid using caffeine or alcohol late in the day. These are adjustments to explore, not a guarantee that sundowning will disappear. When you change the routine, pay attention to whether the person is more comfortable and less overtired, rather than measuring success only by whether they remain awake. [1]

Keep movement within the person’s abilities

Choose movement the person enjoys and can do safely, adapting familiar activities rather than automatically giving them up. Their mobility, balance, other health conditions and preferences matter more than meeting a generic exercise target. Before starting a new activity, ask a clinician or physiotherapist for advice, especially when there are heart or breathing problems, dizziness, joint problems or frequent falls. Stop activity that causes pain or makes the person feel unwell, dizzy or unusually breathless, and seek advice. The purpose is comfortable movement and participation, not exhausting someone so they will sleep. Support can include shorter sessions, a slower pace, suitable equipment or company that makes an activity easier to follow. [20]

Offer meaningful activity rather than a test

A familiar activity can provide connection without demanding perfect memory or performance. Match the task to what the person can currently do, help them get started and watch for frustration. Someone who once cooked complete meals may enjoy mixing ingredients or describing a recipe while another person handles difficult steps. A gardening enthusiast may prefer looking at plants or helping with a small, manageable task. Watching can be a valid form of participation if it brings pleasure. Keep outings brief enough to avoid fatigue, choose the person’s better time of day and preserve familiar meal and rest routines where possible. Prepare visitors to communicate patiently and keep the number of simultaneous demands low. [23]

Music can offer a shared activity even when conversation is difficult. Choose something familiar and enjoyable to this person, and let them influence the choice when possible. A gentle recording may support a calm mood; another familiar song may invite singing or a little movement. Watch the response rather than assuming any playlist labeled “relaxing” will work. Avoid competing television noise, loud volume and recordings interrupted by advertisements. If the music seems to unsettle them, stop or change it. Music is one possible way to connect and engage, not a treatment that reliably ends every episode. Quiet companionship may suit the person better on a particular evening. [35]

Make the evening environment easier to understand

Aim for comfortable, even lighting and fewer confusing shadows or reflections. Close curtains when dark windows become mirror-like, and check whether a mirror is upsetting the person. Turn off a television or radio that nobody is following. A busy soundtrack can make an already confusing room harder to interpret. Keep familiar arrangements where possible; abruptly reorganizing the whole home can create new difficulties. Check for rugs, shiny surfaces or patterns that the person appears to misread as obstacles. Clear signs with simple words and pictures may help them find important rooms. These changes should make the space easier to use, with the person’s response guiding what stays and what needs another adjustment. [21]

Sight and hearing problems can compound confusion and make conversation harder, yet may be mistaken for worsening dementia. Arrange appropriate eye and hearing checks; assessments can often be adapted for a person who has dementia. Notice whether they struggle more in dim light, miss objects in front of them or cannot follow speech with background noise. Support their preferred way of communicating, including letting them see your face and using clear visual cues when helpful. Ask the relevant professional about problems using glasses or hearing aids rather than assuming the device cannot help. Improving access to what is happening around them may reduce avoidable uncertainty, even though it does not treat the underlying dementia. [22]

Keep bedtime recognizable and unhurried. A familiar sequence of quiet activities can signal that the day is winding down more clearly than repeatedly announcing that it is time to sleep. Consider whether afternoon or evening caffeine is interfering, and offer a familiar non-caffeinated alternative. Daytime activity and a regular routine may help, while a stimulating late-evening activity can leave the person more alert. Address known pain or discomfort through the agreed care plan, and ask a pharmacist whether medicines could be contributing to sleep difficulty. The same wind-down activity will not appeal to everyone. Use habits the person finds pleasant, and allow enough time for them to move through each step without feeling pressured. [19]

Plan for wakefulness, walking and safety

A safer night does not depend on forcing sleep

Review the route between bed, bathroom and the places the person commonly walks. Remove loose rugs, trailing cords and clutter, and provide even lighting or appropriate night lights. Keep medicines, cleaning products and other hazardous items safely stored. Check smoke and carbon monoxide alarms, and make emergency contact information easy for caregivers to find. Review appliances and the risk of burns from hot water, heaters or heating devices. Safety needs change as balance, judgment and perception change, so revisit the setup rather than assuming an earlier check remains enough. Aim for a home that supports movement and ordinary activities as safely as possible, rather than one that feels needlessly restrictive. [25]

Walking may have a purpose the person cannot easily explain: looking for someone, following an old routine or responding to discomfort. Where feasible, support safe walking with company and a clear, even route. Make a garden or indoor walking space interesting without introducing obstacles. Note the timing and any explanation the person gives so the care team can help understand the pattern. If considering location technology or sharing information with neighbors, include the person in the decision and consider consent, privacy and the appropriate best-interests process when they cannot decide. Tell day-care or residential staff about the person’s need to walk and ask how they support it safely. [27]

What to record and discuss with the healthcare team

For an established pattern without emergency symptoms, a brief diary can reveal practical opportunities to help. Record what happened, when and where, who was present, and what came just before the distress. Include how the person appeared to feel and what response helped or made matters harder. Look for a pattern rather than labeling them “difficult.” A busy room, an unfamiliar caregiver or a particular personal-care task may be relevant. Develop changes with the person and others involved in care, then review the effect. The diary should support care, not delay assessment of a new illness or become a burdensome account of every minute. [10]

A clinician should consider whether illness, medicine effects, discomfort or sensory difficulty is contributing to a behavioral change. The person’s surroundings and care interactions matter too. An assessment is more useful when it identifies a specific problem to address, rather than treating “sundowning” as the final answer. Explain whether symptoms are new, worsening, linked to particular situations or preventing safe care. Discuss approaches that promote physical and emotional comfort before relying on medication. If a medicine is being considered, ask what exact symptom it is intended to improve and how that improvement will be recognized. An apparently quieter person is not necessarily experiencing better comfort or quality of life. [28]

Prepare a small number of priority questions for the appointment. Describe the person’s usual abilities, the change you have noticed and its effect on everyday care. Bring observations about sleep, meals and behavior, together with all medicines and supplements. Ask what the likely contributors are, which problems need further assessment, what to try at home, and when to get back in touch. Request clear advice about changes that would need urgent help. Involve the person with dementia in the discussion as far as they wish and can participate. If instructions are unclear, ask for an explanation or a written plan. A shared understanding is especially important when several relatives or paid caregivers alternate responsibility. [34]

Sleep problems and medicines need an individual review

Check for a separate sleep problem

Difficulty sleeping may have contributors beyond the late-day dementia pattern. Sleep apnea involves repeated interruptions in breathing; restless legs can produce unpleasant sensations and a strong urge to move. Depression, physical illness and discomfort may also affect sleep. Tell the clinician about snoring, observed breathing pauses, leg discomfort, daytime sleepiness and the timing of wakefulness. A thorough assessment can identify a problem that needs its own treatment. For sleep difficulty related to Alzheimer’s disease, non-drug measures are generally the starting point. Ask which measures fit the person’s circumstances and what follow-up is planned if they continue to sleep poorly. The aim is restorative sleep and daytime wellbeing, with treatment risks considered alongside possible benefits. [24]

Some medicines used for dementia or other conditions can disturb sleep or cause vivid dreams. Other health problems, including pain, constipation, bladder difficulties and breathing symptoms, can also make nights uncomfortable. Bring these possibilities to the prescriber or pharmacist rather than changing the timing or stopping a prescription yourself. Sleeping medicines may cause dizziness and increase falls risk; they are not a simple solution to every restless night. When one is proposed, ask why it is appropriate for this person, how long the trial will last and which adverse effects should prompt a call. Ongoing review matters because a treatment that initially helped may later offer less benefit or create new difficulties. [30]

Antipsychotics have a limited role

Antipsychotic treatment is a careful clinical decision, not routine treatment for sundowning or a way to make care easier through sedation. NICE recommends considering these drugs in dementia only when there is risk of harm or agitation, hallucinations or delusions causing severe distress. Clinicians should first assess underlying causes and provide psychosocial and environmental support, which should continue if a medicine is used. Discuss expected benefit, harms and the review plan with the person and family as appropriate. NICE advises using the smallest effective amount for the shortest necessary period and reassessing at least every six weeks. Dementia with Lewy bodies and Parkinson’s disease dementia require particular caution because severe sensitivity reactions can occur. Decisions to change or stop treatment belong with the prescriber. [29]

Potential antipsychotic harms include drowsiness, increased confusion, unsteadiness, falls and fractures, as well as a higher risk of stroke and death. These risks must be weighed against the specific distress or danger being treated. Walking about, repeated vocalizing or ordinary resistance during personal care are not, by themselves, reasons to expect these drugs to help. Ask how the team will distinguish meaningful relief from a person merely becoming less alert. Report changes in walking, wakefulness, drinking or other functioning after treatment starts. A medication review should revisit whether the original target symptom is still present and whether the person is receiving an ongoing benefit. Never use another person’s prescription or add extra doses to manage a difficult evening. [37]

Do not assume that melatonin or a product sold for sleep is automatically suitable. NICE advises against offering melatonin for insomnia in Alzheimer’s disease and instead recommends personalized sleep support combining routine, daylight, activity and other non-drug measures. Discuss supplements with the healthcare team before use. [29]

Keep one up-to-date medication record that every caregiver can use. Check with the doctor or pharmacist about possible interactions, and report troubling side effects rather than improvising a new schedule. A clear record of what was actually given helps prevent a second caregiver from repeating a dose. Store medicines securely while preserving the person’s involvement in their care where possible. If tablets have become difficult to swallow, ask about an appropriate alternative formulation. Do not crush, split or mix a medicine into food without checking that it is safe for that exact product and agreeing an appropriate administration plan. Some preparations become unsafe or ineffective when altered. [31]

Support the caregiver as part of the care plan

Repeated disrupted evenings and nights can affect a caregiver’s sleep, health, patience and ability to concentrate. Irritability, exhaustion, withdrawing from friends or feeling unable to keep up are reasons to seek support, not evidence that you do not care enough. Tell your own clinician when stress or poor sleep is persistent. Be specific about what is becoming difficult, such as getting adequate rest, remembering appointments or managing ordinary tasks. It is easier for others to help when the need is clear. A care plan should take account of the caregiver’s limits as well as the person’s symptoms. Advice to remain calm is incomplete if one person has no reliable break or opportunity to sleep. [32]

Respite means another suitable person or service provides care while the usual caregiver has a break. It may involve help at home, an adult day service or a short residential stay. Match the service to actual needs, including support during the hours that are hardest. Ask about dementia training, reliability and how staff respond to distress. If possible, try support before an emergency so the person and caregiver can become familiar with it. Keep emergency contacts and the medication list accessible, and identify who can help if the main caregiver becomes ill. Asking for assistance does not mean abandoning someone. Planned rest can help sustain care, while a backup arrangement reduces the risk of a crisis when the usual routine suddenly becomes impossible. [33]

Choose a small, reviewable next step

For a familiar pattern that has already been medically assessed, choose a specific change connected to an observed need: a less crowded room, an earlier demanding activity, more help with toileting or a calmer transition to bed. Keep the person’s response at the center of the decision. Several difficulties can interact, so a useful change may improve comfort without eliminating every restless evening. If the pattern changes, reconsider illness, pain or another unmet need rather than assuming dementia has inevitably worsened. [2]

Previously included video

Historical video note: The video retained below was included in an earlier version of this article. Its medical content has not been independently reviewed for this update. Use the written guidance and linked sources for current context, and consult the person’s healthcare team for individual advice.