En español | If your loved one has Alzheimer’s disease or dementia, you may be seeing changes in their behavior in the late afternoon or early evening — a phenomenon known as sundown syndrome, sundowners or sundowning.
What are the signs of sundown syndrome?
According to the Alzheimer’s Association, as many as 20 percent of people with Alzheimer’s experience sundown syndrome. When your loved one has dementia (and some other conditions, as well), the approach of sundown can trigger sudden emotional, behavioral or cognitive changes. These might include:
- mood swings
- energy surges
- increased confusion
These may lead in turn to challenging behaviors like pacing, rocking, screaming, crying, disorientation, resistance, anger, aggression — or even violence. Many people experiencing sundown syndrome feel the urgent need to go somewhere or do something, but they can’t always explain why.
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For some, the behavior soon abates; for others it continues for hours. Some even flip their sleep schedules so they are wide awake all night and sleepy during the day.
What triggers sundown syndrome?
There are many theories about why sundowning happens, and the triggers seem to vary among people with dementia. For some, sundowning may be triggered by the dimming light and a sense that it’s time to change activities or “go home.” Evening and darkness may also tap into fears of being unsafe and insecure.
Other factors may include fatigue, hunger, thirst, pain or discomfort, or hormonal changes that occur as the sun goes down.
Whatever the cause, seeing their loved ones with these symptoms can be a nightmare for family members.
In what stage of dementia does sundowning occur?
Sundowning can occur at any stage of dementia, although many families observe the behaviors primarily in the middle stages of dementia and then subsiding as the disease progresses.
We first noticed sundown syndrome in my dad, who had Alzheimer’s, when he was in the disease’s moderate stage. Questions or observations that were occasional for most of the day — “What’s the plan?” “What should I be doing?” “We’d better get going!” — became more frequent, and more urgent, around 5 or 6 in the evening. As the disease progressed, his symptoms improved, and I believe that’s at least in part due to a variety of techniques we used regularly to treat and manage sundowners.
What are the ways to treat, manage and reduce sundown syndrome?
1. Observe and minimize triggers. Watch for fatigue and other things that seem to spur on sundowning behaviors. Afternoon transitions and activities that you consider normal can be anxiety-producing for your loved ones.
For example, does the household get chaotic and noisy as people get home from work? Does the TV get switched to something loud or intense, like a crime show or the news? Is there are a lot of cross talk during mealtimes? Is there a caregiver shift change?
Watch, too, for nutritional triggers and adjust eating and drinking schedules. Cut back on caffeine and sugar, which can be too stimulating, and limit liquids later in the day, as they can cause increased toileting needs.
2. Maintain routines and structure activity. Maximize activity earlier in the day and minimize napping (especially if your loved one isn’t sleeping well at night). Try to avoid challenging, stressful tasks around dusk and at night. Keep to a regular daily routine — there’s security in the familiar.
3. Simplify surroundings and adjust the sleep environment. Too much sensory stimulation can cause anxiety and confusion, worsened by changing light. Try to minimize physical, visual and auditory clutter in your loved one’s bedroom.
At night, keep the room calm and comfortable for sleeping (experts often suggest a temperature between 60 and 67 degrees), and dark (try light-blocking curtains or an eye mask, plus dim night-lights for safe navigation). Evaluate your loved one for sleep disturbances such as sleep apnea.
4. Validate and distract. Simply trying to reason with someone in the midst of sundowning probably won’t work. Instead, try to validate your loved one’s feelings (even if they don’t make sense to you) to let them know you are listening. Try to draw them away from troubling thoughts and anxieties by diverting or redirecting attention to favorite activities, foods, animals and people.
For example, maybe they are soothed by watching a favorite TV show, taking a walk, snuggling with a pet or reminiscing. My dad loved The Lawrence Welk Show; we would give him TV earphones to amplify the volume and limit other sounds. It was almost always an effective distraction.
5. Adjust light exposure. Some experts theorize that our hormones and body clocks are regulated by exposure to light, and too little exposure throws us off. If adequate exposure to direct sunlight isn’t possible, try a light box and use bright lights in the room.
As it gets dark outside, increase indoor lighting. In the winter, when days got shorter, I would often turn on the bright back porch lights outside our dining-room window, which helped prevent Dad from thinking it was already bedtime.
6. Play music and calming sounds. We used music throughout the day for Daddy — instrumental music as he woke up, sing-along favorites or show tunes to activate him, and calming music when sundowning set in. I recommend trying solo piano or classical guitar, or creating a "relaxation" or "spa music" channel on a music app such as Pandora, Spotify or Amazon Prime Music.
If Dad got anxious at sundown, my sister and I started singing his favorite songs and he would join in — a great diversion. Playing nature sounds like rain or ocean waves all night, or just white noise, helped him fall asleep and slumber longer.
7. Use essential oils. Lavender, rose, ylang-ylang, chamomile, blue tansy, frankincense and other essential oils can be soothing. If you want to encourage waking up and staying active during the day, try bergamot, jasmine, peppermint, rosemary or citruses such as grapefruit, lemon or orange. Test which scents your loved one responds to.
Essential oils also can be used in various ways, including for aromatherapy. (We used lavender oil in a diffuser for Dad, but you can also use it to scent a cotton ball, or mix it with water and spray it in the air.) Consult with a doctor or other professional to ensure you are using essential oils safely, whether topically or as aromatherapy. They can be potent, so be sure to use appropriate amounts and dilutions.
8. Give healing touch. Never underestimate the value of a hand or foot massage to relax tense muscles and increase feel-good hormones. For example, when Dad was at the height of sundowning, we prepared a warm footbath with herbs and essential oils and soaked and massaged his feet about an hour before his sundowning generally started, which eased him through the transition incredibly well.
He always loved having his head rubbed and scratched, so doing that immediately calmed him. He also got a professional massage once a week, which helped on an ongoing basis. A loving hug or holding hands can be physically calming and emotionally reassuring for your loved ones, breaking the cycle of anxiety.
9. Try complementary medicine. For example, traditional Chinese medicine (TCM) involves acupunture, Tui na massage, Chinese medicinal herbs and other techniques. Acupuncture has been used to treat anxiety and depression for many generations and is increasingly being accepted by Western medicine. I started taking Dad for acupuncture to help with grief, depression and anxiety and was pleased with how it relaxed him; he continued with TCM for the last five years of his life. The sessions would start with a short Tui na massage to calm him (very important), and he generally slept through the treatment. Because his primary sundowners behaviors were anxiety-based, the acupuncture and TCM medicinal herbs his doctor prescribed helped ease them. Talk with your loved one’s doctor about this option, and find a traditional Chinese medicine doctor who understands dementia.
10. Use herbs, supplements and medications wisely. Ask the doctor about medications that might help with symptoms, such as anti-anxiety drugs and antidepressants. Be sure to ask about and monitor possible side effects; for some people with dementia, sedating drugs can cause the opposite effect (this happened to my dad). A geriatric psychiatrist is an excellent resource.
Also ask about herbs and supplements, such as lemon balm, valerian, chamomile, kava and holy basil. There are many supplements that claim to be calming and stress reducing, including melatonin, magnesium, and B, C and E vitamins. Some research studies have indicated that taking melatonin at night can lessen sundowners behaviors. Ask your loved one’s primary doctor or dementia-focused practitioner about the use and dosage of melatonin and other supplements.
Managing sundown syndrome requires creativity, flexibility, empathy and strong observational skills as we try to determine what triggers our loved ones and how to address the behaviors. No two people with dementia are exactly alike, so be prepared to test different approaches and treatments. Some may not work, but others will. Successes might be temporary or intermittent. But even a little bit of success can greatly ease your loved one’s anxieties, as well as your own stress.
Editor’s note: This column, originally published in May 2017, has been updated to reflect that Amy’s father died in 2018 and updated with new information in October 2022.
Amy Goyer is AARP’s family and caregiving expert and author of Juggling Life, Work and Caregiving. Connect with Amy on Facebook, Twitter, in AARP’s Online Community and in the AARP Facebook Family Caregivers Group.