Understanding Sundowning: Why Dementia Symptoms Can Worsen in the Evening
For some people living with dementia, the late afternoon and evening can bring noticeable changes in behavior, confusion, or anxiety. This pattern is commonly known as sundowning.
Research has reported widely varying rates of sundowning because there is no single universally accepted definition. One 2025 review found estimates ranging from 1.6% to 66% of people with dementia, while a 2023 study involving 184 people with dementia identified sundowning in 21.2% of participants.
For families and caregivers, these changes can sometimes seem to appear almost like clockwork. A loved one may seem relatively comfortable during the morning and early afternoon but become restless, anxious, confused, or agitated as evening approaches.
Understanding sundowning can help caregivers recognize these patterns, identify possible triggers, and find ways to make the evening hours calmer and safer.
What Is Sundowning?
Sundowning describes a pattern in which confusion, agitation, anxiety, restlessness, or other dementia-related behaviors appear or become more noticeable during the late afternoon, evening, or nighttime.
Sundowning is not a separate disease or diagnosis. Instead, it describes a collection of symptoms or behaviors that can occur in people living with Alzheimer’s disease and other forms of dementia. The Alzheimer’s Association describes sundowning as increased confusion that may occur from dusk through the night.
A person experiencing sundowning may seem noticeably different from how they appeared earlier in the day.
Understanding Sundowning Symptoms
Common Signs of Sundowning in Dementia
Understanding sundowning symptoms begins with recognizing that they can look different from one person to another.
Common signs may include:
Increased confusion or disorientation
Restlessness or pacing
Anxiety or fear
Irritability
Agitation
Difficulty settling down
Repeated questions or statements
Calling or yelling
Wandering
Difficulty sleeping
Suspiciousness
Hallucinations or delusions
Wanting to “go home,” even when already at home
A person may also become increasingly focused on finding a particular person or completing a task they believe needs to be done.
These behaviors are not necessarily intentional. Dementia changes how a person interprets their environment, communicates needs, processes information, and understands what is happening around them.
Why Does Sundowning Happen?
There is no single confirmed cause of sundowning.
Researchers continue to study why dementia symptoms sometimes become more pronounced later in the day. Changes caused by Alzheimer’s disease and other dementias may affect the brain's internal biological clock and disrupt normal sleep-wake patterns.
However, several factors may contribute to or worsen evening confusion.
Changes in the Body's Internal Clock
The body's circadian rhythm helps regulate when we feel awake and when we feel tired.
Dementia-related changes in the brain may interfere with this internal clock, making it harder for someone to distinguish between daytime and nighttime.
A person may consequently sleep more during the day, become restless during the evening, or remain awake during the night.
Mental and Physical Fatigue
By late afternoon, someone living with dementia may simply be tired.
Processing conversations, recognizing surroundings, completing everyday activities, and coping with memory loss can require significant effort. As fatigue increases, it may become more difficult to manage confusion or frustration.
Changes in Lighting
As daylight fades, rooms naturally become darker and shadows become more noticeable.
Someone with dementia may have difficulty interpreting what they see. A shadow on the wall, reflection in a window, or unfamiliar shape in a dimly lit room may be confusing or frightening.
Too Much Stimulation
A busy day can also contribute to evening distress.
Visitors, appointments, television, conversations, errands, unfamiliar surroundings, or excessive noise may become overwhelming, particularly when the person is already tired.
Unmet Physical Needs
Sometimes what appears to be sundowning may be related to something the person cannot easily communicate.
They may be:
Hungry
Thirsty
Too hot or cold
Uncomfortable
In pain
Constipated
Needing to use the bathroom
Tired
Looking for a possible physical need can be an important first step when behavior suddenly changes.
Does Sundowning Mean Dementia Is Getting Worse?
Not necessarily.
Sundowning can occur at different points in dementia, although behavioral and sleep changes may become more noticeable as cognitive impairment progresses.
Dementia itself also changes over time, and someone's abilities, behaviors, communication, and care needs may gradually change along with it.
Families who want to better understand the broader progression of dementia may also find our Oasis Hospice article “What Are the Seven Stages of Dementia? Understanding How Dementia Progresses” helpful. It explains how memory, daily functioning, communication, and care needs may change throughout the different stages of dementia.
How Caregivers Can Help Manage Sundowning
There may not be one strategy that completely prevents sundowning, but caregivers can often experiment with the person's environment and daily routine to determine what seems to help.
Keep a Consistent Daily Routine
Predictability can be reassuring for someone living with dementia.
When possible, try to keep waking, meals, activities, medications, and bedtime at approximately the same times each day.
Use Daylight During the Day
Exposure to natural light during daytime hours may help support the body's normal sleep-wake cycle.
Opening curtains, sitting near a window, spending time outdoors when appropriate, or taking a short daytime walk may help reinforce the difference between daytime and nighttime.
Keep Evenings Calm
Consider gradually reducing activity as evening approaches.
This might include:
Lowering background noise
Limiting unnecessary visitors
Playing familiar or calming music
Looking through photographs
Folding towels together
Watching a familiar, relaxing program
Sitting together quietly
The goal does not necessarily have to be stopping every behavior. Sometimes creating a reassuring environment is more helpful than repeatedly trying to correct the person.
Keep the Home Well Lit
Turning lights on before the room becomes dark may reduce confusing shadows and make the environment easier to interpret.
Nightlights can also help someone safely recognize hallways, bathrooms, and bedrooms during the night.
Avoid Arguing
If someone with dementia insists they need to go home, find a family member, or complete a task that does not make sense to you, correcting them repeatedly may increase frustration.
Instead, acknowledge the emotion behind what they are saying.
Someone saying, “I need to go home,” may actually be communicating fear, uncertainty, or a desire to feel safe.
A calm response such as, “You're safe here. I'm staying with you,” may provide more reassurance than explaining why they are mistaken.
Look for Patterns
Keeping a simple record can help caregivers identify triggers.
Write down:
What time symptoms begin
What happened shortly beforehand
Meals and drinks
Naps
Visitors
Activities
Changes in environment
Signs of discomfort
What seemed to calm the person
Over time, patterns may become easier to recognize.
When Sudden Confusion May Not Be Sundowning
Not every episode of evening confusion should automatically be attributed to dementia.
A sudden or significant change in behavior or mental status can sometimes be associated with an underlying medical problem.
Illness, infection, dehydration, pain, medication effects, sleep disorders, or other medical conditions can contribute to changes in behavior or confusion. The Alzheimer’s Association specifically recommends discussing persistent sleep or sundowning problems with a physician because physical conditions can sometimes cause or worsen these symptoms.
If a loved one's confusion or behavior changes suddenly, becomes significantly worse than usual, or is accompanied by concerning physical symptoms, contact their healthcare provider.
Sundowning and Caregiver Stress
Sundowning can be difficult not only for the person experiencing it but also for the person caring for them.
Evening is often when caregivers themselves are exhausted.
After spending the day helping with medications, meals, bathing, appointments, household responsibilities, and supervision, several additional hours of pacing, repeated questions, wandering, or sleeplessness can become physically and emotionally draining.
Caregiver support matters.
Family members, friends, respite services, caregiver support groups, healthcare professionals, and hospice teams when appropriate can all become part of a larger support system.
Needing additional help does not mean a caregiver has failed. Dementia care can become increasingly complex, and care needs may eventually exceed what one person can safely manage alone.
When Hospice May Help Someone With Advanced Dementia
Dementia is a progressive illness, and in its advanced stages, a person's needs may change significantly.
Someone may eventually require extensive assistance with eating, bathing, dressing, mobility, communication, and other daily activities.
When dementia becomes advanced and a person meets hospice eligibility requirements, hospice can provide comfort-focused care while also supporting the family and caregivers.
Hospice support may include:
Symptom management
Nursing care
Personal care assistance
Medical equipment and supplies related to the hospice diagnosis
Social work support
Spiritual support
Caregiver education
Respite support
Bereavement support
Families can ask about hospice before a crisis occurs. A hospice evaluation can help determine whether someone currently meets eligibility requirements and explain what services may be available.
Key Takeaways: Understanding Sundowning
Sundowning describes increased confusion, restlessness, agitation, anxiety, or other behavioral changes that commonly appear or worsen later in the day in some people living with dementia.
Sundowning is not a separate disease, and researchers do not believe there is one single cause.
Fatigue, changes in the brain's internal clock, reduced lighting, overstimulation, discomfort, pain, hunger, thirst, and changes in routine may all contribute.
Caregivers may be able to reduce some symptoms by maintaining consistent routines, encouraging daytime activity and natural light, reducing evening stimulation, keeping rooms well lit, identifying unmet needs, and responding calmly rather than arguing.
Most importantly, a sudden or significant change in someone's behavior should not automatically be assumed to be sundowning. New or worsening confusion may warrant evaluation by a healthcare professional.
Frequently Asked Questions About Sundowning
What is sundowning in dementia?
Sundowning is a term used to describe increased confusion, agitation, restlessness, anxiety, or other behavioral changes that occur or become more noticeable during the late afternoon, evening, or nighttime in some people living with dementia.
What time does sundowning usually start?
There is no exact time when sundowning begins. Symptoms often emerge during the late afternoon or early evening as daylight begins to fade, but the timing can vary from person to person and may continue into the night.
What are the most common signs of sundowning?
Common signs can include increased confusion, agitation, anxiety, irritability, pacing, wandering, repeated questions, difficulty sleeping, disorientation, hallucinations, or wanting to “go home.”
What triggers sundowning?
Possible triggers may include fatigue, disrupted sleep-wake cycles, reduced lighting, shadows, overstimulation, changes in routine, unfamiliar surroundings, hunger, thirst, pain, boredom, or other unmet physical needs.
How can caregivers calm someone who is sundowning?
A calm environment, reassurance, familiar activities, adequate lighting, reduced noise, a consistent routine, and addressing possible needs such as hunger, thirst, pain, or needing the bathroom may help. Avoiding arguments and gently redirecting the person can also be helpful.
Does sundowning mean dementia is getting worse?
Not necessarily. Sundowning may occur at different stages of dementia. However, changes in sleep, behavior, communication, and daily functioning can also occur as dementia progresses. Significant or sudden changes should be discussed with a healthcare provider.
Can sundowning happen every night?
It can. Some people experience sundowning frequently, while others experience it only occasionally. Tracking when symptoms occur and what happens beforehand may help caregivers identify patterns or triggers.
When should I contact a doctor about sundowning?
Contact a healthcare provider if symptoms begin suddenly, become significantly worse, create safety concerns, interfere substantially with sleep, or are accompanied by other changes in health. Medical conditions, pain, infection, medication effects, or other problems can sometimes cause or worsen confusion.
Supporting Families Living With Dementia
Understanding sundowning can make evening behavioral changes feel less mysterious, but it does not necessarily make caregiving easy.
Every person living with dementia experiences the disease differently. What comforts one person may not work for another, and strategies may need to change as the disease progresses.
Families do not have to navigate those changes alone.
At Oasis Hospice, we provide compassionate support, education, and comfort-focused care for patients and families navigating advanced dementia and other life-limiting illnesses. Our team works alongside families to help manage symptoms, answer questions, support caregivers, and preserve comfort and dignity throughout the end-of-life journey.
Continue Learning
If you found this article helpful, you may also enjoy these Oasis Hospice resources:
What Are the Seven Stages of Dementia? Understanding How Dementia Progresses
Alzheimer's & Dementia Awareness Month: Resources for Caregivers and Families
Why Is My Elderly Parent Losing Weight? Common Causes and When to Seek Help
Why Do Seniors Stop Eating? Understanding Appetite Changes in Older Adults
What Happens in the Last 48 Hours of Life?
Looking for more helpful information? Explore our Hospice Education and Health & Disease Education categories for compassionate guidance, practical resources, and answers to common questions about hospice care, caregiving, chronic illness, and the end-of-life journey.
Why Families Trust Oasis Hospice:
Oasis Hospice has been recognized as one of the highest-rated hospice providers based on Medicare.gov quality ratings. Families searching for compassionate, high-quality hospice support can compare hospice providers and learn more through Medicare.gov Care Compare. For additional education, caregiving guidance, and end-of-life support resources, families may also find helpful information through the Hospice Foundation of America.
From Houston to Huntsville, Houston to Livingston, and the many communities in between, Oasis Hospice is committed to providing compassionate hospice care, guidance, and support for patients and families during life’s most difficult moments. If you or a loved one have questions about hospice support services, Oasis Hospice is here to help families throughout Southeast Texas navigate care with compassion, dignity, and guidance every step of the way. To learn more about our hospice services and family support resources, please visit our website below.
Explore more hospice resources, support, and articles here:
This article is intended for general educational purposes and is not a substitute for medical advice, diagnosis, or treatment. Questions about a specific medical condition, prognosis, or hospice eligibility should be discussed with a qualified healthcare professional.
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