Sundowning: Evening Confusion and What Helps

What sundowning looks like

• Increased confusion about place, time and people, "I want to go home" when at home.
• Restlessness, pacing, picking at clothes, wandering; see wandering and dementia safety.
• Anxiety, fear or tearfulness; calling out.
• Suspiciousness, accusations or seeing things that are not there.
• Irritability, shouting, resistance to care and sometimes aggression.
• Following the carer from room to room ("shadowing").
• Difficulty settling at night, and sleep reversal.

It usually begins about the time of dusk and may last into the night. Not everyone with dementia has it. It can come and go.

Why it may happen

Causes are not fully understood, and several factors combine:

• Body clock disruption. Dementia damages the brain areas that regulate the sleep-wake rhythm, so daytime and night-time cues blur.
• Tiredness. By evening, mental effort of coping through the day has exhausted the person.
• Fading light and shadows, which can look threatening or cause misperceptions, and reduce visual cues.
• Hunger, thirst or a full bladder or bowel.
• Pain or discomfort that builds through the day.
• Noise and bustle: cooking, television, people returning from work, children, which overload the senses.
• Unmet needs and boredom during the day.
• Medicines: timing and side effects; some wear off or cause restlessness; see dementia and medicines at home.
• Infection or illness: urinary infection, chest infection, constipation, dehydration, which cause delirium; see delirium in older adults.
• Poor sleep the night before; see sleep problems in older adults.
• Change: a new place, hospital stay, a new carer or travel.
• Hearing and sight problems, which worsen as light fades.
• Emotional tension in the household, which the person senses.
• Caffeine, alcohol and sugar later in the day.

First rule: rule out medical causes

A sudden or marked increase in evening confusion, particularly if new, may signal an illness. Call the doctor the same day or seek urgent care if there is:

• new or sudden confusion, drowsiness, or marked change from usual (possible delirium);
• fever, cough, burning urine, pain, vomiting or diarrhoea;
• a fall, or head injury;
• very poor intake of food or fluid;
• constipation for several days or inability to pass urine;
• a new medicine or dose change;
• hallucinations or severe agitation that are new.

Call 112 for severe breathlessness, chest pain, collapse, signs of stroke or a seizure. See knowing when to call the doctor.

What helps in the daytime

• Keep a regular routine: wake, meals, activity and bedtime at consistent times; see daily routines that calm dementia.
• Get daylight and fresh air in the morning and early afternoon: a walk, sitting in a sunny spot, gardening. Daylight helps reset the body clock.
• Stay active in the day, with meaningful tasks and gentle exercise; see chair exercises for seniors and walking programme for older adults.
• Limit long daytime naps: one short rest after lunch is fine; avoid late naps.
• Avoid caffeine after midday and large amounts of sugar; limit alcohol.
• Offer regular drinks and snacks through the afternoon; see hydration for older adults and dementia, eating and weight loss.
• Treat pain and attend to constipation and continence; see chronic pain in older adults and constipation in older adults.
• Check eyesight and hearing; see hearing and vision checkup schedule.
• Plan the busiest or most demanding tasks for the morning.

What helps in the late afternoon and evening

Light and environment - Turn lights on before dusk; close curtains as light fades to avoid reflections and shadows; use soft, even lighting; see lighting and contrast at home. - Cover mirrors if they distress at night. - Reduce noise and bustle: switch off the television or choose gentle programmes, keep voices low, avoid several people talking at once. - Keep the home calm and uncluttered; see dementia home setup. - Keep a comfortable temperature.

Activity and company - Plan a calming, structured late-afternoon activity: folding laundry, sorting, helping with dinner, music, a gentle walk, looking at photographs, hand massage, a pet. - Keep company: a familiar person nearby gives reassurance. Avoid leaving the person alone as light fades. - Offer a snack and drink in the late afternoon. - Play familiar, soothing music, devotional songs or old songs.

Meals and bedtime - Serve the main meal earlier, keep dinner light and familiar. - Create a wind-down routine: a warm wash, nightclothes, a warm drink, quiet music or prayer, low lights. - Take the toilet visit before bed. - Keep the night route lit; see motion-sensor night lights and bedroom setup for night safety.

Safety - Keep doors safe: chimes or sensors, not locks that trap; see door sensor guide and lock and door safety for seniors. - Make the kitchen safe for night wandering; see auto-off kettle and stove safety. - Tell neighbours and security, if wandering occurs; see safety in gated societies and apartments. - Have ID and a photo ready; see wandering and dementia safety.

Responding in the moment

When sundowning starts, how you respond matters as much as what you prepare.

1. Stay calm, speak slowly in a soft, warm voice, and approach from the front so that the person sees you. 2. Do not argue or correct ("Your mother died years ago"). Respond to the feeling: "You miss your mother. Tell me about her." 3. Look for the unmet need: toilet, hunger, thirst, pain, cold, boredom, fear. 4. Offer reassurance: "You are safe. I am here with you." 5. Distract gently: with tea, a snack, a song, a walk to another room, a familiar task or photograph. 6. Go with the walking: walk together safely for a few minutes; it may settle. 7. Reduce stimulation: move to a quiet, softly lit room. 8. Use touch if welcome: hold a hand, gentle massage. 9. Keep sentences short and simple; give one instruction at a time; see communicating with someone who has dementia. 10. Do not restrain, and avoid raised voices. Step away for a moment if you are overwhelmed, once the person is safe. 11. If aggressive, protect yourself and others, give space, and avoid cornering; call for help if needed. Later, tell the doctor; see dementia challenging behaviours. 12. Afterwards, note what happened and what helped.

Keeping a diary

Record for a week or two: time of day, what happened before, what the person was doing, food and drink, medicines, pain, noise, who was present and what helped. Patterns often reveal triggers, such as a particular visitor, late tea or a noisy time. Share with the doctor; see care diary and handover notes.

Medicines and the doctor

Medicines may be part of the picture, but they must be prescribed carefully. Sedating medicines and sleeping tablets increase confusion, falls and risk in older people, and are not a first answer. Never give extra or borrowed medicines. Ask the doctor to review current medicines and their timing, and to look for infection, pain and other causes. Discuss any non-drug approaches first. See medicine side effects families should watch and polypharmacy and deprescribing. Some people with severe distress or risk may need specialist input from a psychiatrist or memory clinic.

Light therapy and melatonin

Some people try bright light in the morning or other measures to reset the body clock, and doctors sometimes consider other options. Evidence is mixed. Ask the doctor before using any supplement, including those marketed for sleep.

Looking after the carer

Sundowning coincides with the time when carers are tired and the household is busiest. Share evening duties, plan help at that time, rest in the afternoon, and ask for support; see night-time caregiving routines, caregiver burnout signs and prevention and respite care and taking a break. A day centre may help tire the person and give you a break. If you feel unsafe or unable to cope, tell the doctor; see when home care is no longer enough.

When to ask a professional

A doctor or memory clinic should assess new or worsening evening confusion, review medicines and look for medical causes. An occupational therapist can advise on environment and routines. A dementia support organisation can offer practical advice. For senior services, call Elderline 14567. In an emergency, call 112.