Sundowning: What Helps and What Does Not

What sundowning is

Sundowning is the name for confusion and restlessness that gets worse in the late afternoon and evening in people living with dementia. The Alzheimer’s Association describes it as increased confusion from dusk through the night, which can show up as trouble sleeping, anxiety, agitation, pacing, hallucinations and disorientation.

It is common. It is not the person being difficult, and it is not something you caused. It is a signal, and most of the time the signal means something simple: tired, in pain, hungry, needs the toilet, too much noise, cannot work out where they are.

Two things this page will do. It will tell you what is worth trying, in order. And it will tell you where the evidence is thin, because a lot of advice about sundowning is repeated with more confidence than the research supports.

Why late in the day

Nobody knows the full answer. Mayo Clinic says the exact cause is unknown. These are the factors that keep coming up:

Tiredness. A full day of concentrating uses up whatever reserve there was. Late afternoon is when it runs out.
The body clock. Dementia damages the part of the brain that keeps day and night in order. Day and night can end up swapped.
Fading light and shadows. As the light drops, a familiar room stops looking familiar. Shadows, reflections in dark windows and glare all make it harder to read the room correctly.
Unmet physical needs. Hunger, thirst, pain, a full bladder, constipation.
Noise and activity. Television, several conversations, people arriving home, cooking, phones.
Your own state. The Alzheimer’s Association notes that people with dementia pick up stress from those around them. By 5pm you are tired too.

Check the simple things first

Before changing the lighting or the routine, rule out the physical causes. The Alzheimer’s Association is direct about this: look for the reason behind the behavior, and get a doctor to check for causes related to illness or medication. That means checking for:

Pain, including from teeth, joints, pressure sores and old injuries
Infection, especially urinary tract, chest, ear and sinus infections
Constipation or a full bladder
A new medicine, or a dose changed in the last two weeks
Hearing aids not in, glasses not on, or the wrong glasses
Too hot, too cold, clothing that itches or scratches

If the confusion is new, or much worse than usual over hours or days, this is a medical question, not a lighting question. Call the doctor before you try anything on the rest of this page.

What helps

Keep the day in the same order

The same wake time, the same meal times, the same bed time. The order matters more than the exact clock times. Put the demanding parts of the day early, when concentration is best. Bathing in the morning rather than at 6pm removes one of the most common triggers of an evening fight.

Daylight early, lights on before dusk

Get outside, or sit by a window, during the day. Then turn the lamps on before the light starts to fade, so the room never passes through the dim stage. Close the curtains before the windows turn into black mirrors. Add lights in the corners that go dark first.

What the research says: a 2023 meta-analysis of randomized trials found light therapy produced a small reduction in the number of night-time awakenings, and did not show a clear effect on agitation or on depression. An earlier Cochrane review concluded there was not enough evidence to recommend bright light therapy in dementia. So daylight and good lamps are cheap, carry almost no risk, and are worth doing. Do not expect them to fix the problem on their own.

Move the big meal to the middle of the day

A larger lunch and a lighter supper is standard advice from the Alzheimer’s Association. Offer a snack and a drink at around 4pm, before the difficult hour starts, because hunger and thirst are easy to miss in someone who no longer asks.

Cut caffeine and alcohol in the afternoon and evening. That includes coffee, black tea, cola and, in many of our families, a strong afternoon buna. If coffee matters to your parent, move it to the morning rather than removing it.

Take the noise down after 4pm

One voice at a time. Television off, or a familiar film with a calm soundtrack rather than the news. Fewer people in the room. If visitors come, ask them to come earlier in the day.

Watch the naps and the exercise

Limit long naps late in the day, because sleep at 4pm is borrowed from the night. Some daily physical activity helps, whether that is a walk, sweeping, or folding laundry. Do not fill the day so full that there is nothing left by evening.

Keep a log for one week

This is the step families skip, and it is the one that finds the answer. For seven days write down the time each episode started, what happened in the hour before, what they had eaten and drunk, when they last used the toilet, who was in the house, and what the light was like. Patterns show up fast. Very often the trigger turns out to be one specific thing at one specific time, and it can be moved.

What to do during an episode

Slow down and lower your voice. Speak calmly and try not to show frustration. Your pace sets theirs.
Do not argue or correct. Do not test them with questions like “who am I”. If they say they need to go to work, ask about the work.
Check the body. Toilet, pain, thirst, hunger, too hot, too cold. Offer a drink and a snack.
Turn more lights on and move to the brightest room in the house.
Give them something to hold or do. A familiar task, a photo album, music they know.
Let them walk if walking is safe. Pacing is often the way the agitation comes down. Clear the route rather than blocking it.
Step out of sight for a moment if you can do it safely. Sometimes the caregiver’s own tension is part of the loop.

What makes it worse

Bathing, medical appointments and hard conversations scheduled late in the day
A dim room at dusk, and dark windows
Correcting, arguing, or explaining that the person is wrong
Being rushed
Television news, several people talking, a loud television in a room nobody is watching
Caffeine, alcohol and nicotine late in the day
A long afternoon nap
Being somewhere unfamiliar, or a room that was rearranged
An exhausted caregiver. This is a real cause, and it is treatable with help rather than willpower

Where the evidence is weak

Being straight with you about this saves money and disappointment.

Melatonin. A 2020 Cochrane review found low-certainty evidence that melatonin at doses up to 10 mg may have little or no effect on the main sleep measures over eight to ten weeks in people with dementia. No serious harms were reported. If you want to try it, ask the doctor first, because it interacts with other medicines.
Sleeping tablets in general. The same Cochrane review found the commonly prescribed sleep medicines have very little trial evidence behind them in dementia.
Light boxes. Small effect on night waking, no clear effect on agitation, as described above. Daylight through a window costs nothing and is a reasonable first step.
Antipsychotic medicines. The Alzheimer’s Association says non-drug approaches should always be tried first, and that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The FDA requires a boxed warning on them. They are sometimes the right choice when someone is in danger or in severe distress. That decision belongs to the doctor, with the risks explained to you first.
Supplements, essential oils and gadgets sold for sundowning. Music the person loves, a warm blanket and a familiar smell may comfort them, and comfort is worth something. Treat strong claims from anyone selling a product with suspicion.

The routine, daylight, meal timing and quiet advice above comes from the National Institute on Aging, the Alzheimer’s Association and Mayo Clinic. It is sensible, low risk and widely recommended. The trial evidence behind it is thinner than the confidence with which it is usually stated. Try it because it is safe and often works, and keep the log so you can see whether it is working for your parent.

When to call the doctor

Call the doctor’s office, the same day, if:

The confusion came on suddenly, over hours or a few days
There is a fever, shivering, or the person feels hot
There is burning when passing urine, a change in the smell of the urine, or new incontinence
They seem to be in pain and cannot say where
They have not had a bowel movement for several days
A medicine was started, stopped or changed in the last two weeks
They are not drinking
They have fallen
The agitation is putting them or you at risk of injury

Call 911 for sudden weakness on one side, a drooping face, sudden trouble speaking, chest pain, trouble breathing, a seizure, a head injury, or a person you cannot wake properly. Tell the operator that the person has dementia.

If you are the one awake at 3am

Broken sleep, night after night, is the thing that ends home care arrangements. It is worth treating as a problem in its own right rather than something to endure. If a caregiver covers the evening hours a few days a week, or takes an overnight so you can sleep through, the same household can often keep going for years longer.

Ask your parent’s health plan whether respite care is part of their benefit. Ask us what an evening or overnight shift would look like.

Talk to a care coordinator

Tell us what the evenings look like in your house. We will explain what a caregiver can do at that hour, what it costs, and what we would need to cover it. We will tell you quickly if your situation does not fit what we do.

Call (703) 941-8412, Monday to Friday, 9:00 am to 5:00 pm. We speak English, Amharic, Tigrinya and Spanish, and meals can be cooked the way your family eats, including fasting days. The in-home assessment is free and there is no obligation. Millennium Home Health Care, 4200 Evergreen Lane, Suite 312, Annandale, VA 22003.

Sources

This page is general information for families, written in August 2026. It does not replace advice from your parent’s doctor. Anything involving medication, a possible infection or a sudden change in behavior is a question for a clinician.