Smiling Senior Sitting Outside with his Caregiver

Sundowners Syndrome: Facts, Misconceptions, & Tips for Care

"Sundowners syndrome," "sundowning," and other similar terms are commonly used in hospitals and long-term care environments when older patients become confused or agitated in the late afternoon, evening, or nighttime. But did you know that the whole concept of sundowning is somewhat controversial? This topic makes some caregivers and medical professionals uncomfortable for exactly that reason. They believe that opportunities for better care and treatment of patients with dementia may get missed as a result of this concept being too casually used to explain problematic behavior.

That's why it's essential to understand what sundowning really is—and what it's not. Once you know how and why terminology like "sundown syndrome" gets applied (or misapplied) to various behaviors, you can take actions that may lead to a better quality of life for both you and the person you care about. This article will help clarify some of the popular misconceptions you may have encountered.

What Is Sundowning?

Sundowning is best described as a subjective phenomenon in which older adults or people with dementia are observed as having heightened confusion, agitation, or other troubling behavior when the sun is setting or after it becomes dark. Patients who display this phenomenon are often labeled as "sundowners." Other common, interchangeable terms for this phenomenon include:

  • Sundowners syndrome
  • Sundown syndrome
  • Sundowner syndrome
  • Sundowning syndrome

Here's the problem: Technically speaking, sundowning is not an illness. At most, it is a set of symptoms or a pattern of observable behaviors. In fact, there is no separate medical term for sundowning. It can't be legitimately diagnosed, in large part because there isn't a scientific consensus about the phenomenon or a formal sundowning definition that everyone agrees on.

Sundowning terminology does appear in many medical journals and textbooks; however, the definitions and conceptual frameworks often vary significantly from one source to the next. Plus, nobody seems to know exactly where or when the terminology first originated.

So here's the key point to take away: Sundowning describes the debated phenomenon of late-day or nighttime behavioral problems, but it doesn't explain the phenomenon. In order to explain it, you have to find an underlying cause, which may differ from one individual to another.

Among most people labeled as sundowners, dementia is a major contributing factor. The percentage of dementia patients who display sundowning behavior has been estimated to be as low as 2.4 percent or as high as 66 percent.1 The phenomenon is said to affect up to 20 percent of people with Alzheimer's disease.2

Sundowning behavior is also sometimes observed in elderly hospital patients without diagnosed dementia, especially after undergoing invasive surgical procedures.

Sundowning Symptoms

Have you ever become cranky and restless after a long day that left you feeling exhausted yet wired? It's probably fair to say that everyone has felt that way at some point in their lives, especially during childhood. Many adults experience that feeling on a regular basis due to poor sleep and demanding work and family schedules. From that perspective, becoming moody when the sun goes down is a rather common human experience. But some people believe that sundowning deserves to be treated as a separate phenomenon given that the behaviors and mood swings of so-called sundowners tend to be more extreme.

What do you think? Try putting yourself in the shoes of an elderly person with dementia. Even small, simple tasks would be mentally and physically challenging. After a full day of activities, perhaps without adequate breaks for rest, you'd likely be completely exhausted. And you may have a lot of built-up anxiety from trying to meet the expectations of your caregivers while struggling to express your own needs. Now add in some possible discomfort caused by medications or other medical issues. Would you be able to rest easy? Or might all of your mental and physical challenges feel more intense and hard to cope with?

At the end of the day, many people labeled as sundowners may simply be reacting to challenging circumstances in a way that shouldn't surprise us. That said, this phenomenon is widely perceived as something distinct from "normal" behavioral reactions.

Sundowning behavior is generally considered to be any kind of disruptive personal conduct that occurs in the hours between sunset and sunrise. When people describe sundown syndrome symptoms, they are usually referring to observable behaviors or feelings such as:

  • Confusion
  • Agitation
  • Disorientation
  • Heightened anxiety
  • Paranoia
  • Restlessness
  • Anger
  • Aggression
  • Delusional thinking
  • Refusal to comply with directions
  • Trouble telling dreams apart from reality
  • Crying
  • Moaning
  • Yelling
  • Screaming
  • Rocking
  • Wandering
  • Pacing
  • Hiding objects
  • Acting out hallucinations

What Causes Sundowners Syndrome?

So far, nobody has been able to discover just one underlying cause that can explain all of the possible behaviors associated with sundowners syndrome in all patients who are said to have it. It's much more likely that there are different causes for different individuals. For so-called sundowners, disease, fatigue, and all kinds of other physical, environmental, and psychological factors may contribute to sundowning behavior. Dementia is at the top of the list. Sundowning is generally associated with the middle and late stages of Alzheimer's disease and other types of dementia.

Some professional caregivers believe that, in many cases, sundowning behavior may be a direct consequence of placing too many demands on dementia patients over the course of a day. In many care settings, patients go from one task or activity to another without adequate periods of rest and relaxation in between. Fatigue and anxiety set in, making it even more difficult for them to function or communicate their needs. By dusk, they are overtired and may feel intimidated by additional demands or expectations, making it hard for them to get into a restful state.

Of course, caregivers themselves can also get fatigued and suffer from burnout, which can make them less tolerant of disruptive behavior and more prone to overlooking their patients' real needs—especially in the evening. In under-staffed care facilities, patients may not have enough structure or activity built in to their day, which can be just as bad as overstimulation. And staffing shift changes in the late afternoon can make some dementia patients feel confused, nervous, or agitated. As they witness people going home at the end of the day, they may feel a strong urge to "go back home" themselves, leading to wandering or attempts to escape.

So unbalanced or inattentive caregiving may explain why some people with dementia display behaviors associated with sundowning. According to various studies, the following factors may also play a significant role in certain patients:

  • Damage to the part of the brain that regulates sleep-wake cycles
  • Sleep apnea or other sleep disorders
  • Inadequate exposure to sunlight during the day
  • Poor lighting in the evening
  • Too much noise or commotion
  • Changes in body temperature
  • Medication side effects
  • Depression or other psychiatric disorders
  • Loneliness
  • Vision or hearing problems
  • Low blood sugar
  • Hunger
  • Thirst from dehydration
  • Low blood pressure
  • Hormonal imbalance
  • Discomfort from needing to go to the bathroom
  • Incontinence
  • Urinary tract infection or other types of infection
  • Chronic pain
  • Acid reflux
  • Asthma or other breathing disorders
  • Heart disease
  • Problems with digestion

What is sundown syndrome caused by when a person displaying the behavior hasn't been diagnosed with dementia? Aside from the factors already listed, here's one scenario: In hospitals, nurses often perceive some of their patients as having sundowners syndrome after surgery. There may be a couple of explanations for this. First, anesthesia can cause temporary symptoms of cognitive decline. In some patients who are at higher risk for dementia, anesthesia may also help bring on permanent cognitive decline that hasn't been diagnosed yet. Second, surgeries are often traumatic experiences. Between pain, inflammation, medications, sleep disruptions, boredom, immobility, and a completely unfamiliar (and often chaotic) environment, the whole experience can be very disorienting.

In addition to observing sundowners syndrome in hospital patients, some people have contemplated a potential link between sundowners syndrome and alcoholism. After all, heavy drinkers can develop alcohol-related dementia as a result of a poor diet that leads to a deficiency in thiamine (vitamin B1). And based on a wide review of data, some researchers have determined that chronic heavy drinking might play a contributing role in up to 24 percent of dementia cases.3

Care and Treatment

When you perceive somebody as having sundowners syndrome, treatment becomes a natural priority. But how do you treat a behavioral phenomenon that doesn't have a clear cause? The last thing you want to do is make faulty assumptions that worsen the behavior or lead to additional problems.

First, you may want to use terms like "sundowning" in moderation (or consider avoiding them altogether). Although this terminology is popular, it may not be necessary. And it may not be as clinically relevant as you think. Some caregivers even feel that the terminology dehumanizes the very people you're trying to help—or gets in the way of effective treatment.

So it might not be very useful to refer to the behavior as sundowners syndrome. Elderly patients may benefit more from an approach that focuses on pinpointing their unmet needs. Remember that behaviors are often symptomatic of underlying problems. You can't get rid of the behaviors until you get rid of the actual problems (or successfully manage those problems).

This is where it may help to examine your own behavior and caregiving routines. Ponder questions such as:

  • Could you be missing or overlooking a potential medical or psychological issue that deserves investigating?
  • Does the daily schedule include time for your patient or loved one to relax in between more cognitively or physically demanding activities?
  • Is there something about the care environment itself that might be triggering the problematic behavior?
  • What might your patient or loved one be trying to communicate with his or her behavior?

Keep a detailed journal of what happens each day so that you'll have an easier time identifying potential patterns, problems, or dietary or environmental triggers. Take notes about every activity, carefully recording your observations. Over time, you may start to recognize clues to what's causing the late-day behavior.

It's also important to get a physician involved when you notice behaviors that are new and concerning. What you assume to be sundowning behavior may actually be delirium, which can indicate a medical emergency. Sudden symptoms like agitation, restlessness, delusions, and hallucinations may be caused by a serious infection or some type of life-endangering metabolic problem. So it's essential to have potential medical issues ruled out before trying to manage troubling behavior through non-medical interventions.

If no clear medical or psychological cause is found, then try making some adjustments to the daily routine or to your caregiving strategies. When it comes to the phenomenon known as sundown syndrome, treatment and care is heavily dependent on the particular needs of each individual. Here are some of the strategies that have been used by caregivers:

  • Allowing for ample periods of physical and mental recuperation between each activity
  • Developing a schedule based on what feels most natural to the patient
  • Sticking to a regular bedtime and waking routine
  • Providing foot or neck-and-shoulder massages in the evening
  • Keeping rooms well-lit throughout the day and into the evening before bedtime
  • Closing blinds or curtains (or pulling down shades) when the sun begins to set (while still keeping rooms brightly lit until bedtime)
  • Ensuring that the patient is exposed to plenty of natural sunlight during the day (if the weather allows)
  • Limiting daytime naps to the morning or early afternoon and to a maximum of 20 to 30 minutes
  • Providing regular reassurance about the time of day
  • Sticking to a regular meal routine that includes three balanced meals each day plus healthy snacks
  • Avoiding stimulants like coffee, tea, caffeinated sodas, alcohol, sugar, and television in the late afternoon and evening
  • Providing entertaining distractions during staffing changes
  • Making sure the patient has familiar company when the sun is setting
  • Keeping plenty of objects around that are familiar to the patient
  • Minimizing noise levels in the late afternoon and evening
  • Keeping a calm dog or cat around for evening pets and cuddles
  • Reading books as part of a regular bedtime routine
  • Using white-noise machines or playing soft nature sounds at bedtime
  • Putting night-lights in bedrooms and hallways
  • Avoiding physical restraints (but keeping doors and windows locked)
  • Using baby monitors and motion detectors to help keep track of wandering behavior or restlessness

When trying to manage sundowners syndrome, medications are also sometimes used. However, many health professionals view certain prescription drugs as secondary, less-preferred forms of treatment since they often cause unwelcome side effects and sometimes worsen the behaviors they're meant to control. That said, in some cases, medications like the following are used for sundowners syndrome:

  • Low doses of melatonin in order to help induce sleepiness
  • Sedatives and sleep aids such as Ambien or Lunesta
  • Anti-anxiety drugs such as Ativan, Valium, or Xanax
  • Antidepressants such as Prozac, Paxil, or Zoloft
  • Antipsychotics such as Droleptan or Haldol
  • Drugs such as Aricept, Exelon, or Razadyne that can improve cognitive function

Of course, sundowning behavior doesn't just affect patients. If you're a caregiver, always remember to look after your own well-being. It's perfectly normal for caregivers to feel overwhelmed at times, especially when dealing with something as hard to control and hard to understand as sundowners syndrome. Make time for activities you enjoy and don't ignore your own eating and sleeping habits. And seek help and support when you need it. You can find local or online support groups for caregivers through organizations like the Alzheimer's Association and the Family Caregiver Alliance.