Part 1 of 3: What is Sundowning, What Causes It, and How is it diagnosed?

If you provide direct care for someone, be it a loved one in your family, a dear friend, or as part of your job as a companion, and you notice a change in their behavior in the onset of evening hours, it might not be a coincidence. They might be suffering from a condition known as Sundown Syndrome, especially if they are already suffering from Alzheimer’s or experiencing any stage of dementia.

Typically, it works like this: Later in the day when you may observe the sun beginning to set, you may also notice a change in your loved one’s behavior that seems out of character or excessive. You certainly perceive that something is wrong and that there is more going on at this time of day than usual. This type of behavior happening during this time of day is commonly known as sundowning. Doctors don’t know why this phenomenon happens, but it affects approximately one in five Alzheimer’s patients and can affect people who suffer from any stage of dementia.

Over the next three blog posts, we are going to learn what sundowning is and explore its causes and how it manifests itself via varying types of noticeable behavioral changes. We will also discuss events and situations that likely trigger sundowning, as well as its typical symptoms, including various options that studies have shown may help some people in managing this condition.

Where did the term come from?

The term “Sundowning” was created in 1987 by nurse Lois K. Evans, who worked at a geriatric center where elderly with various stages of dementia and Alzheimer’s were housed. Over time, she observed conditions that manifested primarily in the late afternoon and early evening, usually around sunset. Hence, she referred to her patients as “Sundowners” when coining the term.

What is “Sundowning”?

As people age, their bodies, minds, and lifestyles undergo changes; one of these changes is sundown syndrome, also known as sundowning. This phenomenon describes when an individual’s behavior changes significantly as the day progresses, manifesting as a state of confusion and/or restlessness that affects some elderly individuals, particularly those with dementia in the late afternoon or evening. This period of confusion and agitation can be difficult for family members to manage if they are not knowledgeable about this condition. Therefore, knowing more about sundowning can help you to better understand and support your loved one through this difficult experience.

What causes Sundowning in the elderly?

Though there is no single answer to this question, scientists have identified a few potential causes for sundowning syndrome. One possible explanation is that reduced light levels lead to disrupted circadian rhythms, which can cause confusion and disorientation at night. Additionally, fatigue due to lack of sleep during the day may contribute to increased irritability or agitation in the evening hours. Lastly, some experts suggest that sundowning may be caused by an overload of sensory input during the late afternoon and early evening when lights are brighter and noise levels are higher than usual.

According to Spencer Liebel, PhD, a clinical neuropsychologist and assistant professor in the Department of Neurology at the University of Utah Health, Sundowner’s Syndrome may be related to the shift between daylight and nighttime. “It’s not necessarily a cognitive issue,” he says, “but rather a change in behaviors. There is newer research emerging suggesting that it may be linked to our circadian rhythm. The body wants to sleep, but some of the brain structures responsible for regulating sleep may be damaged due to the dementing process.”

A study that supported this theory was conducted and published, called “Sundowning and Circadian Rhythms in Alzheimer’s Disease”. The goal of the study was to find out if changes in people’s circadian rhythms were induced by Alzheimer’s and if it had a relationship with sundowning. The data from the study indicated that Alzheimer’s does cause disturbances in circadian rhythms, which, in layman’s terms, means their sleep phase is out of a standard rhythm of sunrise and sunset.

Light treatments and brain health

There is another study related to this theory that tested bright light treatments for behavioral and sleep disturbances in Alzheimer’s patients, which also included Sundowners. The results of the test showed promise in the treatment, as it showed that some of the test subjects’ sleep disturbances were mitigated.

Other studies have shown that the neurons in the brains of Alzheimer’s patients who exhibited sundowning continue to degrade over time, which can inadvertently lead to an increased likelihood of agitation, behavioral outbursts, and in rare cases, physical outbursts as well. This condition is still under study with a host of factors identified as having links to sundowning, but the overall consensus is likely an imbalance of messaging chemicals in the brain.

To this day, the source and cause of sundowners are still being researched; and while science has gained great insight, they are no closer to learning the exact specific cause today than they were back in 1987 when Nurse Evans first coined the term. So, without knowing the cause, how do we help our loved ones?

The answer? Start by getting your elderly loved one diagnosed as early as you can. Consult with your doctor to determine the scope of the underlying Alzheimer’s and/or dementia, and the severity of sundowning that your loved one is presenting.

How to diagnose Sundowning in the elderly?

Diagnosing Sundowners Syndrome is much different from many other mental diseases in that it is viewed as a “feature” of Alzheimer’s or dementia rather than a stand-alone ailment. As such, it is usually first discovered by a family caregiver who may notice drastic changes in the loved one’s mood during specific times of the day. Or, it may be discovered by a paid in-home companion who, if made aware their clients have a pre-existing condition of Alzheimer’s or Dementia and if they work during the twilight hours, will likely connect the dots once they notice the recurring drastic change in behavior occurring in that time frame.

The main behaviors you are likely to notice are:
• Suspiciousness.
• Abnormal demands of attitude.
• Mood swings.
• Delusional thinking.
• Paranoia.
• Hallucinations that are both visual and auditory.

These are the usual symptoms, but you may also see others that include irritability, restlessness, anxiety, disorientation, refusal to cooperate, repetition of questions or statements, pacing, wandering, and difficulty sleeping. Oftentimes, these symptoms will worsen throughout the evening and into the night before beginning to dissipate as morning approaches. Of course, consult with the patient’s physician for an accurate diagnosis.

What do you do when you see these things happening?

Sundowning can be a difficult experience for both those affected by it, as well as their family members and companions. The most important thing you can do if you suspect someone you know has Sundown Syndrome is to seek professional help from a doctor or medical specialist, who can diagnose the condition and suggest treatment options that are best for their individual needs.

It is also important to create an environment that minimizes stress and discomfort for your loved one—make sure they have enough light during the day but not too much at night so that their circadian rhythms are regulated; provide reassurance when needed; and make sure they get enough sleep each night. By understanding what may cause sundowning and taking steps to minimize its effects, you can help your loved one feel more comfortable and secure throughout the day and nighttime hours.

How does a family cope with and best deal with a loved one who has Sundowner’s Syndrome?

Dealing with a loved one who is unpredictable at the same time every day can be a challenge for family members. While paid companions typically deal with this regularly, they are usually not around your loved one 24/7. So, how do you cope on a daily basis?

We will cover that topic in Part 2 of our three-part Sundowner series.

Sundown Syndrome and the Elderly: Part-2 • Diagnosing your loved on
Part 2 of 3: Finding the right doctor, Tracking behavior, Asking the right questions

In this part-2, of our three part series, on Sundown Syndrome “Finding the right doctor, Tracking behavior & Asking the right questions”, we will discuss recommended steps you can take to address the needs of a loved one that experiences sundowning. You’ll also learn that there’s a process you can follow that will help you discover the scope of the underlying disease, by finding the right physician, and following a process of information gathering that will help the physicians make informed decisions regarding your loved one’s condition.


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Part 1 of 3 – What you need to know • What is Sundowning, What Causes It, and How is it diagnosed?

Part 2 of 3:  What Are Your Next Steps? • Find the Right Doctor, Track Behavior & Ask the Right Questions

Part 3 of 3: What You Can Do at Home • Household tips, Daily management, and At-home therapies


How to Deal With Sundowners

Help reduce sundowning agitation

Sleep disturbances in patients with Alzheimer’s disease

Dementia and Behavior Changes at Sundown: by Dr. Spencer Leibel
Spencer W. Liebel, PHD

Sundown Syndrome in Institutionalized Elderly

Sundowning and circadian rhythms in Alzheimer’s disease,and%20in%20nine%20healthy%20individuals.