Sundowning is confusion, anxiety, agitation or restlessness that gets worse in the late afternoon and early evening. The Alzheimer Society of Canada calls it late-day confusion, and says it can be a problem for as many as 66% of people with Alzheimer's disease or other dementias. It is a symptom, not a bad mood.
If you care for someone at home, you already know the shape of it. The afternoon goes fine. Then around four or five, your mother starts pacing, or your dad puts his coat on and says he needs to get home, standing in the house he has lived in for 40 years.
This post covers what sundowning is, what sets it off, what helps in the moment, and an evening routine you can start tonight. It also covers the changes that are worth a call to their doctor rather than a change of routine. World Alzheimer's Day falls on September 21 each year, so this is a good week to read up. For the wider day-to-day picture, our practical tips for dementia caregivers and family members covers the rest.
What is sundowning in dementia?
Sundowning is a pattern of increased confusion, anxiety, agitation or restlessness that appears later in the day, usually in the late afternoon or early evening. The Alzheimer Society of B.C. defines it that way in its care partner handout (2020). You may also hear the older word "sundowners". The Alzheimer Society of Canada's own term is late-day confusion.
It can happen at any stage. The Alzheimer Society of Canada says it tends to peak in the middle stages of dementia and lessens as the disease progresses.
That is worth holding onto on a hard week. This is a phase of the illness, not a permanent new normal, and it is not something you caused.
Sundowning tends to peak in the middle stages of dementia and lessens as the disease progresses, according to the Alzheimer Society of Canada.
What are the early signs of sundowning?
The Alzheimer Society of Canada lists pacing, restlessness, becoming demanding or aggressive, doing impulsive things, trying to leave home, and having trouble with tasks that were easy earlier the same day. A person may also become suspicious or upset, see or hear things that are not there, or believe things that are not true.
The everyday version looks smaller than the clinical list. Repeated questions about where someone is. A search for keys or a purse that keeps starting over. Wanting to "go home" while sitting at home. Standing at the window. Refusing a supper they ate happily last week.
One detail matters more than any single sign: the timing. Write down what time it starts for two or three days. Families often find it is the same half hour each afternoon, which is what makes it something you can plan around.
Some people also have no idea any of this is happening, which is its own source of friction. That is common and it has a name. Our post on whether people with dementia know they have it explains why arguing about it rarely works.
Why does sundowning happen, and what triggers it?
The Alzheimer Society of Canada names four common triggers: being tired at the end of the day, low lighting and more shadows, disruption of the sleep and wake cycle caused by the dementia, and less activity in the afternoon than in the morning. Shadows matter because familiar objects look different in dim light, which can feed confusion.
The Alzheimer Society of B.C. adds three more in its 2020 handout. Over-stimulation, meaning too much noise or activity at the hour the person is already tired. Diet, meaning sugar, caffeine or a large meal later in the day. And side effects of some medications, which can increase confusion, restlessness or sleep problems.
There is a fourth explanation that is easy to miss. The B.C. handout warns that behaviour can look like sundowning when it is really an unmet need. Hunger, thirst, needing the toilet, pain, a hearing aid left in a drawer. Before you treat the clock as the cause, check the simple things.
An evening routine that lowers the odds
Here is the day laid out end to end. The actions come from the Alzheimer Society of Canada's guidance and from the Alzheimer Society of B.C. and P.E.I. handouts. No routine stops sundowning, and some evenings will still be hard. A steady one gives you fewer of them.
| Time of day | What to do | Why it helps |
|---|---|---|
| Morning | Open the blinds and curtains wide. Put the walk, the exercise, the shower and any appointment here | Daylight steadies the sleep and wake cycle, and the harder tasks land while energy is highest |
| Late morning | Offer coffee, tea and anything sweet now, not later | The Alzheimer Society of Canada advises restricting sweets and avoiding caffeine at night |
| Lunch | Make lunch the larger meal of the day | The P.E.I. handout suggests a big lunch and a simple supper so the evening is not heavy |
| Early afternoon | If there is a nap, cap it near 30 minutes | The B.C. handout suggests limiting naps so night sleep is not disturbed |
| Mid-afternoon | Finish any exercise at least four hours before bedtime | The P.E.I. handout recommends daily exercise, but not close to bed |
| About an hour before the usual flashpoint | Turn on lamps and overhead lights before the light drops, and close the blinds as the sun goes down | Extra light reduces shadows and stretches the feel of daylight |
| Late afternoon | Switch to one calm, familiar activity: folding laundry, sorting photographs, soft music | Calm activity at the hour agitation usually arrives gives the restlessness somewhere to go |
| Evening | Turn the television down or off, keep visitors few, keep the room quiet | Less noise and fewer people at the tired hour lowers over-stimulation |
| Bedtime | Run the same short wind-down every night: a decaf tea, the same music, a hand massage | A repeated sequence cues the body to wind down |
| Overnight | Leave a night light on in the hall and bathroom | Waking in a dark, unfamiliar-looking room adds to confusion |
Keep the clock steady too. The B.C. handout asks care partners to hold sleep times, meal times and exercise at the same hour each day, because a predictable day gives a person a sense of security.
How do you help someone who is sundowning?
When it has already started, the Alzheimer Society of P.E.I. advises staying calm, checking for discomfort, offering reassurance, avoiding arguments, using distraction, gently naming the time, and making sure the room is well lit. You are not trying to win the exchange. You are trying to get to the other side of it.
- Slow yourself down first. Approach calmly. Your voice and pace set theirs, and a tired care partner at five o'clock is part of the room.
- Check the body before the behaviour. Are they hungry, thirsty, in pain, or do they need the toilet? Fixing that ends a surprising number of evenings.
- Reassure instead of correcting. "Everything is all right, I'm right here" does more than a calendar or a photograph proving them wrong.
- Do not argue. You will not win an argument with dementia, and trying raises the temperature for both of you.
- Turn the lights up. Adequate light helps a person recognise objects and faces, which is half of what is unsettling them.
- Offer movement. If they are restless, suggest a short walk, even just to the end of the hall and back.
- Distract, gently. A favourite blanket, a photograph from years back, a familiar song. Reminiscing works as a distraction because it moves to ground they still know well.
- Let it pass. Take a breath and stay with them. P.E.I.'s handout is honest about this: sometimes the job is simply offering understanding until the episode ends.
When is it worth a call to their doctor?
Anything that arrives suddenly is worth a call, not a routine change. The Alzheimer Society of Canada recommends a full medical assessment for behaviour changes, to rule out infections such as a urinary tract infection, to check treatable conditions such as depression or constipation, and to review medications.
Raise these with their doctor:
- A sudden change. HealthLink BC says to seek care now if a person with Alzheimer's disease has a sudden, significant change in normal behaviour, or if symptoms suddenly get worse.
- Pain you cannot see. Untreated pain can show up as restlessness, agitation or withdrawal, and the Alzheimer Society of Ontario notes it can be mistaken for the dementia itself. The Alzheimer Society of Canada says pain should be assessed routinely as a possible cause of any behaviour change.
- A possible infection. Infections can set off confusion. Choosing Wisely Canada is firm on the other half of this: do not assume a urinary tract infection is the cause of a change in behaviour until other explanations have been ruled out. That is exactly why it is a doctor's call and not a conclusion to draw at home.
- Medications and their timing. Some dementia medications can disrupt sleep, particularly depending on the time of day they are taken. The Alzheimer Society of Canada's advice is to discuss the medication and the timing with their doctor or pharmacist, never to adjust it yourself. A review is a good moment to look at the whole list, since some common medications also raise the chance of a fall.
- Constipation or dehydration. Both are on the Alzheimer Society of P.E.I.'s list of physical causes of late-day restlessness, and both are easy to overlook.
A change that arrives over hours or days, rather than months, is worth a call to their doctor the same day.
The Canadian Coalition for Seniors' Mental Health puts this plainly: delirium, a sudden change in thinking and attention, is a medical emergency, and a provider should be contacted right away when the signs appear suddenly, even if they come and go.
Night-time wandering and keeping them safe
Leaving the house is one of the changes the Alzheimer Society of Canada lists under late-day confusion, and it is the one with real safety stakes. The Alzheimer Society of Ontario says six in ten people with dementia become lost at some point, often without warning.
A note on the word. The national Society prefers "walking" or "walking about" to "wandering", because wandering can sound stigmatising. The behaviour is usually purposeful from the inside: the person is going to work, or collecting a child, or heading home.
Practical steps Canadian families take:
- Register with MedicAlert Safely Home, the national identification service run with the Alzheimer Society of Canada, so first responders can identify the person and reach you quickly.
- Tell a neighbour or two, and the local police non-emergency line, that this is a possibility.
- Keep a current photograph and a written description of what they usually wear.
- Put a night light in the hall and bathroom, and make the exit route to the door less inviting than the route to the bathroom.
- Consider a location-sharing wearable if the person is still walking outdoors alone. These devices share a location; they do not supervise anyone, and they work alongside a plan rather than replacing one.
If you are weighing up that last point, our guide to GPS tracking for seniors with dementia in Canada sets out what the options actually do and what they cost.
Looking after yourself
The evening that wears a person out is yours as well as theirs. The Alzheimer Society of Canada's Landmark Study found that care partners in Canada provided about 470 million hours of unpaid care in a year, an average of 26 hours a week each, using 2020 data. That is a second job, performed at the tiredest hour of the day.
The P.E.I. handout makes a point worth repeating: if you are running on empty by late afternoon, the person you care for may pick up on it, and that can feed the agitation. Your rest is part of the routine, not a reward for finishing it.
Two things help more than willpower. Hand the late-afternoon hour to someone else once or twice a week, even for 90 minutes. And learn the early warning signs in yourself, which our post on caregiver burnout and how to prevent it walks through.
Frequently asked questions
What stage of dementia is sundowning?
It can occur at any stage. The Alzheimer Society of Canada says late-day confusion tends to peak in the middle stages of dementia and then lessens as the disease progresses. It is not a marker of how far along someone is, and its arrival does not mean the dementia has suddenly advanced a stage.
How long does sundowning last?
Canadian sources do not publish a typical episode length, and neither does Mayo Clinic, a US source often quoted on this. The pattern usually described is confusion that begins in the late afternoon and carries into the night. As a phase of the illness, it tends to ease in the later stages, according to the Alzheimer Society of Canada.
What time does sundowning start?
The Alzheimer Society of B.C. describes it as starting later in the day, usually in the late afternoon or early evening. Its handout uses examples around four o'clock. There is no fixed hour, and the practical step is to track your own person's pattern for a few days, then move the calm activities in front of it.
Is sundowning the same as delirium?
No. Delirium comes on suddenly over hours to a few days, fluctuates through the day, and usually has a medical cause such as an infection or a medication effect, according to the Canadian Coalition for Seniors' Mental Health. It often improves once that cause is found. Sundowning follows the clock instead, most days.
Where to get help next
You do not need a doctor's referral to get support. First Link connects a person living with dementia and their family to their local Alzheimer Society, and while a health-care provider can make that referral, a family member or friend can also contact the Society directly.
To find yours, use the Alzheimer Society of Canada's find-your-society page, or call its national information and referrals line at 1-855-705-4636. Most provincial societies run their own toll-free number, and Saskatchewan runs a named Dementia Helpline.
One small task for tonight, before anything else: write down the time it started today. Three days of that, and you will know exactly where in the afternoon to put the lamps, the walk and the quiet.
