Sundowning: Symptoms, triggers & strategies

Sundowning: Symptoms, triggers & strategies

Found in: Activities Articles Dementia

The term ‘sundowning’ or ‘sundown syndrome’ refers to an end-of-day confusion and restlessness that manifests as dusk approaches. This syndrome affects people living with Alzheimer’s Disease and other forms of dementia.
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The term ‘sundowning’ or ‘sundown syndrome’ refers to an end-of-day confusion and restlessness that manifests as dusk approaches. It affects people living with Alzheimer’s Disease and other forms of dementia.

This psychological phenomenon causes behavioral problems that begin to occur as the sun is setting. Those affected may go into a heightened state of aggression or fearfulness, they may suffer from delusions or paranoia and will often begin pacing or wandering.

Sundowning is thought to be related to the body’s internal rhythms (circadian clock) although some people believe it has something to do with boredom and fatigue among other factors.

Either way, reducing the negative behaviors associated with sundowning benefits both those affected and those caring for them.

Related: How to Motivate Residents in Long Term Care

Sundowning Behaviour Management

There is no cure for Sundowning, however the underlying causes can be managed.

Identifying the issues that trigger the behaviour is the key to any management strategy.

  • Observe signs of increased anxiety and confusion as afternoon approaches.
  • Listen calmly to the concerns of each resident and empathize with them.
  • Console and reassure individuals that everything is going to be all right.
  • Invite them to share a hot or cold drink
  • Find a daily living activity that may distract them.

Keeping a log book for a few days may help you to establish possible causes of sundowning behaviour and find strategies to mitigate them. Try to determine if there are any unresolved emotional issues that may be contributing to the behaviour.

It is helpful to actively engage with individuals exhibiting sundowning behaviour so as to interrupt their thought-pattern. Keep in mind that everyone likes to remain 'in control’; allow choices (but not too many) and involve them in the decision-making process.

Attentive listening and acknowledgement of their struggle may help individuals to regain awareness and find some relief.

Related: Activities for People Living with Dementia

Common triggers to Sundowning Behaviours

  • Poor sleeping patterns
  • Unmet needs (thirsty, cold, hungry)
  • Boredom
  • Poor lighting
  • Fatigue – end-of-day mental and physical exhaustion
  • Being unwell
  • Loss of purpose and sense of security
  • Noisy surroundings - tv or radio and even their peers if they are wailing or screaming
  • Stimulating drinks (coffee, alcohol)
  • Delusions (difficulty separating reality from dreams)

Related: Communication Cards for Dementia Care

14 Strategies to Improve Sundowning Behaviour

  1. Predictable routines: structured activities that are simple, achievable and ‘successful’
    Related: Dementia Activities
  2. Compassionate listening and affirming their feelings
  3. Exercise, dance or waltz to music in the mornings to get the blood flowing
  4. Listening to soft music
  5. Familiar things and comfort objects (dolls, favourite blankets, soft toys, family photographs)
    Related: Doll Therapy
  6. Comfortable climate: not too hot or cold, windy or drafty.
  7. Enough rest, but making sure that napping is not excessive during the day
  8. Well-lit surroundings; poor lighting/shadows often cause disturbances
  9. Calming scents (use essential oils and a diffuser)
    Related: Aromatherapy for the Elderly
  10. Healthy diet: avoid stimulating drinks and too much sugar
  11. Have the person medically evaluated, there may be a physical reason for the behaviour
  12. Promote a calm atmosphere by watching videos of landscapes and rural settings to music or natural sounds
    Related: Tropical Reef Aquarium DVD
  13. Some people may enjoy a shoulder or hand massage
    Related: Hand Massage
  14. Providing a nutritious snack and drink one hour before normal Sundowning time may help residents to cope better.

There will be times when nothing seems to work and only patience, compassion, and a deep connection (holding hands and listening) feels right. Keep trying; each word you say or gesture you make may have a positive impact when you least expect it.

Be aware that agitation can be contagious and it’s important to remain calm. Aim to reduce the intensity of symptoms; let them know you are there for them.

There is a great deal you can do to soothe and support those affected by Sundowning and to help them maintain a sense of dignity and quality of life.

Good luck!

We'd love to hear your feedback!
What strategies have you found to work well to manage people with sun-downing?


carol 7th Jul 2016
We have a "twilight program". In a quiet room with older type music playing quietly between 6 to 8 residents depending. Between 2 and 6pm. We play picture bingo, card bingo, read poetry, short and simple exercise, sing a long, do hand massage, play jenga, have a washing basket with baby and children's clothes to sort, ball games, baby stuffed animals, to mention some activities. A group setting, but each has an individual activity. We have structure, but are also very adaptable. Keep each activity going for a short time to maintain attention We have afternoon tea and dinner. Then each resident is collected and taken either to bed or into the lounge. We find this a successful program, also minimising falls. Our "all important paperwork" is then completed. Shift finishes at 7.
kathie 8th Jun 2016
I work in a nursing home, as Div 2 nurse as well as doing activities, it is hard to manage sundowners after activity staff have gone home, as the ratio of nursing staff to residents on an evening shift is 2-15. there is just not enough time or staff to do 1:1 between the hours of 4pm and 6pm. other residents need pressure area care and toileting. would be great if activity staff could be rostered on for afternoon shifts as well.
Solange 10th Jun 2016
Hi Kathie

I know exactly what you are talking about. Often the nurses are left high and dry by late afternoon and it is not right or fair.

I would recommend bringing up the problem in the Nurses Meeting and trying to extend Activity staff hours.

All the best
Thea 8th Apr 2016
I have found that a strategy that "often/sometimes" works depending on the day is to roll activities into one session. Having a calendar of events is just a guide and being prepared to incorporate some simple activities into one helps with agitation. It could be cooking and playing music, or a calm and social gathering, not all our residents are interested or comprehend the designated activity so it is important to understand what suits them as individuals and accommodate as best and as practically as possible.
Jessica 28th Aug 2015
Something I have frequently discovered works well, is to commence something relaxing after lunch, eg music, video, etc in a group setting with the lights dimmed and the enviroment otherwise quiet. Have everyone seated comfortably and offer hand massages. You will be surprised by how many will sleep, and even those who don't will generally be more settled at the end of the hour. :)
Dorothy 30th Jul 2015
we are finding that short focused activities are working well for the calling out residents, changing the activitty after about 5 min
Jennifer 14th Jul 2015
Unfortunately I find sundowners usually require one to one interaction. For those who call out nothing really seems to stop this, because as soon as you leave they start calling out again. They like the physical presence of someone being there . Wanders enjoy having someone to walk with them but once seated again, they jump up and off they go again.Often looking for children, need to go home, get the dinner etc. wanting the usual routine. Its great if you have a good home design with kitchenettes set up, fiddle corners, games set up with instruction on box for \staff to initiate, washing basket in a wheelie trolley, clothes horse to hang out the washing. I found when setting areas up like this we had the best result. I alwasy find it best when you have open door to the outside so they can safely wander and try themselves out with regular walking. I also found sitting in a giant circle with exercise ball to kick from one to another was a great calming activity before tea time, despite the fact it;s roundy and fun.
Clare 25th Jun 2015
Find out from family what the person use to do at that time maybe a bar man,set up a bar sceane,Mummy bathing kids set up a bath scene with a doll and a kitchen.Sport activies for men.All very nice strategies set above however all missing the pointFamiliar routines they use to do before their ailments.


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