Sundowning: late-day confusion in dementia

Sundowning is restlessness, confusion, irritability or agitation that starts or gets worse in the late afternoon and evening. It can carry on into the night.

A person may pace, have trouble sleeping, feel anxious, or see things that are not there. Experts do not know exactly why it happens, but it may be tied to changes in the brain.

Sundowning often has a reason behind it, even when that reason is hard to see. Possible triggers include:

• Tiredness, in body and mind, after a busy day
• Dim light and shadows that the person may misread
• A body clock that is out of step, so the person is sleepy by day and awake at night
• Unfamiliar places, too much noise, or stress picked up from others
• Unmet needs, such as pain or loneliness

Small changes to the day often matter more than anything done in the evening itself. The Alzheimer's Association and the National Institute on Aging suggest:

Keeping short notes on what happened before a hard evening can help you spot the person's own triggers.

• Keep the same times for waking, meals and bedtime each day.
• Get outside or sit by a window for daylight, and stay active without overfilling the day.
• Plan appointments and bathing for the morning or early afternoon.
• Keep the home well lit in the evening, and turn down noise such as the TV.
• Limit caffeine and alcohol late in the day, and discourage long late naps.

Physical problems can cause or worsen late-day confusion, so it is worth asking the person's doctor for an exam. Talk with a doctor if:

In an emergency, call 911 and tell the dispatcher the person has dementia.

• The behavior changes suddenly, or gets much worse
• There are signs of pain, constipation or an infection, such as a urinary tract infection
• A medicine was recently started or changed, since some medicines and combinations can play a part
• The steps above are not helping, or sleep problems continue