Sundowning in Dementia: How To Manage Late Afternoon Confusion

If you’ve noticed your loved one with dementia becoming increasingly confused, agitated or distressed as the day progresses, you’re witnessing a phenomenon called sundowning. This pattern of late afternoon and evening confusion affects many people with dementia and can be one of the most challenging aspects of the condition for both the person experiencing it and their families.

Understanding what sundowning is and how care teams manage it can help reduce your concern and equip you with strategies to support your loved one during difficult periods.

What Is Sundowning?

Sundowning (also called sundown syndrome or late-day confusion) describes increased confusion, agitation, anxiety and behavioural changes that typically begin in the late afternoon or early evening and continue into the night. The term comes from the observation that symptoms often start as the sun goes down.

Sundowning isn’t a separate condition but rather a collection of symptoms that many people living with dementia experience at specific times of day. It can affect people with various types of dementia, though it’s particularly common in Alzheimer’s disease and vascular dementia.

Common Signs of Sundowning

Sundowning manifests differently in each person, but common signs include:

Increased confusion: Greater disorientation about time, place or people compared to earlier in the day

Agitation and restlessness: Pacing, fidgeting, inability to settle or constant movement

Mood changes: Sudden irritability, anxiety, depression or mood swings

Behavioural changes: Aggression, demanding behaviour, stubbornness or suspicion

Sleep disturbance: Difficulty falling asleep, reversed sleep-wake cycles or wandering at night

Perceptual problems: Hallucinations or delusions that weren’t present earlier in the day

Communication difficulties: Increased problems with finding words or following conversations

Desire to leave: Repeatedly asking to “go home” even when already at home, or attempting to leave the care home

The intensity of sundowning varies considerably. Some people experience mild restlessness, whilst others have severe distress that significantly impacts their wellbeing and that of those around them.

Why Does Sundowning Happen?

The exact causes of sundowning aren’t fully understood, but several factors likely contribute:

Disrupted body clock: Dementia damages the brain’s internal clock that regulates sleep-wake cycles. As natural light fades, this disruption becomes more pronounced, leading to confusion about whether it’s time to sleep or be active.

Fatigue: By late afternoon, someone with dementia has used considerable mental energy coping with confusion and memory problems throughout the day. This exhaustion can reduce their ability to manage symptoms.

Reduced lighting: Dimming light in the evening can make it harder for someone with dementia to interpret their environment correctly, leading to misidentification of objects or people (seeing a coat on a door as a person, for example).

Unmet needs: Hunger, thirst, pain or need for the toilet that haven’t been addressed during the day become more pressing by evening, but the person may struggle to communicate these needs clearly.

Overstimulation: A busy day with multiple activities, visitors or changes to routine can become overwhelming, with the effects surfacing in the late afternoon.

Medication timing: Some medications cause side effects like drowsiness or confusion that coincide with evening hours.

Memory confusion: In late afternoon, people with dementia often mentally “time travel” to earlier periods of their life. They may believe they need to collect children from school, go to work or prepare dinner because that’s what they did at this time for decades.

How Care Home Staff Manage Sundowning

At care homes experienced in dementia care, staff use various strategies to reduce sundowning and support residents when it occurs:

Creating Consistent Routines

Predictable daily routines help people with dementia feel more secure. Care staff maintain regular times for waking, meals, activities and bedtime. This structure reduces confusion about what’s happening next and helps regulate the body’s internal clock.

Managing Light Levels

Staff balance natural and artificial lighting throughout the day. In the afternoon, they ensure living areas remain well-lit to prevent the shadows and dim conditions that can trigger confusion. Bright light therapy earlier in the day sometimes helps reset disrupted body clocks.

Monitoring for Triggers

Experienced care teams track and understand when sundowning occurs and what precedes it. If someone consistently becomes agitated after group activities, staff might schedule quieter alternatives for late afternoon. If hunger triggers restlessness, an earlier evening meal or substantial afternoon snack can help. Through the use of person-centred care plans, our care teams can tailor these options to suit each residents needs.

Reducing Stimulation in Late Afternoon

Whilst morning and early afternoon might include group activities, music or outings, care homes often schedule calmer activities for late afternoon. This might include gentle walks, quiet crafts, light sensory activities or one-to-one pamper time with staff rather than busy group sessions.

Checking Physical Comfort

Staff regularly check for basic needs that someone with dementia might not communicate clearly. Is the person in pain? Do they need the toilet? Are they thirsty? Uncomfortable? Too hot or cold? Addressing these needs often reduces agitation significantly.

Using Distraction and Redirection

When someone becomes distressed or insistent on going somewhere, staff use gentle distraction rather than direct contradiction. They might suggest a cup of tea, show old photographs or ask for help with a simple task. This redirects attention without confrontation.

Providing Reassurance

Calm, gentle reassurance from familiar staff members helps. Care staff use simple language, maintain eye contact and offer physical comfort like holding hands if the person finds this soothing.

Creating Quiet Spaces

Care homes should have quiet areas where residents experiencing sundowning can spend time away from busy communal spaces. These calmer environments with fewer people and less noise can help someone settle. Such as at care homes at Newgate Lodge Care Home, where there are dedicated living spaces for residents to relax, watch television, read or use the sensory tablet.

Avoiding Confrontation

Staff are trained never to argue with someone experiencing confusion. If a resident insists they need to go to work or collect their children, staff acknowledge these feelings rather than pointing out the person retired decades ago or their children are now elderly adults.

Monitoring Medications

Care teams work with GPs to review medications that might contribute to sundowning. Sometimes adjusting timing or dosage reduces symptoms, though medication alone rarely solves the problem.

What Families Can Do During Visits

If you visit your loved one in the late afternoon or evening, understanding sundowning helps you respond more effectively:

Consider visit timing: If possible, schedule visits for earlier in the day when your loved one is typically calmer and more alert. Morning or early afternoon visits often go more smoothly.

Keep visits calm: Avoid bringing multiple family members at once during vulnerable times. Large groups can overwhelm someone already struggling with confusion and fatigue.

Accept confusion without correction: If your mother insists she needs to go home to make dinner for your (long-deceased) father, don’t remind her he died. Instead, acknowledge her feelings: “You were a wonderful cook. What was Dad’s favourite meal?” This validates her emotions whilst gently redirecting.

Use familiar activities: Bring activities associated with calmer times. Looking at photograph albums, listening to favourite music, or folding laundry together can provide comforting occupation.

Watch for tiredness: If your visit seems to be increasing agitation rather than providing comfort, keep it brief. Sometimes the kindest thing is a short, positive visit rather than a long, distressing one.

Speak to staff: Let care staff know when you plan to visit. They can tell you if your loved one is having a particularly difficult day or suggest better timing.

Be patient with repetition: Sundowning often includes repetitive questions or statements. Answer patiently each time rather than saying “I just told you that.”

Reduce stimulation: Keep the television off, speak quietly and clearly and choose a calm area of the care home for your visit if late afternoon confusion is occurring.

Managing Sundowning at Home

If your loved one with dementia still lives at home, these strategies can help:

Maintain daylight exposure: Encourage time outdoors or near windows during the day. Natural light helps regulate the body clock.

Structure the day: Create a consistent daily routine with regular meal times and activities.

Plan demanding activities for morning: Schedule appointments, outings, or challenging tasks for earlier in the day when energy and cognitive function are better.

Limit afternoon napping: Long afternoon naps can worsen evening confusion and night-time wakefulness. If naps are needed, keep them short and earlier in the day.

Reduce caffeine: Avoid tea, coffee and cola drinks after midday as they can increase restlessness.

Prepare simple evening meals: By late afternoon, someone with sundowning may struggle to eat complex meals. Simple, favourite foods are often better accepted.

Create a calm evening environment: Reduce noise, close curtains to minimise confusing reflections and keep lighting consistent rather than allowing rooms to become dim.

Establish bedtime routines: Consistent pre-bed routines (warm drink, television programme they enjoy, getting into nightclothes) signal that sleep time is approaching.

When Sundowning Becomes Dangerous

Most sundowning involves agitation and confusion that, whilst distressing, doesn’t pose immediate danger. However, sometimes symptoms become more serious:

• Aggressive behaviour that puts the person or others at risk
• Attempts to leave the house inappropriately dressed or at night
• Severe distress that doesn’t respond to usual calming techniques
• Complete reversal of day-night sleep patterns affecting health
• Refusal to eat, drink, or take medications during evening confusion

If sundowning reaches this level, speak to your GP or the care home’s clinical lead. Occasionally, short-term medication helps manage severe symptoms whilst longer-term strategies are implemented.

The Progression of Sundowning

Sundowning doesn’t affect everyone with dementia, and when it does occur, it doesn’t always follow a predictable pattern. Some people experience it throughout their dementia journey, whilst others find it improves in later stages as they become generally less active.

Understanding that sundowning is a symptom of dementia rather than deliberate difficult behaviour helps families respond with compassion. The person experiencing sundowning feels genuinely confused, anxious or frightened. They’re not being awkward or attention-seeking.

Supporting Someone Through Sundowning

Whether your loved one lives at home or in a care environment, the most valuable support you can offer is:

Patience: Sundowning is frustrating for everyone, but the person experiencing it is most distressed.

Consistency: Predictable routines and responses help reduce anxiety.

Flexibility: What works one day might not work the next. Be prepared to adapt approaches.

Compassion: Remember the person didn’t choose to have dementia or experience sundowning.

Communication: Share observations about triggers or successful calming techniques with care staff or family members.

Dementia Care in Mansfield and Nottinghamshire

At Lidder Care, our staff at both Newgate Lodge Care Home and Lowmoor Nursing Home are trained in managing sundowning and other challenging aspects of dementia care. We understand that late afternoon confusion is a symptom of the condition, not a behaviour problem, and we respond with patience and person-centred care.

Our structured daily routines, appropriate lighting, calm environments, and experienced staff help reduce the frequency and intensity of sundowning episodes. When they do occur, we support residents through them with dignity and compassion.

If you’re concerned about sundowning in your loved one and would like to discuss how specialist dementia care might help, call us on 0330 223 6600 or visit liddercare.com to learn more about our approach to dementia care.