Neurology Video Library
Amarish Dave, DO, Board-Certified Neurologist, explains what sundowning is, why confusion and agitation can worsen in the evening in dementia, and what caregivers can do to help.
Written and medically reviewed by Amarish Dave, DO, board-certified neurologist. This page is educational and does not replace an individual medical evaluation.
Sundowning describes a pattern of increased confusion, agitation, anxiety, restlessness, irritability or behavioral changes that occur later in the day, particularly in the late afternoon or evening. It is commonly associated with Alzheimer's disease and other forms of dementia. Importantly, sundowning is not a separate disease or type of dementia—it is a symptom pattern that can occur as dementia affects the brain. If you are noticing broader changes in memory or thinking, our guides on the signs of dementia and the difference between Alzheimer's and dementia may be helpful starting points.
Every person is different, but families commonly notice behaviors such as:
These changes can be distressing for both the person experiencing them and the family members caring for them. Our video on managing agitation in dementia covers practical ways to respond when distress builds.
The exact cause is not completely understood. Changes in the brain's sleep-wake and circadian systems—the internal systems that regulate when we feel alert and when we feel sleepy—may contribute. Dementia can disrupt those systems, which is one reason evenings can become difficult. For related reading, see our sleep and brain health guide and our video on what sleep apnea is, since disrupted sleep can worsen thinking and behavior in dementia.
Several factors can intensify evening confusion or agitation, including:
Because several of these are treatable, identifying which ones apply to your family member is often the first practical step.
Management often begins with identifying triggers and creating a predictable daily routine. Daytime physical activity, appropriate daylight exposure, reducing late-day stimulation, maintaining regular meals and sleep schedules, and creating a calm evening environment may help some patients. Medication is not automatically the first treatment; when behavioral symptoms are severe or create safety concerns, medication decisions should be individualized with the treating clinician.
Patterns matter. Keep a simple record of when behaviors occur, sleep patterns, meals, medications, environmental triggers, and what seems to improve or worsen symptoms. A pattern log often reveals a trigger that is easy to change—and it gives the care team far more useful information than memory alone. For more caregiver strategies, see our guide on managing agitation in dementia and our video on why hallucinations happen in dementia.
A sudden or dramatic behavioral change should not automatically be assumed to be sundowning. Infection, pain, medication effects, dehydration, delirium or another medical problem may need to be considered. If the change is new, out of character, or significantly different from the person's usual pattern, contact their healthcare professional promptly.
Sundowning tends to follow a recurring late-day pattern in someone with cognitive impairment. A new or sudden change in confusion or behavior—especially if it is significantly different from the person's usual pattern—should prompt consideration of delirium or another medical problem. Delirium can have a treatable medical cause and deserves prompt evaluation rather than watchful waiting.
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NeurologistCare provides neurological and memory evaluations in person in Crystal Lake and Woodstock, Illinois, and Lake Geneva, Wisconsin, as well as telehealth where available for patients located in Illinois or Wisconsin. To learn what an evaluation involves, see our video on what happens after a dementia assessment.
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