What Are Sundowning Symptoms? Recognizing the Signs in Residents with Dementia
Sundowning is a term frequently used in skilled nursing facilities; however, few people agree on its exact meaning. Ask five different staff members, and you might get five different answers. While the behavior is real and well documented, the term is surprisingly vague. We’ll take a look at the recognized pattern behind “sundowning,” its clinical causes, how staff catch and document it, and how to respond when symptoms begin.
What Is Sundowning Syndrome?
As the Mayo Clinic points out, sundowning isn't a disease itself—it’s a group of symptoms that tend to pop up at a specific time of day. It affects people with Alzheimer’s and other forms of dementia, almost always occurring between late afternoon and evening.
Sundowning is not in the DSM-5. Researchers still call it understudied, and there's no formal way to diagnose it. None of that stops staff from spotting it.
What Causes Sundowning in Dementia Patients?
Clinicians have not yet landed on a sole cause. What the research offers instead is a list of contributing factors.
The internal-clock theory is most often cited. The brain region that tells a person when to be awake and when to sleep starts breaking down in Alzheimer's disease, and that can flip a resident's sense of day and night. Fatigue factors in as well. A day of activity wears people down. Residents who seemed fine at breakfast can be running on empty by 4pm.
Light is also a contributing factor. Rooms dim, shadows stretch, and a person with dementia can lose the ability to properly process what they're looking at. That confusion turns into fear pretty quickly. Toss in a shift change, a noisier-than-usual dinner service, an unfamiliar face at the nurses' station, or a spike in evening activity near the day room, and you've created an environment that leads to a hard evening for them.
What Are the Common Signs and Symptoms of Sundowning?
The Cleveland Clinic points to confusion, pacing, restlessness, and irritability as the most typical warning signs of sundowning. It’s a pattern reflected in a 2023 Journal of Alzheimer's Disease study, which found that roughly half of residents who experience sundowning show primary agitation, usually mixed with anxiety and a short temper.
Some residents have varying experiences — suspicion, delusions, wandering, or "shadowing," where they trail a caregiver from room to room. Others cry or yell. Some resist care they normally have no problem with, like getting dressed, taking medication, bathing or moving from one room to the next. Hallucinations occur in a smaller subset of cases. And sleep is almost always impacted, which sets up the patient for an even worse evening the next day. It spirals into an endless loop.
When Does Sundowning Typically Occur?
Symptoms cluster around sunset and often build as the evening goes on. WebMD notes symptoms tend to worsen through the night and ease up by morning. This tracks with why overnight staff logs more incidents than the day shift.
It's not uniform, though. One resident spikes right at dinner. Another stays completely fine until well after the unit's gone quiet for the night. Facilities that track timing resident by resident, instead of assuming one schedule fits the whole floor, tend to catch it earlier.
Who Is at Risk for Sundowning?
Alzheimer's disease and other dementias are at risk. It's more common in the middle and later stages than in early-stage cases.
UCLA Health reports that approximately 19% of people with dementia experience sundowning. Other published research shows much higher rates — some studies cite rates as high as two out of three. Sundowning gets defined and measured differently from study to study, but one constant remains: it exclusively affects people with dementia, not older adults in general.
How Is Sundowning Different From Delirium?
People mix these two up constantly. Delirium is an actual DSM-5 diagnosis, a sudden break in attention and awareness. It can hit at any hour, comes and goes throughout the day, and in older adults, is often traceable to something treatable like a medication reaction or an illness nobody's caught yet.
Sundowning, by contrast, runs on a repeating evening schedule rather than appearing out of nowhere. A staff member who waves off a sudden, out-of-character confusion episode as "just sundowning" could be missing a medical emergency that needs attention that same day. New, sharp, or unusual confusion is a reason to call for evaluation.
How Can Caregivers and Skilled Nursing Facility Staff Members Manage Sundowning Symptoms?
Nothing makes sundowning disappear. But Mayo Clinic and the Alzheimer's Association both back a few strategies that help manage its symptoms. Keep waking, bedtime, meals, and activities on a predictable schedule to keep the internal clock oriented. Get residents natural light during the day. Watch the naps, especially anything late in the afternoon, since that's what throws the clock off in the first place.
Cutting caffeine and sugar in the afternoon and evening helps for the same reason. In the evening hours themselves, a calmer setting can do a lot of positive work: lower lighting introduced gradually rather than flipped on and off and fewer competing sounds and clutter in common areas.
Staff continuity around shift change is worth planning around too. Fewer new faces at dusk means one less trigger. And before assuming a behavior is purely dementia-driven, it's worth ruling out hunger, thirst, unaddressed pain and a full bladder. Sometimes sundowning is really just an unmet basic need wearing a scarier name.
What Are the Limits of Managing Sundowning at Home or in a Facility?
Routine and environment help, but they're not a substitute for clinical judgment. Symptoms that look like sundowning can be a surface sign of something else: a urinary tract infection, a medication side effect, pain that's gone unreported, an untreated mood disorder. Mayo Clinic recommends ruling out physical causes with a doctor before treating a behavior change as sundowning and leaving it there.
A behavior plan without medical backup only covers so much ground. If symptoms escalate into aggression, wandering that puts a resident at risk, resistance to routine care or distress that lighting changes and routines aren't touching, that resident needs evaluation from a clinician who understands dementia-related behavior specifically. Medication has a place in severe cases, but the Alzheimer's Association is clear that non-drug approaches come first, with medication considered only after those approaches haven't worked and a doctor has walked the family through the risks directly.
Getting Support for Sundowning Symptoms in Your Facility
Spotting sundowning is the first step. The next is building a clinical response around it, one with clinical follow-up, staff training, consistent documentation, and ongoing behavioral support for residents. Unfortunately, this is where most skilled nursing facilities run out of internal bandwidth.
Pacific Coast Psychology provides on-site geriatric mental health services to nursing homes and memory care communities throughout California. Our clinicians work inside your building, alongside your residents and staff, so sundowning behaviors receive a clinical response rather than a note in the chart and a hope that tomorrow evening goes better.
If your facility is experiencing sundowning symptoms and wants a clinical partner for the response side of things, contact Pacific Coast Psychology to discuss on-site geriatric mental health support for your California nursing home or memory care unit.
