Dementia Sundowning Playbook

What sundowning looks like

Sundowning is a cluster of symptoms — restlessness, agitation, confusion, wandering, verbal aggression, refusal of care — that emerge in the late afternoon and evening in people with dementia. It usually peaks between 4pm and 8pm, tapers overnight, and starts again the next afternoon. Some families describe the person as “a different person” between morning and evening.

What causes it

• Circadian rhythm disruption — the internal clock that regulates sleep-wake is impaired by dementia
• Fatigue and sensory overload — a full day of processing has depleted cognitive reserve
• Environmental cues — falling light, changing shadows, higher household activity at dinner time
• Medication side-effects — some meds peak in effect in the afternoon
• Unmet needs — hunger, thirst, needing to use the bathroom, being too hot or cold
• Infection — a UTI or other infection can present as new or worsening sundowning

Environmental protocol (do these every day)

1. Turn on lights before dusk. The single most-effective environmental intervention. Bright, warm indoor lighting from 3pm onward, before shadows lengthen.
2. Close blinds when it gets dark. Reflections in windows can look like intruders to a person with dementia.
3. Reduce ambient noise. Turn off the TV news. If music helps, use quiet familiar music — hymns, standards, whatever they knew as a young adult.
4. Warm the room slightly. Feeling cold amplifies agitation.
5. Keep one caregiver. A shift change during the sundown window is one of the worst possible times.

Daily rhythm protocol

1. Cut caffeine after noon. Coffee, tea, cola, chocolate — no caffeine after 12pm.
2. Physical activity in the morning. A walk, a chair-exercise routine, a garden trip. Physical activity earlier in the day reduces evening restlessness.
3. Nap discipline. If a nap is needed, before 2pm and no longer than 45 minutes. Long or late naps disrupt the evening.
4. Consistent dinner time. Same time every day. Simple food. No decision-making about menu.
5. Bathroom before sundown starts. Full bladder is a top-3 trigger. Take them at 3:30pm and again at 6pm without asking.

When agitation begins

1. Do not argue. Do not correct. Do not try to logic. Agree, redirect, comfort.
2. Change environment. Move rooms. Warm blanket. Familiar object.
3. Offer a snack. Blood sugar dips can worsen agitation.
4. Try a task with familiar hands. Folding laundry, sorting cards, an easy puzzle. Repetitive motion reduces agitation for many people.
5. Music. Their music, from age 15–25. Not present-day radio.

Red flags — call the physician the next day

• Sundowning that is dramatically worse than baseline — think infection (UTI, chest, other)
• New physical aggression when the person has not been aggressive before
• Refusal to eat or drink for more than 24 hours
• New medications started within the last 2 weeks
• Signs of physical illness — fever, wet cough, new incontinence, unusual sweating

When medication becomes appropriate

Non-medication strategies should always come first. Consider medication (with physician oversight) when: (a) the person is at risk of harm to themselves or others; (b) the family caregiver is at true burnout; (c) non-medication interventions have been tried consistently for 3–4 weeks without improvement. Common options include melatonin, low-dose trazodone, and — carefully — antipsychotics with a black-box warning for elderly dementia patients. Never start a psychotropic without a physician evaluation.

The nurse read

Sudden change in sundowning severity is almost always a signal, not the dementia progressing. UTI, chest infection, new medication, dehydration, constipation, undiagnosed pain — all can amplify sundowning within 24–48 hours. The right response is to check the physical picture, not increase the psychotropic.

Where our Neuro-Aware Dementia Care program fits

This playbook is what our caregivers execute every day inside our Neuro-Aware Dementia Care program. Every family enrolled gets this written into the care plan, and our Care Manager (a former Neuro ICU nurse) audits the daily log weekly to catch the pattern changes that predict a UTI or a medication reaction before the family notices.

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