Understanding sundowning: Why evenings can be difficult for people with memory loss

(Aging Untold) — If you care for someone with memory loss, late afternoons and evenings may bring changes that feel sudden or hard to understand.

Sundowning is when confusion, anxiety or behavior changes increase later in the day.

The Aging Untold experts are offering ways caregivers can look for patterns, reduce stress and seek help when something changes.

Why sundowning can feel so sudden

Sundowning can be especially challenging because families often do not understand what is happening in the brain, Sam Cradduck, a gerontologist, said.

“I think the biggest issue is, you know, you’ve got this pretty passive, really calm person throughout the morning. Throughout the day, things are really, you know, confusion, yes. Memory loss, yes. Changes, yes. But they’re just passively calm,” Cradduck said. “And then you get toward the evening and there’s agitation. There’s aggravation.”

Cradduck said one way to understand the shift is to think about energy reserves.

“That brain is exhausted,” Cradduck said.

Dr. Rhea Rogers, a board-certified physician, said caregivers may see crankiness, agitation or frustration because the person’s brain is signaling that it needs support.

“It’s basically the brain is saying, ‘Hey, I need help. I’m running out of energy,’” she said.

Every person’s experience is different

Amy O’Rourke, an aging expert, said caregivers should know they are not alone and that sundowning does not always last forever.

“This stage is not a forever stage,” O’Rourke said.

She said sundowning is temporary, which could be a year and a half for some people or three months for others.

The next stage could be that the person is so tired that they can’t get up and walk around, it could be that they’re so severely confused that they don’t have the energy to go or it could be that they died, O’Rourke said.

Every person with memory impairment is different, so caregivers should avoid assuming one person’s experience will look like another’s.

“If you’ve seen one person with a memory impairment, you’ve seen one person with a memory impairment,” O’Rourke said.

She said caregivers can listen closely to what the person may be trying to communicate and consider basic needs, such as hunger, thirst, fear, lighting or comfort.

Look for patterns from the person’s past

Cradduck said caregivers should think about the person’s past routines and how those patterns may still affect behavior.

“Knowing what the person did historically helps us understand how to manage the behaviors and the patterns of today,” Cradduck said.

That could include whether the person used to come home from work at a certain time, spend evenings with family or worked afternoon or evening shifts.

Rogers said creating a predictable routine can also help.

“If you can create a routine for the brain, if the brain knows what’s coming next, that’s calming as well,” she said.

Adjust the environment before evening stress builds

Rogers said lighting and shadows can play a role when the day begins to fade. Keeping rooms well-lit earlier in the evening may help reduce confusion caused by shadows.

Caregivers can also learn from memory care communities by paying attention to how spaces are designed, decorated and structured.

Katherine Ambrose, an aging-well coach, said visiting memory care communities can help families come up with ideas for their home or make plans for later.

“You can glean so much from that,” Ambrose said. “And then maybe incorporate that into your lifestyle at home or have a plan for later that is more supportive.”

Do not assume every new behavior is sundowning

Caregivers should not automatically assume a new behavior is sundowning or disease progression, Cradduck said. Changes may be tied to something else, such as an infection, constipation, pain or a medication change.

Small things can overwhelm someone with memory loss, and caregivers should consider whether something treatable may be contributing to the behavior.

If non-medication approaches are not helping, O’Rourke said caregivers can talk with a physician about temporary medication support during an acute period.

Five key takeaways

1. Sundowning often appears later in the day, when confusion, anxiety or behavior changes may increase.
2. The brain may be exhausted by evening and running out of energy reserves.
3. Past routines can offer clues about current evening behaviors.
4. A calm routine, good lighting and fewer shadows may help support the person’s brain.
5. New or sudden behavior changes should be checked for other causes, including infection, pain, constipation or medication changes.

More content on dementia and memory loss

• What to know about dementia: It’s not just memory loss
• How to respond when dementia patients ask about deceased loved ones
• Managing agitation in dementia and understanding the red flags
• When dementia causes a loved one to forget your name