If you've noticed your loved one becoming more confused, agitated, or restless in the late afternoon or evening, you may be witnessing what healthcare professionals call "sundowning." Through my journey caring for Rose, I discovered that these behavioral changes weren't random or simply part of memory loss—they were a specific phenomenon that many families encounter but often don't have a name for. While the early signs of cognitive decline were concerning, understanding and addressing these evening behavioral patterns became crucial for both Rose's well-being, safety and everyone’s ability to care for her.

What Is Sundowning?

Sundowning is far more than simple confusion or memory lapses. It's a neurological phenomenon where a person with dementia experiences increased confusion, anxiety, agitation, and behavioral changes as daylight fades and evening approaches.

What you see in medication commercials barely scratches the surface. In real life, sundowning can manifest as:

• Increased attempts to leave or "escape" living environments
• Constant searching for familiar objects (like Rose looking for her car)
• Intense anxiety and restlessness that peaks in the late afternoon or evening
• Pacing, wandering, or inability to settle
• Mood swings ranging from tearfulness to aggression
• Suspicion or paranoia that worsens as the day progresses
• Hallucinations or delusions that intensify after dark

I first noticed Rose’s sundowning after installing cameras to monitor her safety. She lived alone at that time and I wanted her to retain as much independence as was safe. She didn’t understand technology, so she didn’t think I was spying on her though in reality, I was. I was mostly concerned about her falling. However, her behaviors overnight were completely bananas - she would get into her pajamas and watch TV to fall asleep. She would wake up in the middle of the night, get up and change into her daytime clothes. She would eventually realize it was dark outside and changed back into her pajamas. This would go on sometimes two and three times a night. Without cameras, I would have never noticed this.​
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If you can spend time with them between 3pm and bedtime, watch for behaviors that are out of character—confusion in the evenings, increased agitation, and patterns that are just not normal. Unfortunately, our society brushes off boisterous seniors assuming they just lose their filter when they age. If the behavior only shows up in the late afternoon and evening, consult their doctor. There are no lab tests for sundowning and not all dementia and Alzheimer’s patients get it. It’s up to care givers to monitor behaviors and communicate with each other. Doctors will know nothing more than you can tell them.

The Reality Behind Those TV Commercials

Those pharmaceutical commercials for agitation medications often feature an aggressive, angry elder who takes a pill and then happily joins a family gathering. What they don't show is the actual day-to-day reality of sundowning.

The truth is that those medications are targeting sundowning behaviors, but they are not the answer for everyone. They're designed to reduce agitation, manage irregular sleep patterns, and help with the behavioral aspects of dementia that are so challenging for both patients and caregivers which makes them sound like a perfect solution.

The reality is each person responds differently. Most Alzheimer/dementia patients have comorbidities - multiple health issues - and take a unique combination of medications for them. These new medications may work for your elder, but it will require you, other caregivers, and their doctor to work together over time - sometimes months to get it right.

The Emotional Hurdle in Medicating Sundowners

One of the most difficult emotional decisions I faced with Rose was accepting that she needed anti-psychotic medication to treat her sundowning. Those words alone - “anti-psychotic" - carried tremendous weight and stigma. This wasn't my loved one with a psychiatric disorder; this was Rose who had been sharp and independent not long ago.

If you're facing this decision now, know that you're not alone in your hesitation. I worried about side effects, about her being "drugged" or losing her personality. I feared I was taking the easy way out.

Let me be absolutely clear: deciding to medicate a loved one for sundowning behaviors is not taking the easy way out. It is often the kindest, most compassionate choice we can make—though it rarely feels that way when you're faced with this decision. I can imagine, it’s even more challenging when you have siblings with different opinions.

The Trial and Error Process

Finding the right medication and dosage requires patience and persistence. There is no one-size-fits-all solution for sundowning. What you don't see in those commercials is the weeks or months of adjustments it may take to find the right balance.

For Rose, the journey wasn't straightforward:

• Some medications made her too sleepy
• Others didn't adequately address her wandering behaviors
• Each environmental change temporarily worsened her symptoms
• It took coordinated efforts between her doctor, care staff, and hospice team to find the right approach

When I hear other caregivers say their loved ones are always sleeping or have undergone dramatic personality changes due to medication, I immediately encourage them to advocate with their doctor. Don't settle. Keep trying different approaches.

Humor Helps

When Rose started night-wandering at her AL and taking the stairs - with her walker - instead of the elevator, the staff would try to redirect her. She would get aggressive, not wanting them to help her. The medical director and I talked about adjusting her medication for sundowning as it obviously wasn’t working anymore.

I was worried that she was going to get tossed out. This happens more often than these facilities report when you’re touring. If your elder has uncontrolled violence or agitation, you will have a hard time finding someplace that will accept them or they will charge you higher rates to monitor your elder.

She suggested a combination of antipsychotics that when I looked them up, seemed like very heavy medications. I was worried they wanted me to drug her into submission. The nurse, a young but experienced director, used a funny LSD reference that landed for me, “Right now, she is having a ‘bad trip’ every night. We need the flowers to sing to her. Let’s find what will give her a ‘good trip’.”
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I never forgot those words. She helped me understand what Rose must be going through. I had to help her and I was the one who could authorize it.
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Once we found the right combination, I could see the difference in her facial muscles. Her brow and eyes relaxed. She was peaceful and able to sleep better. Rose stayed on anti-psychotics until she died. It was the kindest way to minimize her mental pain and suffering.

Beyond Medication: Environmental Strategies

While medication often becomes necessary, there are environmental approaches that can help manage sundowning. Try these first:

• Maintain a predictable daily routine with consistent meal and sleep times
• Ensure adequate lighting in the evening to reduce shadows and confusion
• Limit caffeine, sugar, and alcohol, especially after lunch
• Schedule more challenging activities earlier in the day when cognitive function is typically better
• Create a calm, quiet environment as evening approaches
• Use familiar items, photos, and comfort objects to provide reassurance
• Consider using night lights to reduce disorientation if they wake during the night

The Importance of Documentation and Advocacy

Care staff can only document what they observe during their shifts, but you know your loved one. Your insights are invaluable in developing an effective care plan.

I recommend:

• Taking notes about when sundowning behaviors occur and what seems to trigger them
• Using video in their home or in their AL apartment (with appropriate permissions) to document behaviors
• Bringing specific examples to staff meetings and doctor appointments rather than general complaints
• Being persistent when medication isn't working or is causing concerning side effects
• Building relationships with care staff who can provide consistent updates

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CARE HACK: Cameras

Problem: I needed to monitor Rose’s fall potential and increasingly unusual behaviors even when she lived alone.

Solution: Video was the best technology solution. I used the Kami system with the upgraded account that kept recordings. I set them up for motion detection and watched them daily. Over time, I documented her sundowning pattern and was able to work with her doctor on a solution.

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Sundowning Changes Over Time

What makes sundowning particularly challenging is that it isn't static—it evolves as the underlying cognitive condition progresses. What works today may not work six months from now.

For Rose, her sundowning behaviors changed significantly after each move and after her COVID hospitalization. What started as mild evening confusion eventually became more pronounced. Regular monitoring and willingness to adjust approaches became essential.

When we finally found the right combination of environment and medication, Rose still had her personality—her love of McDonald's Happy Meals, her preference for the color purple, and cheeky comments. She wasn't "drugged"; she was more present, more herself, less tormented by the confusion and fear that sundowning had caused.

Compassion—For Them and Yourself

Remember that sundowning is frightening for your loved one. They aren't being difficult intentionally. Their brain is struggling to process information as fatigue sets in, causing genuine fear and confusion.

Equally important is compassion for yourself. Managing sundowning is emotionally exhausting. The anticipatory grief that comes with watching your loved one's behavior change is real and valid. Take breaks when possible, accept help when offered, and remember that your efforts make a difference even when progress seems slow.

Final Thoughts

If there's one message I want to leave you with, it's this: sundowning can be managed, but it requires recognition, patience, and flexibility. What works for one person may not work for another, and what works today may need adjustment tomorrow.

Proper care for sundowning isn't about convenience for caregivers. It's about dignity and quality of life for our loved ones. It's about allowing them moments of peace in the chaos that dementia creates.

So advocate fiercely. Document behaviors. Work with doctors who specialize in geriatric care and dementia. And don't give up until you find the approach that brings your loved one comfort.

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