Neurological Awareness
Rising Restlessness at Dusk: The Silent Story of Sundowning Syndrome
Ms. Ayşe’s mother was a 78-year-old Alzheimer’s patient. During the day, she was relatively calm; she glanced at newspapers and watched the sky from the window. But when the evening hours arrived, an inexplicable restlessness appeared on her face, and her voice was filled with growing anxiety. "I want to go home!" she’d say, looking for things that weren’t there. This picture, experienced by Ms. Ayşe and many others, points to a phenomenon in medicine known as "sundowning" (evening sundowning syndrome). If you have witnessed this situation in a loved one, you are not alone. So, what lies behind this restlessness, and what can be done about it?
What is Sundowning Syndrome?
Sundowning syndrome defines a group of behavioral and psychological changes that occur especially in people with dementia and Alzheimer’s, during the late hours of the day—afternoon and near night. These changes often include increased restlessness, agitation, irritability, confusion, disorientation, and sometimes aggressive behaviors. Although its exact cause hasn’t been fully explained yet, this phenomenon shapes the lives of millions of patients and their families around the world every year.
Worldwide, approximately 20–45% of dementia patients show signs of sundowning to various degrees.[1] Especially for caregivers of Alzheimer’s patients, one of the most challenging moments is coping with behavioral changes during these hours.
Symptoms of Sundowning Syndrome
Confusion, disorientation (mixing up the time of day or their location)
Anxiety, agitation, rapid speech or deviation from the topic
Restlessness, wandering, aimless movements
Aggression, shouting, or oppositional behaviors
Delusions and sometimes even hallucinations
Difficulty falling asleep, frequent awakenings during the night
Symptoms may vary depending on the individual's characteristics and the progression of dementia.
What Causes Sundowning Syndrome?
Sundowning has complex causes. Scientific studies point to various biological, environmental, and psychosocial factors. Here are the main reasons:
Biological Factors
Circadian Rhythm Disorders: The suprachiasmatic nucleus (SCN) in the hypothalamus of our brain manages the body's biological clock. Dysfunction in this center in dementia patients can make it harder to distinguish between day and night. This can trigger confusion and restlessness in the evening hours.[2]
Reduced Melatonin Production: Melatonin is a hormone that facilitates the onset of sleep at night. In people with dementia, evening secretion of this hormone may decrease, disrupting the sleep-wake cycle.
Environmental and Psychosocial Factors
Decrease in Light and Visual Stimuli: When light levels drop in the evening, it becomes harder for people with dementia to adapt to their environment. Low light can make it more difficult to perceive objects and faces, leading to restlessness.
Fatigue and Accumulated Daytime Stress: The physical and mental fatigue accumulated throughout the day becomes more noticeable in the evening and reduces tolerance.
Changes in Noise and Activity: Activity in the house decreases and the environment becomes quieter in the evening. This change can increase anxiety in people with dementia.
Physiological and Health Conditions
Insufficient hydration (fluid intake)
Low blood sugar levels
Effects or side effects of medications
Infection, pain, constipation, or other medical issues
The above are just the tip of the iceberg. Since every patient has a unique history and current health status, the causes can be personalized. However, science generally agrees that neurobiological vulnerability during the evening and the lack of environmental cues increase sundowning symptoms in adults.
Who Can Experience It?
Although sundowning syndrome is most commonly seen in people suffering from Alzheimer’s and other types of dementia, it can also occur in some healthy older adults—especially if there is severe stress, sleeplessness, or depression. Slightly higher rates have been reported among women with dementia. It also occurs more frequently and more severely in advanced stages of the disease.
Methods for Coping with Evening Restlessness
Now we come to the most important question: How can these uneasy hours be spent more calmly? Recent studies and expert recommendations offer many practical tactics for both caregivers and health professionals.
1. Improving the Daily Routine
Regular Sleep and Wake Times: Creating an unchanging daily schedule is very beneficial for those with dementia. Especially going to bed and waking up at the same time every day supports the body’s biological clock.
Daytime Activities: Short walks, light household chores, or conversations during the day can facilitate falling asleep at night and reduce evening tension.
2. Light Therapy and Environmental Arrangements
Light Therapy: Clinical studies show that exposure to bright light in the morning (2,500–10,000 lux) can reduce sundowning symptoms by up to 26%.[3] This application can be done at home through daylight coming from large windows or with light panels.
Not Lowering Light Levels in the Evening: Keeping lighting a bit brighter as dusk falls can strengthen the patient’s connection with the environment.
Adding Safe and Familiar Elements to the Setting: Use favorite photos, familiar items, and warm-colored lights. It’s important not to change the arrangement.
3. Calming Routines – Evening Rituals
Relaxing Music: Gentle classical music, reading favorite poems.
Herbal Teas and Warm Milk: For many, especially chamomile tea or warm milk can have a calming effect (as long as there’s no allergy!).
Massage, Holding Hands: A simple shoulder massage or holding hands can help them relax.
Ending the Day with a Calming Bath: A warm shower or bath encourages muscle relaxation and facilitates sleep.
4. Reducing Stimuli
Avoiding Caffeine and Sugar: Coffee, tea, or soft drinks consumed in the afternoon can trigger restlessness.
Noise and Crowded Environments: Turning down the TV in the evening and avoiding too many visitors is helpful.
5. Monitoring Illness and Medications
Controlling Chronic Illnesses: Diabetes, infections, or painful conditions can increase night-time restlessness.
Review Medication Dosages: Some medications can trigger agitation. Especially review those given in the evening with your doctor.
6. Empathy and Patience
Sometimes the best thing you can do is to make them feel you’re there, remaining calm and reassuring. Remember that your loved one’s fears are very real to them, even if you know they aren’t. Trying to understand events from their perspective is the most valuable part of the process.
Practical Tips for Caregivers Dealing with Evening Restlessness
Remember that what you’re dealing with stems from the illness, not your loved one themselves. This is not just a behavioral change—it’s a complex biological process.
When restlessness begins, focus on their emotions rather than arguing or “explaining the facts”: "Yes Mom, you’re safe here. I’m here with you."
The room’s temperature and humidity should be appropriate; fear can increase in dim settings.
Allow short naps during the day, but avoid long siestas.
Be sure to set aside time for rest and support for yourself. Burnout among caregivers is very common in this process.
When to Seek Professional Help?
If restlessness during sundowning hours is increasing, or if there are new complaints such as severe aggression, intense fear, or ongoing insomnia, professional support should definitely be sought. Sometimes, an underlying infection, urinary tract disease, or another medical condition may be the sole cause of the behavioral change. Furthermore, getting expert advice on medication adjustments and psychosocial interventions is essential.
Living With Sundowning Syndrome: You Are Not Alone
Dealing with the same restless hours every evening can be a challenging process for both patients and their loved ones. However, this picture can become more manageable with love, patience, and knowledge. Remember, you’re human too. Making problems visible, talking about them, and seeking support are just as valuable for you as they are for your loved one.
At the end of the day, sometimes just sitting quietly next to them can be the most magical remedy.
Table: Main Causes and Solutions for Sundowning Symptoms
Main Cause | Recommended Approach |
|---|---|
Circadian rhythm disorder | Regular sleep-wake routine; morning light therapy |
Melatonin deficiency | Melatonin supplementation under medical supervision |
Light and environmental changes | Good evening lighting, familiar objects |
Fatigue, physical problems | Daytime physical activity, medication checks |
Social and emotional loneliness | Being present, gentle contact, sense of security |
Conclusion: With Awareness, Love, and Patience…
Sundowning syndrome is not a disease, but rather part of a person’s journey. Evening restlessness is an expression of the brain’s struggle with darkness. While supporting them, both scientific knowledge and the warmth of being human can serve as your guide. As with every journey, you don’t have to walk this path alone; there are always various support groups and health professionals for both patients and caregivers.
With small touches, it is possible to create peace—from darkness to light.
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