Crisis Resources
Managing Agitation and Sundowning
Sundowning is not a behavioral choice. It is a neurological phenomenon with identifiable triggers, documented patterns, and evidence-based responses. You are not doing something wrong. The brain is malfunctioning.
What Sundowning Actually Is
Sundowning refers to a pattern of increased confusion, agitation, anxiety, and behavioral disturbance that occurs in the late afternoon and evening hours. It affects 20-66% of people with dementia, and it is one of the most exhausting phenomena caregivers face.
The term is somewhat misleading because it implies the sun going down causes it. The reality is more complex. Sundowning results from the intersection of circadian rhythm disruption (the brain's internal clock is damaged), accumulated fatigue (the damaged brain has been working overtime all day to compensate), reduced sensory input (fading light increases visual confusion), and hormonal shifts (cortisol and melatonin cycles are dysregulated).
This is why it's neurological, not behavioral. The person is not choosing to be difficult at 5 PM. Their brain is running out of compensatory capacity at the end of the day.
Common Triggers
Overstimulation (too much noise, activity, or visual clutter), understimulation (boredom, lack of structure), changes in routine, unfamiliar environments, too much or too little light, temperature discomfort. The late afternoon light shift is a primary trigger for sundowning — as natural light fades, confusion and anxiety increase.
Pain (often unrecognized and unreported), urinary tract infections (UTIs are the #1 medical cause of sudden behavioral change), constipation, dehydration, hunger, medication side effects, vision or hearing changes. Always rule out physical causes first — a person with dementia may not be able to tell you they're in pain.
Feeling rushed, being corrected or argued with, loss of control, frustration at inability to communicate, caregiver stress (they can feel your tension even when they can't understand its cause), loneliness, fear.
Complex questions ("What do you want for dinner?" offers too many choices), abstract language, sarcasm, being spoken about as if not present, raised voices, rapid speech, too many people talking at once.
Home Safety Audit
Identify and fix environmental triggers room by room with our interactive audit.
Environmental Modifications That Help
Lighting
Increase indoor lighting before sunset. Full-spectrum light therapy in the morning (2,500-10,000 lux for 30-120 minutes) has shown modest but consistent benefits in reducing sundowning. Keep nightlights in hallways and bathrooms. Avoid sudden transitions from bright to dark rooms.
Sound
Reduce background noise in the afternoon. Turn off the TV unless they're actively watching. Familiar music from their era (typically ages 15-25) has the strongest calming effect. Avoid sudden loud noises. Consider a white noise machine for nighttime.
Routine
Structure the afternoon with a predictable sequence: light activity, snack, quiet time, dinner. Avoid scheduling appointments, outings, or stimulating activities after 3 PM. The afternoon should wind down, not ramp up. Keep a large-print daily schedule visible.
Temperature and Comfort
Check room temperature (aim for 68-72\u00B0F). Ensure clothing is comfortable and not restrictive. Offer warm beverages (decaffeinated) in the late afternoon. A weighted blanket can provide calming sensory input for some individuals.
Communication During Agitation
When the person is agitated, your communication style matters more than your words. Follow these evidence-based guidelines:
- •Approach from the front, at eye level. Never approach from behind.
- •Use their name. Speak slowly, in short sentences.
- •Match their emotional tone, then gradually shift it calmer.
- •Offer one choice at a time, not multiple options.
- •Use distraction: "Let's go look at the garden" works better than "Please stop pacing."
- •Touch can help or hurt — a gentle hand on the arm works for some; others will escalate. Know your person.
- •If nothing is working, ensure safety and give space. Sometimes the agitation needs to pass on its own.
What NOT to Do
The reasoning centers of the brain are damaged. Logical arguments will not resolve the agitation — they will escalate it. You cannot convince someone out of a delusion or correct a misperception through debate. Validation works; correction does not.
Physical restraint increases agitation, causes injury, and is associated with accelerated decline. If the person is at risk of hurting themselves or others, create space and remove hazards rather than holding them down.
This is easy to say and brutally hard to do. When someone you love calls you names, accuses you of stealing, or says they hate you, it wounds. But these behaviors come from a damaged brain, not from their feelings about you. Recognizing this intellectually doesn't make it hurt less, but it can help you not respond from that hurt.
These words have never calmed anyone in the history of human communication, and they are particularly counterproductive in dementia care. They invalidate the person's experience and can escalate the situation.
The UTI Callout
Sudden behavioral change? Check for a UTI.
Urinary tract infections are the single most common reversible cause of sudden agitation, confusion, and behavioral change in people with dementia. A person who was relatively calm yesterday and is climbing the walls today may have a UTI.
The person with dementia often cannot report the typical symptoms (burning, urgency, frequency). The only sign may be behavioral. If there is a sudden change in behavior, request a urinalysis before assuming it's disease progression. This is one of the few genuinely fixable problems in dementia care.
Medication: An Honest Discussion
Medications for agitation in dementia are controversial, imperfect, and sometimes necessary. Here's what the evidence actually says:
SSRIs (e.g., citalopram, sertraline)
Modest evidence for reducing agitation with a relatively favorable side effect profile. Citalopram showed benefit in the CitAD trial but at doses that carry cardiac risk. Generally considered first-line pharmacological approach.
Trazodone
Often used for sleep and mild agitation. Low side effect burden. Evidence is modest but positive. Many clinicians consider this a reasonable early option.
Brexpiprazole (Rexulti)
First FDA-approved medication specifically for agitation in Alzheimer's (2023). Shows statistically significant reduction in agitation scores. Effect size is modest. Carries atypical antipsychotic risks.
Antipsychotics (olanzapine, risperidone, quetiapine)
Carry an FDA black box warning for increased mortality risk in elderly patients with dementia. Should be a last resort for severe agitation that threatens safety. If used, should be at the lowest effective dose for the shortest possible time. Insist on a geriatric psychiatrist, not a general practitioner, for this decision.
When to Seek Professional Help
- •If agitation is escalating in frequency or intensity over days
- •If there is any risk of physical harm to the person or to you
- •If the behavioral change was sudden (suspect UTI, medication reaction, or pain)
- •If environmental and behavioral strategies have been tried consistently for 2+ weeks without improvement
- •If you are at the point where you dread being in the same room