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De-escalating Nighttime Agitation in Memory Care: A Step-by-Step Guide for Family Caregivers and Staff

Nighttime agitation—often called sundowning—can be frightening and exhausting for everyone involved. It usually happens because the person’s internal clock is disrupted, their brain is tired, and they feel unsafe or confused as light fades. You are not alone, and there are concrete, gentle steps you can take to reduce distress and keep the person calm. This guide gives you exact words to say, actions to try, and warning signs to watch for, whether you are a family member visiting or a staff member on duty.

Key points

  • Nighttime agitation is not intentional; it is a symptom of brain changes and environmental triggers.
  • Always check for physical causes first—pain, hunger, thirst, or the need to use the bathroom.
  • Use a calm, low voice and simple, reassuring phrases. Never argue or correct.
  • Create a calming environment: soft lighting, familiar music, and a consistent routine before sunset.
  • Safety first: do not initiate physical contact during an outburst, and never corner or restrain.
  • Document patterns and share them with the care team to adjust the plan.

What Is Nighttime Agitation and Why Does It Happen?

Nighttime agitation, often called sundowning, is a pattern of increased confusion, restlessness, anxiety, or aggression that typically begins in the late afternoon and continues into the evening. It is not a disease itself but a symptom of the brain changes caused by dementia. As the sun goes down, the person’s internal body clock (circadian rhythm) becomes disrupted, and their brain struggles to process the shift from day to night. They may feel disoriented, unsafe, or overwhelmed by shadows, low light, and the quiet of evening. This can trigger pacing, wanting to ‘go home,’ calling out, or even physical resistance to care.

What Behaviors Might You See?

Common behaviors include increased confusion about time and place—for example, the person may insist it is morning when it is actually 8 p.m. They might pace restlessly, try to leave the facility, or become suspicious of staff or family members. Irritability can escalate into verbal outbursts or physical aggression, such as hitting or pushing. Some people become very anxious, asking repetitive questions or crying. These behaviors are not intentional; they are the person’s way of expressing internal distress they cannot put into words. Understanding this helps you respond with compassion instead of frustration.

Why Does This Happen in a Memory Care Facility?

Memory care facilities often have bright lights, busy hallways, and multiple staff shifts that can be overstimulating during the day. By evening, the environment may become quieter, but the person’s brain is still processing the day’s stimulation. Shadows from closing blinds, unfamiliar sounds, or even the sight of a staff member they do not recognize can trigger fear. Additionally, the person may be in pain, hungry, thirsty, or need to use the bathroom but cannot communicate it. Staff turnover and shift changes can also disrupt the person’s sense of safety. Recognizing these triggers is the first step to preventing agitation.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. 1. Check the environment first. Turn on soft, warm lamps or night lights before sunset. Close blinds to eliminate confusing reflections and shadows. Keep the room at a comfortable temperature. Reduce loud or sudden noises—turn off the TV if it is violent or loud, as the person may think it is real. If they are in a shared room, use a white noise machine or soft music to mask hallway sounds.

  2. 2. Offer a calming, repetitive activity. In the late afternoon, engage the person in a simple, soothing task like folding towels, sorting buttons by color, or looking at a familiar photo album. These repetitive actions help the brain settle. Avoid new or high-energy activities after 3 p.m., such as a bath or a trip to the store.

  3. 3. Use a gentle, reassuring tone and simple language. Approach slowly from the front, make eye contact, and say something like, ‘I’m here with you. You are safe.’ Avoid asking ‘why’ questions. Instead, state what you are doing: ‘Let’s sit down together for a few minutes.’ If they are pacing, walk beside them without blocking their path.

  4. 4. Offer a small snack or warm drink. A light snack like crackers, a piece of fruit, or a warm, non-caffeinated drink (like chamomile tea or warm milk) can redirect attention and soothe anxiety. This works especially well if the person is hungry or thirsty but cannot express it.

  5. 5. Redirect to a different location or activity. If agitation is building, gently guide the person to a different room or a quiet corner. Change the activity—for example, switch from pacing to sitting and listening to calming music. Use a favorite song from their youth to spark a positive memory.

  6. 6. Validate their feelings without arguing. If the person says they want to go home, do not correct them. Instead, say, ‘I know you miss home. Tell me about your home.’ This validates their emotion without triggering a power struggle. If they are angry, say, ‘It’s okay to be upset. I’m here to help.’

  7. 7. Check for physical discomfort. Ask staff if the person has been checked for pain, hunger, thirst, or the need to use the bathroom. People with dementia often cannot say they are in pain. Facilities should use a validated pain assessment tool—ask the nursing team what tool they use. If pain is suspected, discuss with the doctor about appropriate pain relief.

  8. 8. Use sensory calming tools. Offer a weighted blanket, a soft stuffed animal, or a hand massage with lotion. Aromatherapy with lavender or chamomile can also help. These tools provide comfort without medication.

  9. 9. If agitation escalates to aggression, prioritize safety. Do not initiate physical contact—this can escalate the situation. Instead, step back, give the person space, and speak in a calm, low voice. If you feel unsafe, leave the room and call for staff assistance. Never corner, restrain, or argue with the person.

  10. 10. Document the episode. Write down the time, what happened before, what you tried, and what worked. Share this with the care team. Patterns will emerge—for example, agitation may happen after a certain staff shift change or after a particular meal. This information helps the team adjust the care plan.

What not to do

  • Do not argue or correct the person. For example, if they say it is morning, do not say ‘No, it’s 8 p.m.’ This only increases confusion and agitation. Instead, say, ‘It’s evening now, and we are safe here.’

  • Do not raise your voice or show alarm. A loud or panicked tone signals danger to the person’s brain. Keep your voice low and even, even if you feel scared or frustrated.

  • Do not initiate physical contact during an outburst. Touching someone who is agitated can be perceived as a threat and may trigger a physical reaction. Wait until they have calmed down before offering a hand or a hug.

  • Do not try to restrain or corner the person. This can make them feel trapped and escalate aggression. Instead, give them space and a clear path to move away if they want.

  • Do not ignore the possibility of pain or medical issues. Agitation can be a sign of a urinary tract infection, constipation, or medication side effects. Always rule out physical causes before assuming it is purely behavioral.

  • Do not blame yourself or the person. This behavior is not intentional. It is a symptom of brain changes. Guilt and frustration only add to your stress. Take a break if you need one—respite care is available.

Practical tools

  • Calming Phrases for Nighttime Agitation

    Use these exact phrases in a soft, slow voice: ‘You are safe. I am here with you.’ ‘Let’s take a deep breath together.’ ‘I know this is hard. I’m going to help you.’ ‘Would you like to sit with me for a minute?’ ‘It’s okay to feel upset.’ Avoid questions that start with ‘why’ or ‘remember.’ Stick to simple, reassuring statements.

  • Nighttime Environment Checklist

    Before 4 p.m., do this: (1) Turn on soft lamps or night lights. (2) Close blinds to reduce shadows. (3) Remove clutter from the floor to prevent falls. (4) Set a white noise machine or play calming music (nature sounds, classical, or a favorite old song). (5) Ensure the room is warm enough but not hot. (6) Place a glass of water and a small snack nearby. (7) Remove any sharp objects or medications from reach.

  • Pain Assessment Tool for Non-Verbal Patients

    Ask the memory care facility what pain assessment tool they use. Common ones include the PAINAD (Pain Assessment in Advanced Dementia) scale or the Abbey Pain Scale. These tools look at facial expressions, body movements, vocalizations, and changes in behavior. If they cannot name a tool, that is a red flag—advocate for a proper pain check with the nursing team.

  • Sensory Calming Kit

    Assemble a small basket with: a lavender-scented hand lotion, a soft stuffed animal or weighted lap pad, a pair of noise-canceling headphones, a small photo album of familiar faces, and a playlist of soothing music from the person’s young adult years. Keep this kit in the person’s room and use it at the first sign of restlessness.

  • Daily Routine Chart for Staff and Family

    Create a simple one-page chart that lists the person’s preferred calming activities, favorite songs, known triggers (e.g., loud TV, certain staff members), and what has worked before. Post it in the room and in the staff break room. Update it weekly based on what you observe.

  • De-escalation Script for Staff

    When a resident becomes agitated, staff should: (1) Stop what they are doing and give full attention. (2) Use a low, slow voice. (3) Say, ‘I see you are upset. I want to help.’ (4) Offer a choice between two simple options: ‘Would you like to sit in the chair or walk with me?’ (5) If the person is pacing, walk beside them without talking for a few minutes. (6) Never block their path or touch them without warning.

Discuss with your clinician

Ask the doctor: Could a urinary tract infection, constipation, or dehydration be causing the agitation? These are common and treatable.

Ask the doctor: Could any of the current medications (including over-the-counter or supplements) be causing side effects like increased confusion or restlessness? A medication review is essential.

Ask the doctor: Is melatonin or light therapy appropriate for this person? Do not start any supplement without medical guidance.

Ask the doctor: If non-drug strategies are not enough, what are the risks and benefits of a low-dose medication for agitation? Discuss specific options like trazodone or certain antipsychotics, and monitor closely for side effects.

Ask the doctor: How often should we reassess the person’s pain and discomfort? Request a pain assessment tool be used daily.

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