Table of ContentsView AllTable of ContentsWhat Is Sundowning?Can Medications Worsen Sundowning and Dementia?Anticholinergic Medications and SundowningBenzodiazepinesOther Factors That Trigger SundowningMedications and Supplements for SundowningWhen to See a Provider
Table of ContentsView All
View All
Table of Contents
What Is Sundowning?
Can Medications Worsen Sundowning and Dementia?
Anticholinergic Medications and Sundowning
Benzodiazepines
Other Factors That Trigger Sundowning
Medications and Supplements for Sundowning
When to See a Provider
Sundowningrefers to a number of behaviors, feelings, and thoughts that people withdementiamay experience toward the end of the day, such as in the late afternoon or evening. During sundowning, these individuals may have more anxiety, agitation, confusion, and sleeping problems.
This article discusses what you should know about sundowning, including contributing medications, triggers, and treatment options.
Getty Images /Bloomberg/ Contributor
Sundowningisn’t a disease. Instead, it’s a group of symptoms or behaviors that people with dementia—likeAlzheimer’s disease—may experience.In these individuals, sundowning tends to happen toward the end of the day and at night when it gets dark.
Some sundowning symptoms or behaviors may include more difficulty with the following:
A Word From VerywellIf you’re a caregiver of an older adult with dementia or Alzheimer’s, you may feel overwhelmed, especially if your loved one experiences sundowning. You might be able to help ease the symptoms of sundowning with some environmental, lifestyle, or medication changes.—MARY CHOY, PHARMD, MEDICAL EXPERT BOARD
A Word From Verywell
If you’re a caregiver of an older adult with dementia or Alzheimer’s, you may feel overwhelmed, especially if your loved one experiences sundowning. You might be able to help ease the symptoms of sundowning with some environmental, lifestyle, or medication changes.—MARY CHOY, PHARMD, MEDICAL EXPERT BOARD
If you’re a caregiver of an older adult with dementia or Alzheimer’s, you may feel overwhelmed, especially if your loved one experiences sundowning. You might be able to help ease the symptoms of sundowning with some environmental, lifestyle, or medication changes.
—MARY CHOY, PHARMD, MEDICAL EXPERT BOARD
In older adults, an altered (changed) part of the brain is linked to sleep-wake cycle medical conditions. People with conditions like Alzheimer’s disease also experience these changes, among others, which may disturb the sleep-wake cycle and lead to behavior problems. Certain medications may worsen these issues.
According to a 2023 study, however, the risk of dementia and Alzheimer’s disease increases with a higher usage or number of anticholinergic drugs taken.
Examples of anticholinergic drugs include:
This isn’t a complete list of anticholinergic medications. If you’re unsure whether your medication is an anticholinergic drug, talk to a healthcare provider or pharmacist.
Though benzodiazepines might have several uses, older adults should avoid these medications.
Older adults experience changes to a part of the brain connected to sleep-wake cycle medical conditions. People with Alzheimer’s disease also experience similar changes—in addition to alterations in other parts of the brain—that interrupt the sleep-wake cycle and result in behavioral problems.
Hypnotic medications—like benzodiazepines—might worsen these concerns.In fact, benzodiazepine use is linked to uninhibited behaviors, brain function decline, and agitation in older adults.
Benzodiazepine examples includeXanax (alprazolam)and Versed (midazolam).
This isn’t a complete list of benzodiazepines. If you’re unsure whether your medication is a benzodiazepine, talk to a healthcare provider or pharmacist.
Aside from medications, other factors may trigger sundowning. Some examples may include:
Sundowning is likely an interplay of several factors, and this isn’t a complete list of possible triggers.
There are treatment options for sundowning. Treatment choices may include:
Melatonin
Melatonin is a naturally occurring hormone that your brain makes when it gets dark.It’s important in regulating your sleep-wake cycle. These levels are lower in older adults and people with certain conditions like Alzheimer’s disease. This is the logic behindmelatoninsupplementation in people who have a disrupted sleep-wake cycle. However, more high-quality clinical trials to confirm this are necessary.
Cholinesterase Inhibitors
Brain cells transfer information to each other using several naturally occurring chemicals, including acetylcholine. Some researchers believe a disruption of acetylcholine-related transfer of information in the brain might interfere with the sleep-wake cycle and lead to behavioral problems.
In fact, cholinesterase inhibitors that block acetylcholine breakdown showed fewer behavioral issues in people with dementia.
However, there is conflicting data when it comes to these medications' effects on sleep conditions, sleep-wake cycle changes, and sundowning-related behavioral problems in people with Alzheimer’s disease and other forms of dementia.
One example of a cholinesterase inhibitor is Aricept (donepezil).
Antipsychotics
Examples of antipsychotics include Haldol (haloperidol), Seroquel (quetiapine), and Risperdal (risperidone).
Antipsychotic medications are often taken for sundowning. However, most clinical trials primarily focus ondelusions,hallucinations, and agitation—not sundowning specifically.What’s more, experts typically avoid antipsychotic use due to a higher risk ofstroke, a faster rate of declining brain function, and death in people with dementia.
Hypnotics
Hypnotic (sleep-inducing) medications may include benzodiazepines, such as Ativan (lorazepam). Though these medications have been taken for sundowning, little data supports this use. Though it sounds contradictory, these medications may also exacerbate behavioral issues.
Antidepressants
In a 2021 review article, the authors presented an approach to appropriately treat acute (short-term) and chronic (long-term) agitation.This treatment approach mentioned several different medications, including the followingantidepressants:
Though agitation is a symptom of sundowning, this treatment approach didn’t directly address sundowning.
When to See a Healthcare Provider
If you’re caring for a loved one who experiences sundowning, you might wonder when to see a healthcare provider. When it comes to sundowning, experts typically recommend trying nondrug options first.This may include the following:
If these nondrug tips aren’t helpful, talk with a healthcare provider. A healthcare provider might help identify other potential sundowning triggers, such as pain or certain medications.The healthcare provider might also recognize some medical conditions that may worsen sleeping problems. Examples may include aurinary tract infection (UTI),restless leg syndrome, andsleep apnea.
Summary
Sundowning isn’t a medical condition. Instead, it’s a group of symptoms and behaviors that people with dementia may experience when it gets darker toward the end of the day.
Though the exact cause of sundowning isn’t clear, an interplay of multiple factors may trigger it. For example, certain medications may worsen sundowning.
Other than identifying and removing triggers, there are nondrug ways to help prevent and manage sundowning. If the nondrug tips aren’t enough, reach out to a healthcare provider who may recognize other sundowning triggers, like certain medications and medical conditions.
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16 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.MedlinePlus.Dementia — behavior and sleep problems.Menegardo CS, Friggi FA, Scardini JB, et al.Sundown syndrome in patients with Alzheimer’s disease dementia.Dement Neuropsychol. 2019;13(4):469-474. doi:10.1590/1980-57642018dn13-040015Canevelli M, Valletta M, Trebbastoni A, et al.Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.Front Med (Lausanne). 2016;3:73. doi:10.3389/fmed.2016.00073Alzheimer’s Association.Sleep issues and sundowning.Gray SL, Anderson ML, Dublin S, et al.Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study.JAMA Intern Med. 2015;175(3):401-7. doi: 10.1001/jamainternmed.2014.7663López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L.Anticholinergic drugs in geriatric psychopharmacology.Front Neurosci. 2019;13:1309. doi:10.3389/fnins.2019.01309Poonawalla IB, Xu Y, Gaddy R, et al.Anticholinergic exposure and its association with dementia/Alzheimer’s disease and mortality in older adults.BMC Geriatr. 2023; 23(401). doi:10.1186/s12877-023-04095-7Carrarini C, Russo M, Dono F, et al.Agitation and dementia: prevention and treatment strategies in acute and chronic conditions.Front Neurol. 2021;21. doi:10.3389/fneur.2021.644317Holden RJ, Srinivas P, Campbell NL, et al.Understanding older adults' medication decision making and behavior: a study on over-the-counter (OTC) anticholinergic medications.Res Social Adm Pharm. 2019;15(1):53-60. doi:10.1016/j.sapharm.2018.03.002MedlinePlus.Oxybutynin.Kamell A, Smith LK.Attitudes toward use of benzodiazepines among U.S. hospice clinicians: survey and review of the literature.J Palliat Care. 2016;19(5):516-522. doi:10.1089/jpm.2015.0376National Institute on Aging.Tips for coping with sundowning.Canevelli M, Valletta M, Trebbastoni A, et al.Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.Front Med (Lausanne). 2016;3:73. doi:10.3389/fmed.2016.00073National Center for Complementary and Integrative Health.Melatonin: What you need to know.The American Geriatrics Society.A pocket guide to the 2023 AGS Beers criteria.MedlinePlus.Mirtazapine.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
MedlinePlus.Dementia — behavior and sleep problems.Menegardo CS, Friggi FA, Scardini JB, et al.Sundown syndrome in patients with Alzheimer’s disease dementia.Dement Neuropsychol. 2019;13(4):469-474. doi:10.1590/1980-57642018dn13-040015Canevelli M, Valletta M, Trebbastoni A, et al.Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.Front Med (Lausanne). 2016;3:73. doi:10.3389/fmed.2016.00073Alzheimer’s Association.Sleep issues and sundowning.Gray SL, Anderson ML, Dublin S, et al.Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study.JAMA Intern Med. 2015;175(3):401-7. doi: 10.1001/jamainternmed.2014.7663López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L.Anticholinergic drugs in geriatric psychopharmacology.Front Neurosci. 2019;13:1309. doi:10.3389/fnins.2019.01309Poonawalla IB, Xu Y, Gaddy R, et al.Anticholinergic exposure and its association with dementia/Alzheimer’s disease and mortality in older adults.BMC Geriatr. 2023; 23(401). doi:10.1186/s12877-023-04095-7Carrarini C, Russo M, Dono F, et al.Agitation and dementia: prevention and treatment strategies in acute and chronic conditions.Front Neurol. 2021;21. doi:10.3389/fneur.2021.644317Holden RJ, Srinivas P, Campbell NL, et al.Understanding older adults' medication decision making and behavior: a study on over-the-counter (OTC) anticholinergic medications.Res Social Adm Pharm. 2019;15(1):53-60. doi:10.1016/j.sapharm.2018.03.002MedlinePlus.Oxybutynin.Kamell A, Smith LK.Attitudes toward use of benzodiazepines among U.S. hospice clinicians: survey and review of the literature.J Palliat Care. 2016;19(5):516-522. doi:10.1089/jpm.2015.0376National Institute on Aging.Tips for coping with sundowning.Canevelli M, Valletta M, Trebbastoni A, et al.Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.Front Med (Lausanne). 2016;3:73. doi:10.3389/fmed.2016.00073National Center for Complementary and Integrative Health.Melatonin: What you need to know.The American Geriatrics Society.A pocket guide to the 2023 AGS Beers criteria.MedlinePlus.Mirtazapine.
MedlinePlus.Dementia — behavior and sleep problems.
Menegardo CS, Friggi FA, Scardini JB, et al.Sundown syndrome in patients with Alzheimer’s disease dementia.Dement Neuropsychol. 2019;13(4):469-474. doi:10.1590/1980-57642018dn13-040015
Canevelli M, Valletta M, Trebbastoni A, et al.Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.Front Med (Lausanne). 2016;3:73. doi:10.3389/fmed.2016.00073
Alzheimer’s Association.Sleep issues and sundowning.
Gray SL, Anderson ML, Dublin S, et al.Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study.JAMA Intern Med. 2015;175(3):401-7. doi: 10.1001/jamainternmed.2014.7663
López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L.Anticholinergic drugs in geriatric psychopharmacology.Front Neurosci. 2019;13:1309. doi:10.3389/fnins.2019.01309
Poonawalla IB, Xu Y, Gaddy R, et al.Anticholinergic exposure and its association with dementia/Alzheimer’s disease and mortality in older adults.BMC Geriatr. 2023; 23(401). doi:10.1186/s12877-023-04095-7
Carrarini C, Russo M, Dono F, et al.Agitation and dementia: prevention and treatment strategies in acute and chronic conditions.Front Neurol. 2021;21. doi:10.3389/fneur.2021.644317
Holden RJ, Srinivas P, Campbell NL, et al.Understanding older adults' medication decision making and behavior: a study on over-the-counter (OTC) anticholinergic medications.Res Social Adm Pharm. 2019;15(1):53-60. doi:10.1016/j.sapharm.2018.03.002
MedlinePlus.Oxybutynin.
Kamell A, Smith LK.Attitudes toward use of benzodiazepines among U.S. hospice clinicians: survey and review of the literature.J Palliat Care. 2016;19(5):516-522. doi:10.1089/jpm.2015.0376
National Institute on Aging.Tips for coping with sundowning.
National Center for Complementary and Integrative Health.Melatonin: What you need to know.
The American Geriatrics Society.A pocket guide to the 2023 AGS Beers criteria.
MedlinePlus.Mirtazapine.
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