Agitated at Dusk and Asking to "Go Home"? Causes and Non-Drug Management of Sundowning in Dementia

Many carers have had the same experience. The older adult is fairly calm in the daytime, but at dusk or in the early evening seems a different person: restless, pacing up and down, unable to tell where they are, and asking again and again to "go home" even when they are at home. This confusion and unease that appears or gets worse around sunset is called "sundowning" clinically. It is confusing and tiring for the family, but it is not without explanation. The causes mostly come from a disturbed body clock (circadian rhythm), together with the older adult being worn out after a whole day. This article explains the causes of evening agitation and, around the three directions of light, a regular routine and daytime activity, sets out the clinical evidence and practical methods of non-drug management in occupational therapy.

What is sundowning? Recognising evening agitation

Sundowning refers to the neuropsychiatric symptoms that appear or get worse in people with dementia at dusk, in the early evening or after dark. Common signs include agitation, confusion, anxiety, irritability and even aggression. It should be noted that this is a descriptive term and not a formal DSM diagnosis. For this reason, the definitions and assessment tools used differ between studies, and the reported prevalence varies widely (Reimus & Siemiński, 2025).

TimingSymptoms usually appear or get clearly worse from dusk into the early evening, and sometimes continue into the night. The person's state in the daytime is more settled.

Mood and behaviourThe main signs are restlessness, a short temper and anxiety, and in severe cases aggressive behaviour may appear.

DisorientationThe person loses track of time, place and surroundings, and often asks again and again to "go home" or wants to go out into the street.

Not a formal diagnosis"Sundowning" is a name used to describe a clinical phenomenon and not a formal DSM medical diagnosis, so the proportion of patients recorded varies greatly between studies (Reimus & Siemiński, 2025).

Prevalence and common symptoms of sundowning

Because there is no agreed standard for defining and assessing sundowning, the range of prevalence reported across studies is very wide. Looking at individual studies that used consistent assessment criteria, however, shows clearly how common it is and what it typically looks like.

1.6%–66%

Range of prevalence recorded in different studies

The data differ greatly between studies because the diagnostic criteria and assessment methods differ (Reimus & Siemiński, 2025)

21.2%

Prevalence recorded in a single study

Of 184 patients, 39 had sundowning (Toccaceli Blasi et al., 2023)

Agitation 56.4%

The most common symptom

Followed by irritability (53.8%) and anxiety (46.2%) (Toccaceli Blasi et al., 2023)

This study of 184 people with dementia found that about one in five (21.2%) had sundowning, with agitation, irritability and anxiety as the main signs. The study also found that patients with sundowning were generally older, had more advanced decline in cognition and physical function, woke more often in the middle of the night, more often had hearing problems, and more often took anticholinergic medicines and antipsychotics (Toccaceli Blasi et al., 2023). This shows that evening agitation is not a single event. It is often tied up with the overall level of decline, sleep disturbance and medicines.

Why does it happen at dusk? Four main reasons

"Why does it only start at dusk?" is the question carers ask most often. There is not one single cause behind it. It is the result of several factors acting together: degeneration of the body clock in the brain, a "flattened" day-night rhythm, the older adult's energy being used up over the whole day, and changes in the environment around evening. Together they push the confusion to its peak.

Degeneration of the body clock

The part of the brain that controls the body clock (the suprachiasmatic nucleus of the hypothalamus) degenerates
The day-night rhythm of the body clock becomes less marked, and day and night are hard to tell apart
Less melatonin is released, so the body's signals for "time to sleep" and "time to get up" become weaker
Source: Khachiyants et al., 2011

Energy used up after a whole day

During the day the patient has already spent a lot of mental effort on recognising the surroundings and controlling mood
By the evening the patient is already very tired, and the ability to control mood and behaviour falls too
The sleep-wake pattern is disturbed, which makes confusion worse
Source: Khachiyants et al., 2011

Research data on a disturbed body clock

Activity in the day is low, while the proportion of activity at night is high
The time of day with the highest activity has shifted later
The severity of symptoms is closely related to a later peak of the body temperature rhythm
Source: Volicer et al., 2001

The evening environment

As it gets dark and there is not enough light indoors, shadows form and the patient may misread things
The body is tired and hungry but dinner is not ready yet
The surroundings are too noisy, or there is too much sensory stimulation, such as a television turned up loud
Source: Reimus & Siemiński, 2025

Research findings on a disturbed body clock

Evening agitation may sound like a subjective mood swing, but there are objective physiological data to support it. One study directly measured core body temperature and activity in 25 patients with Alzheimer's disease and 9 healthy controls to look at the circadian rhythm. It found that the Alzheimer's patients were less active in the day, had a higher proportion of activity at night, and showed a tendency for the peak of activity to be delayed. The severity of sundowning was closely linked to a delayed peak of the temperature rhythm, a lower correlation of the temperature rhythm with the 24-hour cycle, and a narrower amplitude of the temperature curve (Volicer et al., 2001).

In terms of physiological mechanism, this fits with degeneration of the suprachiasmatic nucleus of the hypothalamus (the body clock of the brain), a circadian rhythm that tends to be "flat", and reduced release of melatonin (Khachiyants et al., 2011). In other words, the idea that "evening agitation comes from a disturbed circadian rhythm" rests on measurable physiological evidence and is not just speculation. This also explains why non-drug interventions often start with "stabilising the body clock".

Depleted energy and the effect of the evening environment

Besides the body clock, another key clue is "energy". People with dementia use a lot of cognitive resources in the day to keep their bearings in the surroundings and control their mood. By the evening, the energy is used up, and together with a disturbed sleep-wake cycle this magnifies the confusion further (Khachiyants et al., 2011). If the environmental stimulation common in the evening is added at this point, mood can easily flare up. The triggers below deserve special attention in care.

Dimming light—At dusk the light indoors is dimmer and casts shadows, which makes the older adult misread things and become more unsure where they are.
Tiredness and hunger—After a whole day the older adult is already very tired, and with dinner not yet served, being hungry and tired makes a short temper more likely.
Disturbed sleep—When day and night are reversed and the older adult wakes often at night, sleep problems and evening agitation affect each other.
Too much stimulation—Too much noise, a loud television, or family members busy with housework in the evening all make the older adult more unsettled.

Non-drug occupational therapy approaches and the research evidence

Before setting out the specific methods, it helps to look at the current clinical evidence. An analysis pooling 11 randomised controlled trials with 648 people with dementia found that light therapy reduces the number of times the person wakes in the night and helps sleep a little (statistically significant), but its effect on agitation and depression was not clear (not statistically significant) (Fong et al., 2023). A Cochrane review also pointed out that the current evidence is not yet enough to support routine bright light therapy for people with dementia (Forbes et al., 2014). These non-drug methods carry very low risk and can be tried in daily care, but families should also understand that they help sleep more, while the effect on agitation varies from person to person, and they are not a cure-all.

On this basis, when an occupational therapist plans a non-drug programme, the focus is on three measures that are easy to carry out in daily life and carry very low risk: stabilising the body clock through light, building a regular and predictable daytime routine with activities, and improving the home environment in the evening. They are set out one by one below.

Light strategy: natural light in the day and light therapy

Since evening agitation is linked to a "flattened" circadian rhythm, using light to widen the contrast between day and night is a reasonable direction for intervention. A randomised controlled trial in the Netherlands, carried out in 12 care facilities with 189 older residents (average age 85.8, of whom 87% had dementia) for up to 3.5 years, found that all-day bright light (that is, stronger daytime lighting indoors) helped to slow cognitive decline, ease depressive symptoms and slow the worsening of limits in daily function. When combined with melatonin, it also reduced aggressive behaviour, raised sleep efficiency and improved night-time agitation, which shows that using light to stabilise the circadian rhythm brings real benefit (Riemersma-van der Lek et al., 2008).

The overall research results are not one-sided, however. A meta-analysis showed that light therapy reduces night waking and helps sleep by a small but significant amount, but its effect on agitation and depression did not reach statistical significance (Fong et al., 2023). The Cochrane review likewise considered the evidence insufficient to support routine use, noting that light therapy showed no clear benefit for cognition, sleep, challenging behaviour (such as agitation) or psychiatric symptoms, and that only a single study suggested it might help to delay the decline in activities of daily living (ADL) (Forbes et al., 2014). A more practical compromise is therefore to let the older adult have more natural light in the day and to keep rooms well lit, seeing this as a supporting part of stabilising the body clock. It is easy to do and low in risk, but it should not be treated as the only solution.

Building a regular daytime routine and daily activities

Compared with light alone, arranging the whole day's activities to follow the circadian rhythm is a direction with more certainty. The Healthy Patterns randomised controlled trial (209 pairs of patients and carers at home) was designed around this. Patients did cognitive activities in the morning, physical activities in the afternoon and sensory relaxation activities in the evening, carried out by the carer at home for four weeks. The patients' quality of life improved significantly, and in the subgroup of patients with depressive symptoms or poorer sleep quality to begin with, subjective sleep quality also improved significantly (Hodgson et al., 2023). Considering that more than 60% of people with dementia are troubled by sleep disorders, resetting the sleep-wake cycle through regular, timed daily activities is an intervention that suits the patient's needs well.

1
Morning: cognitive activity
When the older adult is at their best in the morning, arrange activities that use the mind, such as looking at old photos or sorting simple objects, with plenty of natural light to help start the body clock for the day.
2
Afternoon: physical activity
In the afternoon, arrange physical activities such as a walk or simple housework, so that the body uses up some energy and sleepiness is kept for the night, while avoiding too long a nap in the day.
3
Evening: sensory relaxation
Around dusk, when agitation tends to start, play soft music early or do some relaxing sensory activity, to help the older adult stay calm.
4
Fixed routine: a predictable rhythm
Keep the times of meals, activities and going to bed as fixed as possible every day. With enough light in the day, this slowly helps to restore a normal sleep pattern.

Improving the home environment in the evening

Evening agitation is often set off by small changes in the environment, so "preparing the environment beforehand" works much better than "trying to talk the person down after an episode". Carers can use the checklist below to review the home before the high-risk time in the evening.

Evening environment checklist

Draw the curtains and turn on the lights before it gets dark, to reduce shadows indoors and stop the older adult misreading things
Turn down the volume indoors and reduce stimulation, for example by switching off a noisy television
Avoid heavy housework in the evening, and avoid receiving visitors
Arrange relaxing activities, such as listening to soft music, looking at old photos or doing simple sensory activities
Serve dinner a little earlier, so the older adult does not lose their temper from being hungry and tired
Keep meals and bedtime at fixed times every day, so the older adult gets used to a regular rhythm of life

Guide for carers: a daily timetable

Bringing all the methods above together, the core idea is to "buy a calm evening with good arrangements in the day". The checklist below puts together a daily care list from morning to night that suits use at home. The idea behind it rests on clinical evidence that timed activity and light help to stabilise the body's rhythms (Hodgson et al., 2023; Riemersma-van der Lek et al., 2008; Reimus & Siemiński, 2025).

Daily routine

Let the older adult have as much natural light as possible in the day and keep the home bright, so the difference between day and night light is clearer
Arrange suitable daily activities in the morning and in the afternoon, so the older adult has things to do in the day
Do not let the older adult nap too long in the day, and keep the sleepiness for the night
Turn on the lights and draw the curtains before dark, to avoid the dimming sky making the older adult uneasy
In the evening, switch to low-stimulation, relaxing activities and have dinner a little earlier
When the older adult insists on "going home", go along with their feelings as far as possible and calm them, and do not argue or correct them by force, which only makes things worse
Keep a fixed daily routine, so the older adult knows what to expect and feels more secure

When to ask a professional for an assessment

If an older adult suddenly shows evening agitation, or gets clearly worse in a short time, first check whether the body is uncomfortable, for example pain, constipation, infection or medicine side effects, because these may be the real cause of the agitation (Toccaceli Blasi et al., 2023). If the family has tried non-drug methods without much effect, or the older adult's behaviour may hurt themselves or others, a healthcare professional should assess. Whether medicine is needed (especially an antipsychotic) must be weighed carefully by a doctor, and it should not be the first choice for managing behaviour problems. An occupational therapist can also visit and observe the older adult in the evening at home, help the family find the details in the environment that set off the agitation, and work with them to draw up a suitable non-drug plan (Forbes et al., 2014).

Key points

Sundowning refers to the confusion, agitation and anxiety that appear or get worse in people with dementia from dusk into the evening. Because it is a name for a clinical phenomenon and not a formal medical diagnosis, the proportion of patients recorded varies greatly between studies (1.6%–66%) (Reimus & Siemiński, 2025).
Research shows that evening agitation has real physiological causes. Patients with Alzheimer's disease are less active in the day and have a higher proportion of activity at night, the daily peak of activity shifts later, and the severity of symptoms is closely linked to a later peak of the body temperature rhythm (Volicer et al., 2001).
Enough bright light in the day helps to slow cognitive decline, ease depression and slow the decline in self-care ability. Used together with melatonin, it can also reduce aggressive behaviour, improve sleep efficiency and reduce agitation at night (Riemersma-van der Lek et al., 2008).
The clinical results for light therapy are not entirely consistent. It helps a little to improve sleep (less waking in the night), but its effect on easing agitation and depression did not reach statistical significance (Fong et al., 2023). The Cochrane review also considered the current evidence insufficient to support routine recommendation (Forbes et al., 2014).
Arranging each day's activities around the body clock (cognitive activity in the morning, physical activity in the afternoon, relaxing sensory activity in the evening) can clearly raise the patient's quality of life and improve the subjective sleep quality of patients with depression or sleep problems (Hodgson et al., 2023).
Improving the home environment in the evening (turn lights on early to reduce shadows, lower noise, arrange relaxing activities, keep a fixed routine), together with less napping in the day, carries very low risk and is an important part of everyday non-drug management.

Frequently asked questions

Does sundowning always need medication?

Not necessarily. International guidelines advise using non-drug methods first, such as setting up a regular routine, increasing daytime activity and light exposure, and improving the home environment in the evening. Because medicines (especially antipsychotics) carry clear risks for older adults with dementia, a doctor usually considers prescribing only when non-drug measures are not enough and there are safety concerns. If an older adult's evening agitation appears suddenly or worsens sharply, reversible triggers such as pain, constipation, infection or medicine side effects should be checked for first (Forbes et al., 2014; Toccaceli Blasi et al., 2023).

Does light therapy really work?

The current clinical evidence can be described as promising but mixed. A meta-analysis showed that light therapy reduces night-time waking and has a small but statistically significant effect on sleep, but the effect on agitation and depression did not reach statistical significance. The Cochrane review also considered the evidence insufficient to recommend it routinely. In practical care, however, increasing natural light in the daytime and keeping rooms bright in the day is simple and low risk, and can be one part of stabilising the body clock, though it should not be seen as a cure-all (Fong et al., 2023; Forbes et al., 2014; Riemersma-van der Lek et al., 2008).

If the older adult sleeps more in the day, will the evening be better?

Often the opposite is true. Too much napping in the day weakens the contrast between day and night rhythms and makes it harder for the older adult to sleep at night, which can make evening agitation worse. A better approach is to arrange purposeful activities of a suitable intensity in the day, with plenty of light, and to limit daytime napping, so that tiredness is kept for the night and the sleep-wake cycle can get back on track (Hodgson et al., 2023; Riemersma-van der Lek et al., 2008).

How can the evening environment be arranged to reduce agitation at dusk?

Before it gets dark, draw the curtains and turn on the lights indoors to reduce shadows that can cause misperceptions. Turn down the volume and other stimulation (for example switch off a noisy television), and avoid heavy housework in the evening. This time can be used for calming things such as soft music, looking at old photos or simple sensory activities. Keep mealtimes and bedtime fixed every day, to give the older adult a predictable rhythm of life (Hodgson et al., 2023; Reimus & Siemiński, 2025).

Managing sundowning is only one part of the daily care of a person with dementia. Readers may first look at the overall picture in occupational therapy for cognitive impairment to learn about cognitive training and the approaches to behavioural and psychological symptoms (BPSD). They can also read on about other common care difficulties, including wandering in dementia (its causes and occupational therapy intervention) and difficulty eating and refusing food in dementia (occupational therapy approaches).