People living with Alzheimer's and other dementia may have problems sleeping or experience increased confusion, anxiety, agitation, pacing and disorientation beginning at dusk and continuing throughout the night (referred to as sundowning). Although the exact cause is unknown, these changes result from the disease’s impact on the brain.

Factors that may contribute to sleep disturbances and sundowning

  • Mental and physical exhaustion from a full day trying to keep up with an unfamiliar or confusing environment.
  • An upset in the "internal body clock," causing a biological mix-up between day and night.
  • Reduced lighting can increase shadows and may cause the person living with the disease to misinterpret what they see and, subsequently, become more agitated.
  • Nonverbal behaviors of others, especially if stress or frustration is present, may inadvertently contribute to the stress level of person living with Alzheimer’s.
  • Disorientation due to the inability to separate dreams from reality when sleeping.
  • Less need for sleep, which is common among older adults.

Tips that may help manage sleep issues and sundowning

  • Get plenty of rest so you’re less likely to exhibit unintended nonverbal behavior.
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    Schedule activities such as doctor appointments, trips and bathing in the morning or early afternoon hours when the person living with dementia is more alert.
  • As much as possible, encourage a regular routine of waking up, meals and going to bed. 
  • When possible and appropriate, include walks or time outside in the sunlight.
  • Make notes about what happens before sundowning events and try to identify triggers.
  • Reduce stimulation during the evening hours (i.e., TV, doing chores, loud music, etc.). These distractions may add to the person’s confusion.
  • Offer a larger meal at lunch and keep the evening meal lighter.
  • Keep the home well lit in the evening. Adequate lighting may reduce the person’s confusion.
  • Do not physically restrain the person; it can make agitation worse.
  • Try to identify activities that are soothing to the person, such as listening to calming music, looking at photographs or watching a favorite movie.
  • Take a walk with the person to help reduce his or her restlessness.
  • Talk to the physician about the best times of day for taking medication.
  • If the person has trouble sleeping at night, it can be helpful to limit daytime naps.
  • Reduce or avoid alcohol, caffeine and nicotine, which can all affect ability to sleep.
  • When behavioral interventions and environmental changes do not work, discuss the situation with your doctor.

Talk to a doctor about sleep issues

Discuss sleep disturbances with a doctor to help identify causes and possible solutions. Physical ailments, such as urinary tract infections or incontinence problems, restless leg syndrome or sleep apnea, can cause or worsen sleep problems. For sleep issues due primarily to Alzheimer's disease, most experts encourage the use of non-drug measures rather than medication. In some cases when non-drug approaches fail, medication may be prescribed for agitation during the late afternoon and evening hours. Work with the doctor to learn the risks and benefits of medication before making a decision.

If the person is awake and upset

  • Approach him or her in a calm manner.
  • Find out if there is something he or she needs.
  • Gently remind him or her of the time.
  • Avoid arguing.
  • Offer reassurance that everything is all right.
  • Don't use physical restraint. Allow the person to pace back and forth, as needed, with supervision.