Sundowning Syndrome in United States: Symptoms, Causes & Treatment | aihealz
Geriatricsmoderate
Sundowning Syndrome.Care & specialists in United States
In United States, sundowning Syndrome is managed by geriatricss. Sundowning syndrome is a cluster of behavioral and psychological symptoms — increased agitation, confusion, restlessness, calling out, wandering, and resistance to care — that emerges in the late afternoon and evening in roughly 20-45% of adults with Alzheimer's disease or other progressive dementias, peaking around dusk and easing after sleep. It is not a separate disease but a circadian-linked neurobehavioral pattern driven by suprachiasmatic-nucleus degeneration, light cue dysregulation, fatigue, and unmet biological needs (pain, hunger, full bladder, infection).
aliases · Sundowning Syndrome (late-day agitation in dementia)· Sundown syndrome· Late-day confusion· Syndrome crépusculaire· reviewed May 14, 2026
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Reviewed by AIHealz Medical Editorial Board · GeriatricsLast reviewed May 13, 2026
Sundowning syndrome (no dedicated ICD-10 code; documented under the underlying dementia, often F03.91 unspecified dementia with behavioral disturbance) is a recurring late-day to evening exacerbation of agitation, confusion, restlessness, mood disturbance, and disorganized behavior in patients with dementia. Symptoms typically begin in the late afternoon (4-6 pm), peak around sunset, and gradually resolve after 8-10 pm or with sleep. The pattern is most documented in Alzheimer's disease but is described in vascular dementia, Lewy body dementia, frontotemporal dementia, and Parkinson's disease dementia. Pathophysiology involves degeneration of the suprachiasmatic nucleus and its serotonergic and melatonergic outputs, blunted endogenous melatonin amplitude, reduced exposure to bright daytime light (particularly in institutionalized elders), accumulated daytime fatigue, sensory overload, low caregiver staffing at shift change, and unaddressed biological needs (pain, hunger, full bladder, constipation, urinary tract infection, hypoxia).
key facts
Prevalence
Estimated 20-45% of people with Alzheimer's disease experience sundowning at some point; up to 66% of dementia patients in long-term care report episodes (multiple cohort studies)
Demographics
Most common in moderate-stage dementia; both sexes affected; institutional residents over community-dwelling
Avg. age
Onset typically age 65+, coinciding with the moderate stage of underlying dementia
Global cases
Approximately 55 million people live with dementia globally (WHO 2023); applying observed sundowning prevalence implies 11-25 million affected
Specialist
Geriatrics
§ 02
How you might notice it
The key symptoms of Sundowning Syndrome are: Increased agitation, irritability, and verbal aggression beginning in the late afternoon and persisting until bedtime or beyond., Pacing, wandering, and attempts to leave home or facility, often with stated intent to go 'home' (even when already at home) or to visit deceased relatives., Worsening confusion and disorientation to time, place, and person after sunset; previously oriented patients may not recognize familiar caregivers., Yelling, shouting, repetitive vocalization, or calling out for relatives, which intensifies when the patient is left alone or in low light., Suspiciousness, paranoid ideas, visual misperceptions (mistaking shadows or curtains for intruders), and visual or auditory hallucinations., Resistance to care: refusal to undress, bathe, eat dinner, take evening medications, or cooperate with toileting., Motor restlessness with rocking, fidgeting, sleeve plucking, picking at clothing, and inability to sit still..
01Increased agitation, irritability, and verbal aggression beginning in the late afternoon and persisting until bedtime or beyond.
02Pacing, wandering, and attempts to leave home or facility, often with stated intent to go 'home' (even when already at home) or to visit deceased relatives.
03Worsening confusion and disorientation to time, place, and person after sunset; previously oriented patients may not recognize familiar caregivers.
04Yelling, shouting, repetitive vocalization, or calling out for relatives, which intensifies when the patient is left alone or in low light.
§ 03
How it’s diagnosed
diagnosis
Diagnosis is clinical. The clinician documents a consistent late-afternoon to evening pattern of agitation, confusion, or behavioral disturbance in a patient with established or newly identified dementia. A structured behavioral diary maintained by family or facility staff for 1-2 weeks captures time of onset, triggers, duration, severity, and response to interventions. The first task is to exclude delirium: acute or subacute onset of inattention, fluctuating consciousness, and full-day rather than evening-only symptoms suggest an underlying medical cause and require urgent work-up (urinalysis and culture, complete blood count, metabolic panel including calcium and glucose, thyroid function, chest imaging, ECG, oxygen saturation, medication review, and review of recent dose changes). Pain assessment using observational scales (PAINAD, Abbey Pain Scale) is essential in patients with limited verbal expression. Sleep history clarifies whether daytime napping, late bedtime, or nocturnal awakenings amplify the cycle. Validated behavioral scales such as the Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory (NPI) track severity over time. If the patient is not already diagnosed with dementia, formal cognitive testing (MoCA or MMSE) plus a neurological exam and brain imaging confirm the underlying disease. Polysomnography is reserved for cases with strong suspicion of REM sleep behavior disorder, severe obstructive sleep apnea, or restless legs contributing to night-time disturbance.
Key tests
01
Structured behavioral diary (1-2 weeks)Documents time of onset, frequency, triggers, and response to interventions for sundowning episodes
02
Cohen-Mansfield Agitation Inventory or Neuropsychiatric Inventory (NPI)Quantifies agitation severity and tracks treatment response
Suprachiasmatic nucleus degeneration and circadian rhythm disruption
Alzheimer's pathology damages the suprachiasmatic nucleus and pineal melatonin output, blunting the normal circadian temperature, cortisol, and melatonin rhythms. The result is a fragmented sleep-wake cycle with vulnerability to time-of-day behavioral surges, particularly around the dim-light transition at dusk.
Reduced bright daytime light exposure
Institutionalized elders typically receive less than 500 lux during the day compared with the 5,000-10,000 lux of outdoor light needed to entrain the circadian clock. Reduced morning light input weakens the day-night signal and increases evening agitation by 30-50% in light-deprived nursing-home residents.
Daytime fatigue and accumulated cognitive load
Patients with dementia exhaust their attentional reserves over the day. By late afternoon, they have reduced capacity to compensate for sensory ambiguity, leading to misinterpretation of cues, paranoid ideas, and emotional dysregulation.
Unmet biological needs
Pain, hunger, thirst, constipation, full bladder, hypoglycemia, and hypoxia commonly trigger or amplify sundowning. Patients with reduced expressive language may communicate these states only through behavior. Systematic assessment of physical needs resolves up to 40% of evening agitation episodes.
Medication effects and polypharmacy
Anticholinergic burden (diphenhydramine, oxybutynin, tricyclic antidepressants), benzodiazepines, opioids, antihistamines, and abrupt withdrawal of sedating medications all precipitate or worsen sundowning. Late-afternoon dosing peaks and trough effects produce predictable behavioral fluctuations.
Sensory deficits and environmental factors
Untreated hearing loss, vision loss, and unfamiliar or over-stimulating environments amplify confusion and paranoid misperception, especially as ambient light fades. Shift changes in long-term care, alarm sounds, and roommate disturbances trigger predictable evening agitation peaks.
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Living with it
01Maintain a predictable daily routine with consistent times for waking, meals, activity, and bedtime.
02Provide 30-60 minutes of bright outdoor light or light-box exposure within 2 hours of waking each morning.
03Limit daytime napping to a single 20-45 minute period before 2 pm; avoid late-afternoon sleep.
04Treat sensory deficits with up-to-date hearing aids and eyeglasses; ensure adequate evening lighting.
05Review medications every 3-6 months with a pharmacist to minimize anticholinergic burden and sedating drugs.
06Screen for and treat pain, constipation, urinary tract infection, hypoglycemia, hypoxia, and depression promptly when behavior changes.
07Reduce evening stimulation: turn off loud or distressing television, dim screens, and keep visitor numbers low after 4 pm.
recommended foods
•Regular meal times anchored to the daily routine, with a substantial early dinner
§ 07
When to seek help
why see a geriatrics
Refer to a geriatrician, geriatric psychiatrist, or memory-clinic neurologist when agitation is severe, persistent, or unresponsive to first-line non-pharmacological measures, when psychotic features dominate, when delirium superimposed on dementia is suspected, when antipsychotic therapy is being considered, or when caregiver burden has reached crisis. Specialists coordinate dementia diagnostics, deprescribing, advance care planning, and family support.
Sundowning in Alzheimer's diseaseThe most studied form, linked to neuronal loss in the suprachiasmatic nucleus and basal forebrain cholinergic system. Peaks in moderate-stage disease (Clinical Dementia Rating 1-2) and may attenuate in late stages as patients become more withdrawn.
Sundowning in Lewy body dementia and Parkinson's disease dementiaOften blends with REM sleep behavior disorder, fluctuating cognition, and visual hallucinations. Patients may have pronounced motor restlessness, paranoia, and exquisite sensitivity to typical antipsychotics.
Sundowning in vascular dementiaLinked to subcortical white-matter ischemia and step-wise cognitive decline. Behavioral disturbance often relates to specific stroke-affected circuits and may be more amenable to environmental modification than pharmacotherapy.
Delirium superimposed on dementiaAcute onset of agitation, inattention, and fluctuating consciousness over hours to days in a patient with baseline dementia. Most often triggered by infection, dehydration, medication, or hospitalization. Distinguished from sundowning by acute onset, full-day presentation, and reversibility — but the two often coexist.
Living with Sundowning Syndrome
Timeline
Non-pharmacological interventions usually take 2-4 weeks to produce measurable change. Bright light therapy effects appear within 1-2 weeks. Melatonin response is typically seen within 7-14 days. Cholinesterase inhibitor behavioral effects appear over 8-12 weeks. Atypical antipsychotic effects begin within days but tapering should be attempted every 4-12 weeks.
Lifestyle
01Schedule the most cognitively demanding activities (medical appointments, complex conversations) in the morning when cognition is best.
02Offer a calm, familiar, well-lit environment from 4 pm onward; close curtains before dusk to reduce confusing reflections and shadows.
03Provide a hearty afternoon snack and ensure dinner at a consistent early time (around 5-6 pm).
04Use distraction (music, family photo album, simple folding tasks) rather than confrontation when agitation begins.
05Walk with the patient for 10-20 minutes in mid-afternoon to discharge pent-up restlessness before sundown.
06Adopt a soft, slow tone of voice in the evening; avoid arguing about misperceptions or correcting confused statements.
07Establish a calming bedtime routine: warm drink, soft music, dim lights, and consistent toileting.
Daily management
Complementary approaches
Personalized music therapyPlaylists tailored to era and personal history of the patient, delivered through headphones for 20-30 minutes during the late afternoon. Reduces agitation and use of antipsychotics in randomized nursing-home trials (Music & Memory program data).
Aromatherapy with lavender or Melissa officinalisTopical or diffused lemon balm (Melissa) and lavender essential oils have shown modest reduction in agitation scores in small randomized trials. Adverse effects rare; cost low.
Doll, robotic pet, and reminiscence therapySoft toys, robotic pets (e.g. PARO seal), and reminiscence activities engage patients in moderate-to-severe dementia, reducing evening restlessness and need for psychotropic medication in observational studies.
Choosing a doctor
Choose a clinician with memory-clinic or dementia-care experience who works in a multidisciplinary team (occupational therapy, social work, dementia care nurse). Ask whether they routinely use non-pharmacological interventions before drugs, whether they apply the AGS Beers Criteria, and how they support family caregivers through behavior diaries, respite, and crisis planning. Continuity of care over months matters because sundowning patterns evolve with disease stage.
Patient support resources
Alzheimer's Association →US patient and caregiver education with 24/7 helpline (1-800-272-3900), care planning resources, and local support groups.
Alzheimer's Society UK →UK-based dementia support charity with national helpline, dementia adviser service, and online community.
WHO iSupport for Dementia →Free, evidence-based online program for family caregivers of people with dementia.
Sundowning is a pattern of increased agitation, confusion, restlessness, and behavioral disturbance that emerges in the late afternoon or evening in roughly 20-45% of people with Alzheimer's disease or other dementias. It usually settles after bedtime and is driven by circadian disruption, fatigue, sensory deficits, and unmet biological needs.
Why does sundowning happen in dementia?▾▴
Dementia damages the suprachiasmatic nucleus and pineal melatonin output, blunting the normal day-night rhythm. Reduced bright daytime light, accumulated cognitive fatigue, sensory deficits, pain, hunger, infection, polypharmacy, and shift changes in care environments amplify the late-day vulnerability. The result is a predictable evening behavior surge.
Is sundowning the same as delirium?▾▴
No. Delirium has acute or subacute onset (hours to days) of inattention and fluctuating consciousness lasting through the day; it is reversible when the medical cause (infection, dehydration, medication) is treated. Sundowning is a chronic, evening-specific pattern in established dementia. They can coexist and any new sudden change must be investigated as delirium.
What time does sundowning usually start?▾▴
Symptoms typically begin between 4 and 6 pm, peak around dusk, and ease after 8-10 pm or with sleep. The exact timing tracks the patient's circadian profile and the light cues in their environment. Documenting the time of onset in a 1-2 week behavioral diary guides intervention.
How can sundowning be treated without medication?▾▴
First-line care includes treating pain, infection, and constipation; bright morning light (30-60 minutes); a predictable daily routine; limited daytime napping; calm low-stimulation evenings; personalized music; familiar caregivers; and updated hearing aids and eyeglasses. These reduce evening agitation in 40-60% of patients within 4-8 weeks.
Does melatonin help with sundowning?▾▴
Yes, modestly. Oral melatonin 1-5 mg taken 1-2 hours before bedtime improves sleep onset by 15-25 minutes and reduces evening agitation by about 20-30% in dementia trials. Prolonged-release formulations are preferred. Side effects are minimal, making it the first-line medication choice for sundowning.
Are antipsychotics safe for sundowning?▾▴
Atypical antipsychotics (risperidone, quetiapine) are reserved for severe agitation, aggression, or psychosis that puts the patient or others at risk. The FDA black-box warning notes 1.6-1.7 fold mortality and 3-fold stroke risk in dementia patients. Use the lowest dose for the shortest duration and review every 4-12 weeks.
What triggers a sundowning episode?▾▴
Common triggers include pain, hunger, thirst, full bladder, constipation, infection, hypoglycemia, hypoxia, sensory deprivation (low light, hearing loss), polypharmacy with anticholinergic or sedating drugs, fatigue from too much daytime activity, and disrupted routines such as caregiver shift change or unfamiliar visitors.
Does bright light therapy work for sundowning?▾▴
Yes. Exposure to bright light (2,500-10,000 lux) for 30-60 minutes in the morning helps resynchronize the circadian rhythm and reduces evening agitation by about 30% in randomized trials in long-term care. Outdoor light is ideal when available. Effects appear within 1-2 weeks of consistent use.
Should caregivers correct dementia patients during sundowning?▾▴
No. Correcting confused statements often escalates agitation. Instead, validate the emotion behind the statement and gently redirect with distraction (music, photos, a snack, a walk). Use a calm slow tone, short simple sentences, and familiar objects to anchor the patient in the present moment.
How long does sundowning last in dementia?▾▴
Sundowning typically emerges in the moderate stage of dementia and persists for 2-4 years before attenuating as patients enter severe disease with limited motor and verbal output. Individual episodes last from 2-6 hours, peaking around dusk and easing after sleep onset. Daily severity varies with triggers.
Can sundowning happen without dementia?▾▴
Pure sundowning is a feature of established dementia. Similar evening confusion in older adults without dementia usually represents delirium from an acute medical cause or severe sleep disturbance. Anyone with new-onset evening confusion without a known dementia diagnosis warrants formal cognitive evaluation and a delirium work-up.
What is the best routine for a person with sundowning?▾▴
Wake at a consistent time, get 30-60 minutes of morning light, eat regular meals, schedule cognitively demanding tasks in the morning, walk for 20 minutes in mid-afternoon, eat an early dinner (5-6 pm), avoid caffeine after noon, dim lights and reduce stimulation from 4 pm, and use a calming bedtime ritual at the same time each night.
Can sundowning be cured?▾▴
Sundowning cannot be cured but is highly modifiable. Treating reversible triggers and applying structured non-pharmacological interventions reduces episode frequency and severity in most patients. Medication is added when needed. Long-term outcome depends on the underlying dementia trajectory and consistency of care.
How do you handle sundowning at home?▾▴
Provide a predictable schedule, bright morning light, daytime activity, mid-afternoon walks, calm evening environment, early dinner, soothing music, and a consistent bedtime routine. Check for pain, hunger, or toileting needs first when agitation starts. Use distraction rather than correction. Plan respite time for yourself daily.
Does sundowning get worse over time?▾▴
Severity often peaks during the moderate stage of dementia (1-3 years) and may attenuate in late stages as motor and verbal expression decline. Periodic flare-ups occur with infection, medication change, hospitalization, or change of environment. Consistent non-pharmacological management blunts the trajectory.
What medications make sundowning worse?▾▴
Anticholinergic drugs (diphenhydramine, oxybutynin, tricyclic antidepressants), benzodiazepines, opioids, antihistamines, and abrupt withdrawal of sedating medications can worsen sundowning. The AGS Beers Criteria flags these as potentially inappropriate in older adults. A pharmacist-led medication review identifies deprescribing opportunities.
Is music therapy effective for sundowning?▾▴
Yes. Personalized music playlists tailored to the patient's era and personal history reduce agitation by 15-30% and lower antipsychotic use in randomized nursing-home trials (Music & Memory program data). Headphone delivery for 20-30 minutes during the late afternoon is the most studied protocol.
Should I let a dementia patient nap in the afternoon?▾▴
Limit naps to one period of 20-45 minutes before 2 pm. Longer or later naps push bedtime later, increase nocturnal awakenings, and worsen sundowning the next evening. A consistent rest period followed by light activity preserves the night-time sleep drive.
Can sundowning cause falls?▾▴
Yes. Up to 20-30% of nursing-home falls occur during sundowning episodes, driven by wandering in low light, impaired gait, and rushed toileting. Adequate evening lighting, night-lights in bathroom and hallway, low-set beds, non-slip footwear, and supervised toileting reduce fall risk.
When should I take a sundowning patient to hospital?▾▴
Seek urgent care when behavior changes acutely over hours (suggesting delirium), with new fever, productive cough, urinary symptoms, vomiting, falls with head injury, focal neurological signs, refusal of fluids beyond 24 hours, or risk of harm to self or others that cannot be managed safely at home.
Suspiciousness, paranoid ideas, visual misperceptions (mistaking shadows or curtains for intruders), and visual or auditory hallucinations.
06Resistance to care: refusal to undress, bathe, eat dinner, take evening medications, or cooperate with toileting.
07Motor restlessness with rocking, fidgeting, sleeve plucking, picking at clothing, and inability to sit still.
08Sleep-wake reversal with daytime drowsiness and night-time wakefulness; bedtime is often delayed, and nighttime awakenings are frequent and prolonged.
09Tearfulness, sadness, or anxiety that emerges late in the day even in patients without prior depression diagnosis.
early warning signs
•Mild evening restlessness or repetitive questioning that becomes more pronounced over weeks
•Caregiver report of a consistent late-afternoon mood change ('she becomes a different person around 5 pm')
•Daytime napping longer than 60-90 minutes that pushes sleep onset later and degrades nighttime sleep quality
•Loss of usual evening interest in TV, reading, or social interaction
•Subtle gait change or unsteadiness in the late afternoon predicting falls
● emergency signs
•Acute onset of confusion within hours to days rather than the typical chronic pattern — exclude delirium from infection, hypoglycemia, stroke, or medication reaction
•Self-harm threats or actions, severe aggression with risk of injury to self or caregivers, or psychosis with command hallucinations
•Falls with head injury or new focal neurological signs (limb weakness, dysarthria, facial droop) — exclude subdural hematoma or new stroke
•Refusal of fluids and food for more than 24 hours with reduced urine output — risk of dehydration, acute kidney injury, and worsening delirium
Excludes infection, electrolyte disturbance, hypoglycemia, thyroid dysfunction, and hypoxia driving delirium superimposed on dementia
04
Medication review with anticholinergic burden score (ACB scale)Identifies sedating and anticholinergic drugs that worsen sundowning
05
Pain assessment with PAINAD or Abbey Pain ScaleDetects pain in patients with limited verbal expression
06
Brain MRI or CT (if dementia not already diagnosed or new neurological signs)Confirms neurodegenerative or vascular pathology and excludes acute lesions (subdural hematoma, stroke, tumor)
07
Sleep history and, in selected cases, actigraphy or polysomnographyIdentifies REM sleep behavior disorder, obstructive sleep apnea, or restless legs syndrome that aggravate sundowning
Outlook
Sundowning typically waxes and wanes with the underlying dementia. In Alzheimer's disease, it usually emerges in the moderate stage (CDR 1-2) and may persist or attenuate over 2-4 years as patients transition into severe disease with motor and language decline. With consistent non-pharmacological management, roughly 40-60% of patients show meaningful reduction in evening agitation within 4-8 weeks, and 20-30% require additional pharmacotherapy. Sundowning is associated with caregiver burnout, premature institutional placement (median 12-18 months earlier than dementia patients without sundowning), and higher fall and injury rates. Mortality is not directly increased by sundowning itself but by associated falls, malnutrition, infection from poor self-care, and antipsychotic-related cardiovascular events. Identification and treatment of reversible triggers, structured caregiver education, and respite support consistently improve quality-of-life measures for both patient and family.
risk factors
Moderate-stage dementia (CDR 1-2)non-modifiable
Highest prevalence of sundowning. In mild dementia, attentional reserves still buffer behavioral output; in severe dementia, motor and language impairment limit overt expression. Moderate disease is the symptomatic peak window.
Female sex (Alzheimer's dementia)non-modifiable
Mixed evidence; some cohorts find women with Alzheimer's are 1.3-1.5 times more likely to develop sundowning, possibly via greater cholinergic vulnerability and longevity in the moderate stage.
Lewy body dementia and Parkinson's disease dementianon-modifiable
Inherent circadian and REM-sleep disturbance plus visual hallucinations create higher baseline behavioral instability. Up to 60% of Lewy body dementia patients show sundowning patterns.
Institutional or hospital settingenvironmental
Disrupted routines, unfamiliar staff, low light levels, shift changes at 3-4 pm, and shared rooms substantially raise sundowning incidence. Acute hospitalization is a particularly potent trigger.
Polypharmacy and high anticholinergic burdenmodifiable
Each additional anticholinergic medication increases sundowning incidence by approximately 20%. Deprescribing with attention to AGS Beers criteria reduces evening agitation in trials.
Untreated pain, infection, or constipationmodifiable
Urinary tract infections, pneumonia, dental pain, joint pain, and fecal impaction are among the most common triggers. Systematic screening and treatment resolve a substantial minority of cases without psychotropics.
Reduced bright morning light exposuremodifiable
Patients who receive less than 30 minutes of bright outdoor light daily have a 2-3 fold higher rate of evening agitation episodes; structured light therapy programs reduce this.
Sensory impairmentmodifiable
Uncorrected hearing or vision loss multiplies confusion and misinterpretation, especially in low light. Hearing aids and updated eyeglasses reduce behavioral disturbance in dementia by 20-30%.
•Mediterranean-style diet pattern, linked with slower cognitive decline in MIND diet studies
•Adequate hydration through the day (1.5-2 L), limited after 5 pm to reduce nocturnal toileting
•Tryptophan-rich evening foods (turkey, dairy, oats) which support melatonin synthesis
•Limit caffeine to before noon; switch to herbal or decaffeinated drinks in the afternoon
foods to avoid
•Caffeine after noon — coffee, tea, cola, chocolate desserts
•Alcohol in the late afternoon and evening, which worsens confusion and fall risk
•Heavy spicy meals close to bedtime causing reflux and sleep fragmentation
•High-sugar snacks after 5 pm that disrupt blood-sugar swings and sleep
•Excessive fluids in the 2-3 hours before bedtime
choosing the right hospital
01Geriatric assessment unit or memory clinic with dementia care nurse specialist
02Multidisciplinary behavioral team including occupational therapy and social work
03Pharmacist-led medication review program
04Access to bright light therapy equipment and dementia-friendly environment design
05Family caregiver support and respite services
Essential facilities
Memory clinic or dementia diagnostic serviceGeriatric psychiatry liaisonOld age psychiatry inpatient unit for severe behavioral crisesLong-term care facilities with dementia-specific unitsHospice and palliative care services
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01Keep a brief behavior diary noting time, duration, suspected trigger, and intervention for any sundowning episode.
02Open curtains in the morning for natural light, close them before sunset to reduce visual confusion.
03Provide a consistent calming evening routine: dinner, hygiene, soft music, low lighting, familiar bedtime story or prayer.
04Offer reassurance with simple, repetitive phrases rather than logical correction.
05Check for pain, full bladder, hunger, thirst, or temperature discomfort first when agitation appears.
06Use night-lights in bathroom and hallway to prevent disorientation during nocturnal toileting.
07Build in respite time for the caregiver every day — even 30 minutes — to sustain the management plan.
Exercise
Aim for 30-45 minutes of moderate physical activity earlier in the day — walking, supervised cycling, dancing, or chair-based exercises. Mid-afternoon walks of 10-20 minutes can discharge restlessness before the typical sundown peak. Avoid vigorous activity within 2 hours of bedtime. In long-term care, structured group exercise programs reduce evening agitation by approximately 25% (cluster-randomized data). Patients with significant balance impairment benefit from supervised tai chi and seated strengthening.