A person living with dementia may seem comfortable and familiar in the morning, then become anxious, suspicious, restless or angry later in the day. Family members may feel as though they are speaking to a different person. A caregiver who managed the morning routine with ease may struggle during the afternoon visit.

This pattern is often called sundowning, or late-day confusion. It is not a separate disease or diagnosis. It describes a group of symptoms that appear or become more noticeable in the late afternoon, evening or night. The exact cause is not fully understood, and not every difficult afternoon is sundowning.

The change can be upsetting for everyone involved. The person living with dementia may feel frightened or overwhelmed without being able to explain why. The caregiver may understand that dementia is affecting the behaviour and still feel hurt, frustrated or unsafe.

Why the later hours may be harder

Several pressures can accumulate as the day continues. A person may be physically and mentally tired. Hunger, thirst, pain, the need to use the bathroom or an uncomfortable room can reduce their ability to cope. A busy day, too many visitors, television noise or repeated instructions may add more stimulation than the person can process.

Light also changes. Dim rooms and longer shadows can make familiar objects or faces harder to interpret, especially when vision is already limited. Dementia may also disrupt the body’s sleep and wake rhythm, making it harder to understand whether it is daytime or nighttime.

The result may be pacing, repeated questions, attempts to leave, resistance to care, accusations, shouting or physical agitation. These actions may communicate fear, confusion, discomfort or a need that has not yet been recognized.

A relationship can change with the time of day

Names have been changed to protect privacy.

Judy and Sabrine had known each other for years. Familiar routines reflected trust and a relationship that had grown through steady care. As Judy’s dementia progressed, however, late afternoons became much more difficult. Judy sometimes directed swearing and hostility toward Sabrine. On one occasion, she struck her during an agitated episode.

Sabrine knew that dementia was influencing the behaviour. That knowledge did not erase the emotional effect of being treated with hostility by someone she had come to care about. Their history, which had once made care easier, now made the afternoon behaviour harder for her to absorb without responding emotionally.

The afternoon visits were assigned to Traci, whose approach was a better match for Judy during that particular part of the day. Judy could still become upset, but the atmosphere became calmer. Sabrine remained a capable caregiver, and the years of successful care still mattered.

This is an important part of person-centred care: the best match may depend on the person’s current needs, the task and even the time of day.

What can help before agitation begins

Start by looking for a pattern. Record when the change begins, what happened beforehand, how the person behaved, how others responded and what seemed to help. A few days of useful notes may reveal that the difficult period follows a long outing, a noisy meal, a missed snack, a late nap or a change in lighting. Do not wait to collect several days of notes if confusion is new or rapidly worsening; seek medical help right away.

Where possible, plan demanding activities for the person’s calmer hours. Appointments, bathing, errands and unfamiliar visitors may be easier in the morning or early afternoon. As evening approaches, reduce background noise, turn on lights before the room becomes dim and choose familiar, low-pressure activities. A short walk, quiet music, folding towels, looking at photographs or sitting with a familiar object may help, depending on the person.

Routines matter, but rigid routines can create another struggle. The goal is to make the surroundings easier to understand and reduce unnecessary demands, not to force the person through a schedule that is no longer working.

How to respond in the moment

Begin with your own pace and tone. Approach slowly, use a calm voice and give the person more physical space. Ask one simple question at a time. Check for an immediate need such as pain, hunger, thirst, toileting, fatigue or fear.

Avoid arguing about facts or trying to prove that an accusation is wrong. The person’s distress is real even when their explanation does not match yours. A brief reassurance may work better than a detailed correction: “You are safe. I am here with you.” If a task is increasing the agitation and can safely wait, pause it and try again later.

Reduce the number of people speaking. Lower the television, close curtains if reflections or shadows are confusing, and remove unnecessary choices. If the person needs to pace, allow safe movement with supervision rather than trying to hold them still.

If anyone is at risk, create distance and get help. Call 911 for immediate danger or a medical emergency. Understanding dementia does not require a caregiver to remain in an unsafe position.

Why the reminder alone is not enough

“Do not take it personally” may remind a caregiver that dementia is affecting the person’s words and actions. It does not tell the caregiver what to do with the hurt, fear or frustration that remains afterward.

Useful support is more specific. The caregiver may need to report the event, review possible triggers, practise a different response, receive relief from the most difficult hours or discuss whether the assignment still fits. A changed schedule or a second caregiver can protect both the person receiving care and the caregiver who has been carrying too much.

Feeling hurt is understandable. Professional caregivers remain responsible for responding respectfully, reporting incidents and seeking support when their own reactions begin to affect care.

Reassignment should not automatically be treated as failure. Sometimes it is the safest and most respectful response to a relationship that has changed.

When a health professional should be contacted

Sudden or rapidly worsening confusion needs urgent medical assessment, even in someone already living with dementia. Seek medical help right away rather than assuming it is sundowning or waiting to see a pattern. Pain, infection, dehydration, medication effects and other health conditions can cause or worsen confusion and agitation. Call 911 for immediate danger or a medical emergency.

Persistent changes in behaviour or sleep also deserve discussion with the person’s health-care professional. Document what changed, when it began and any other symptoms, but do not let note-taking delay urgent help.

Caregivers should not diagnose the cause or change medication on their own. Their role is to observe, document, report and respond safely.

Care that adjusts as the day changes

Sundowning asks families and care teams to pay attention to timing. A person may not need the same approach at every hour, and a caregiver who is an excellent match in one part of the day may need support or relief in another.

The behaviour may come from dementia. The emotional impact on caregivers is still real. When both realities are acknowledged, families and care teams can adjust the plan before the same difficult interaction keeps repeating.

Further reading: Alzheimer Society of Canada | Alzheimer’s Association | Caregiver safety | Sudden confusion

If afternoons are becoming difficult to manage, contact ComForCare Halton to discuss home care support and a caregiving arrangement that fits your family’s needs.