If you work in UK health and social care, you are familiar with dementia. Around 982,000 people in the UK are living with it today, and the figure is projected to reach 1.4 million by 2040. You will have supported people with it directly, or worked alongside colleagues who do. You know the language: Alzheimer’s, vascular dementia, Lewy body, mixed. You know the daily reality of memory loss, communication difficulty, and the slow, careful work of person-centred care.

What is less often talked about is the part of the day that gets harder. Late afternoon, into the evening. The same person who was settled at lunchtime becomes restless. They ask when they can go home, even though they are home. They pace, refuse food, become anxious or distressed for no obvious reason. They have a name for it.

Sundowning is one of the most common, most under-managed, and most preventable patterns of distress in dementia care. This guide covers what it is, why it happens, how to recognise it, and how UK care providers should manage it through evidenced, non-pharmacological approaches that align with NICE guidance, the Mental Capacity Act 2005, and the CQC’s expectations of person-centred care. It also covers how documented sundowning management strengthens your dementia evidence base in bid writing for care contracts.

What sundowning is

Dementia UK defines sundowning as a common symptom of dementia that causes feelings of intense confusion, anxiety, and agitation, typically in the late afternoon and evening, around dusk. It is not a separate condition. It is not a psychiatric diagnosis. It is a recognisable pattern of behavioural and psychological symptoms of dementia (BPSD) that occurs at a particular time of day.

It is thought to affect around 20 per cent of people with dementia, though clinical estimates vary widely depending on setting and methodology. A 2025 review in the Journal of Clinical Medicine reports prevalence ranging from 1.6 to 66 per cent across studies, with rates over 60 per cent observed in some institutional populations. Sundowning is the second most common type of disruptive behaviour in dementia care home residents after wandering.

What does sundowning actually look like? The person may:

• Become restless or agitated in the late afternoon or evening, when they were calm earlier in the day
• Develop a strong sense that they are in the wrong place, even at home or in a long-term care setting
• Ask the same questions repeatedly, often about going home, going to work, or picking up children
• Become confused about who people are or what is happening around them
• Experience hallucinations or delusions
• Pace, fidget, pluck at clothing, or try to leave the building
• Refuse food, care, or medication they normally accept
• Sleep poorly that night, then wake exhausted, completing the cycle the next day

Why sundowning happens

The exact cause is not fully understood. The most plausible explanations sit across three categories.

Biological factors:

• Circadian rhythm disruption: Dementia damages cells in the suprachiasmatic nucleus (the brain’s master body clock), reducing the brain’s ability to respond appropriately to changing light levels. As natural light drops, the person’s internal cues fall out of sync with the external environment
• Sleep disturbance and fragmented rest: Many people with dementia sleep poorly. Cumulative tiredness peaks late in the day
• Reduced cerebral blood flow: In some types of dementia, which may worsen as the day progresses

Psychosocial factors:

• Mental and physical exhaustion from the cognitive load of a full day
• Unmet needs that are easier to mask in the morning: hunger, thirst, pain, needing the toilet, needing repositioning
• Boredom or under-stimulation during the day, leading to restlessness in the evening
• Anxiety driven by loss of routine cues as familiar daytime activity ends

Environmental factors:

• Reduced natural light and increased shadows which can be misinterpreted as people, animals, or threats
• Noise and activity changes at shift handover
• A different staff team in the evening, with different faces and approaches
• Visitors leaving, which can trigger separation distress
• Unfamiliar surroundings, particularly after a recent move

For UK care providers, the practical insight is that sundowning is rarely caused by a single trigger. It is usually a combination of biological vulnerability, accumulated unmet needs, and an environment that becomes harder to navigate as the day ends.

Recognising sundowning, and what it isn’t

Sundowning shares features with other conditions that need urgent clinical attention. The most important differential to rule out is delirium.

Delirium is an acute, fluctuating disturbance of attention and cognition, usually triggered by a medical cause: infection (urinary tract infections are common), dehydration, constipation, pain, medication side effects, or post-operative recovery. Delirium can mimic sundowning, but it does not respect the daily clock, it is more severe, and it has a clear medical trigger. Missing a delirium and treating it as sundowning is one of the more serious clinical errors in dementia care.

Practical rule of thumb: if behaviour changes acutely, escalates over 24-72 hours, or appears alongside physical symptoms (fever, reduced fluid intake, urinary changes, recent falls), treat it as suspected delirium and arrange clinical review. NICE guidance CG103 on delirium prevention, diagnosis, and management is the relevant reference.

Sundowning, by contrast, is predictable in its timing (late afternoon or evening), consistent day-to-day, and responsive to environmental and routine adjustments. The pattern is the diagnosis.

Other conditions to consider before assuming sundowning include pain (often under-recognised in advanced dementia, particularly where verbal communication is limited), depression, anxiety disorders, sleep apnoea, and side effects of medications including hypnotics, anticholinergics, and some antipsychotics.

Non-pharmacological management: the first line of care

NICE guidance (NG97 on dementia: assessment, management and support for people living with dementia and their carers) is clear: non-pharmacological approaches should be the first-line response to behavioural and psychological symptoms of dementia. Antipsychotic medication should only be considered where non-pharmacological approaches have been tried and the person is at risk of harming themselves or others, or experiencing severe distress.

Effective non-pharmacological management of sundowning falls into five categories.

1. Identify individual triggers and patterns

Every person with dementia experiences sundowning differently. The starting point is structured observation:

• What time does the change in behaviour begin? Recording onset to the nearest 30 minutes over 7-14 days reveals the pattern
• What was happening immediately before? Shift handover, mealtimes, visitor departure, a particular television programme, a specific care task
• What was happening earlier that day? Poor night’s sleep, reduced fluid intake, missed activity, missed medication, constipation, a difficult phone call from family
• What helped previously, and what made it worse?

A simple ABC chart (Antecedent, Behaviour, Consequence) over a fortnight, completed by all shifts, builds the evidence base for an individualised care plan. This is also the documentation a CQC inspector will look for under the Quality Statements covering person-centred care.

2. Maintain a consistent daily routine

Predictability reduces anxiety:

• Regular waking, meal, and bedtime cues, with consistent staff where possible
• Activities timed to the person’s energy curve. Cognitively demanding tasks (visits, complex conversations, GP appointments) scheduled in the morning when alertness is higher
• A wind-down period from late afternoon onwards, with calming activities (familiar music, hand massage, gentle conversation, looking through a memory book)
• Avoid overstimulation in the late afternoon: reduce television noise, limit new visitors after a defined time, avoid complex group activities at handover

3. Optimise the physical environment

• Maximise natural daylight exposure earlier in the day. Sitting by a window or, where possible, a short outdoor walk strengthens circadian cues
• Manage indoor lighting at dusk. Turn lights on before the natural light drops, gradually rather than suddenly. Avoid harsh overhead lighting that creates shadows
• Reduce reflective surfaces. Mirrors, glossy windows at night, and shiny floors can be misinterpreted by a person with visual processing difficulties
• Maintain a comfortable temperature, neither too warm nor too cool
• Reduce noise in communal areas during the late afternoon

4. Meet physical needs proactively

A surprising proportion of evening agitation is caused by physical needs that are easy to miss:

• Pain assessment, using a validated tool such as Abbey Pain Scale or PAINAD for people with limited verbal communication
• Hydration through the day, with a clear monitoring system at handover
• Toileting routines that pre-empt urgency
• Repositioning for those at risk of pressure damage
• Hunger: for people with dementia, hunger does not always present as asking for food
• Constipation, which is common, distressing, and frequently missed

5. Use calming and distraction techniques during episodes

When a person is sundowning despite preventative measures:

• Validate the feeling rather than the content: A person saying “I need to go home to pick up the children” is communicating a need to feel safe, useful, or connected. Arguing with the literal content rarely helps. Acknowledging the feeling does
• Offer reassurance through familiarity: A familiar object, a photograph, a piece of music from earlier in the person’s life
• Redirect with purpose: A task that gives a sense of usefulness (folding towels, helping lay the table) can resolve restlessness
• Use one-to-one time: Where staffing allows, sitting with the person calmly is often more effective than any intervention
• Avoid restraint: Restrictive practice should only ever be used as a last resort, in line with Restraint Reduction Network standards and the Mental Capacity Act 2005

When pharmacological treatment is considered

NICE guidance is clear that antipsychotics should not be the default response to BPSD, including sundowning. Where they are considered, the threshold is:

• Non-pharmacological approaches have been tried and documented as ineffective
• The person is experiencing severe distress, or there is a risk of harm to self or others
• The decision is made jointly with the GP or dementia specialist, the person where they have capacity, and family or attorneys where they do not
• The intervention is reviewed regularly, typically every 6-12 weeks, with a clear plan for tapering

Antipsychotics carry significant risk in older people with dementia: increased risk of stroke, falls, and mortality. Inappropriate antipsychotic prescribing in dementia care has been the subject of repeated NHS England and CQC focus. For care providers, the documentation standard is high. Every antipsychotic prescription needs a documented rationale, a recorded best interests decision where capacity is lacking, and a planned review.

Other medications sometimes used include short-term hypnotics for severe sleep disturbance, melatonin (limited evidence in dementia), and treatment of underlying depression where present. None should be a first-line response to sundowning.

What this means for UK care providers and bid writing

Sundowning is one of the clearer indicators of how well a service understands and delivers person-centred dementia care. Inspectors and commissioners look for it because it sits at the intersection of three things they care about: the experience of people drawing on care, the maturity of the provider’s clinical governance, and the appropriateness of medication use.

For CQC inspections, sundowning management evidences:

• Caring key question: how the service responds to distress with dignity and individuality
• Effective key question: how care plans are based on assessment, evidence, and best practice
• Responsive key question: how the service responds to changing needs across the day
• Well-led key question: how the registered manager leads on quality of life outcomes and medication oversight

For bid writing in dementia-specialist or dementia-friendly contracts, evidenced sundowning management strengthens responses to questions about:

• Person-centred care planning
• Behavioural and psychological symptoms of dementia
• Reducing antipsychotic use
• Staff training and competence
• Family and carer engagement
• Continuous quality improvement

Providers with structured ABC charting, individualised triggers documented in care plans, named non-pharmacological interventions, and audit data showing reductions in evening incidents have a substantively stronger evidence base than providers whose dementia narratives are general. Examples of how this kind of evidence shows up in winning submissions are documented in AssuredBID’s case studies.

A simple sundowning care plan structure

For Registered Managers, dementia leads, and senior carers building or reviewing sundowning care plans:

1. Pattern observation (7-14 days of ABC charting across all shifts)
2. Trigger identification, recorded in the care plan with named contributors
3. Individualised prevention plan covering routine, environment, and physical needs
4. Defined response steps for when sundowning episodes occur, including who does what
5. Family and carer involvement, including known calming approaches from before admission
6. Medication review if any psychotropic medication is in place, with a documented rationale
7. Outcome measurement: incident frequency, duration, severity, and resolution
8. Review cycle: minimum monthly, with earlier triggers for incidents or hospital admissions

This structure satisfies the documentation expectations of CQC, the Mental Capacity Act 2005, and most local authority and NHS dementia contract specifications.

FAQ

At what stage of dementia does sundowning typically occur? Sundowning can occur at any stage but is more common in the middle and later stages, according to the Alzheimer’s Society. It is rarely the first symptom of dementia and is usually one pattern within a broader picture of cognitive change.

Is sundowning the same as delirium? No. Sundowning is a predictable late-day pattern in someone with established dementia, responsive to environmental and routine adjustments. Delirium is an acute, fluctuating disturbance of attention triggered by a medical cause (infection, dehydration, pain, medication, post-operative recovery). Where behaviour changes acutely, treat as suspected delirium and arrange clinical review.

Should antipsychotics be used to treat sundowning? Not as a first-line response. NICE guidance NG97 places non-pharmacological approaches first. Antipsychotics carry significant risk in older people with dementia and should only be considered where non-pharmacological approaches have been tried and documented as ineffective, the person is at risk of harm, and a structured review plan is in place.

How can family members support sundowning management in a care setting? Families know the person’s pre-dementia routines, preferences, and calming approaches better than any new staff team. Care providers should actively gather this information at admission and during reviews, including familiar music, foods, photographs, religious practices, and the times of day the person was historically most settled.

How do UK care providers evidence sundowning management for CQC and tenders? Through structured ABC charting, individualised care plans naming triggers and interventions, training records covering dementia and behaviour that challenges, audit data showing trends in evening incidents, and documented best interests decisions where any restrictive intervention is used. This evidence base strengthens both CQC inspection outcomes and tender submissions for dementia-specialist contracts.

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