She's Up All Night (Sundowning)

Late-afternoon and nighttime agitation, commonly called sundowning, is one of the most disruptive patterns in dementia care because it targets the caregiver’s own sleep along with the person’s. The mechanism isn’t fully understood, but a few things are usually at work.

• A disrupted internal clock. The part of the brain that once cued the body toward winding down as light fades no longer sends a clear signal.
• A day’s worth of fatigue. A tired brain has less capacity to filter confusion and stimulation by evening.
• Dim light. Shadows and unfamiliar shapes in a dim room are genuinely harder to interpret, which can look like agitation but is really a perception problem.
• Something making tonight worse. Pain, a full bladder, hunger, or thirst going unaddressed, since these often intensify after dark simply because no one is checking as closely. Medication timing, particularly anything with a stimulant effect scheduled too late in the day. A recent illness, or a change in the daytime routine.

A single unusually bad night is often explained by the last of these. A consistent pattern over weeks is closer to the disease process itself.

Start by adjusting the day rather than only managing the night.

1. Get natural light exposure earlier in the day if possible, since morning and midday light helps reinforce the body's sense of a day-night cycle.
2. Limit napping late in the afternoon, which can work against nighttime sleep even though it feels like relief in the moment.
3. Keep evening lighting warm and consistent rather than switching between bright and dark rooms, and reduce noise and activity as bedtime approaches.
4. If agitation peaks, offer a familiar, low-stimulation activity, folding a blanket, listening to familiar music, to redirect the anxious energy.
5. If nothing is working on a given night, prioritize safety over sleep, secure the space, stay nearby, and accept that this particular night may not resolve quickly.

Keep it to one line a night for two weeks: what time it started, what the afternoon looked like, and what finally settled it. The cause usually sits hours upstream of the hour it shows up, and nobody can hold that connection in their head at three in the morning.

Print the one-page log if you want somewhere to keep this, and take it to the appointment.

This is what the tracking is for. Dates, times and specifics turn "something's off" into something a clinician can act on in a ten-minute appointment.