My Mom With Alzheimer's Is Sundowning Every Evening — Why Does She Get Worse at Night and What Can We Try?

The call always comes around five. My mother, who taught fourth grade for thirty-one years and could recite every capital of every country, will look at my father across the kitchen table and ask him who he is. By six she is pacing the hallway, picking at the hem of her cardigan, asking where her own mother is — a woman who has been gone since 1998. By seven she is crying, and by eight she is exhausted, and by nine she is asleep, and my father and I sit in the living room in the dark, not speaking, because we have learned that the loudest thing in the house is our own helplessness. We have done the neurology appointments. We have the MRI on the fridge, the MMSE score written in a notebook, the prescription for donepezil and the memantine added later. Each doctor has been kind and each has told us, essentially, the same thing: this is the natural history of Alzheimer's disease, and there is no cure. All of that is true. But nobody has ever asked what her evenings are actually like — the light in the kitchen, the noise of the television, the fact that she has not had a proper bowel movement in four days, the way she startles when the garage door opens. Everyone has been looking at her brain. Nobody has been looking at her whole day. It was only when I started reading outside the neurology literature — about circadian rhythms, about Chinese medicine's idea of a spirit that settles at dusk, about the simple physiology of a body that cannot tell day from night — that I realized only one lens had ever been pointed at my mother, and that the lens was very good and very narrow.

Two things you should know first

This will not take her mind entirely, all at once, tonight. Sundowning — the late-day worsening of confusion, agitation, and distress in Alzheimer's disease — is not a sign that a final decline has begun, and it is not a separate disease arriving to finish the job. In most people it fluctuates. It is worse on some days and gentler on others, and it is shaped by things that can be changed: light, sleep, noise, hunger, pain, constipation, infection, and the emotional weather of the household. It will not, by itself, mean she must be moved to a facility, and it does not mean you have done something wrong.

Some families do find the evenings get a little easier once the whole picture is seen from more than one angle — not because any one tradition has the answer, but because looking at light, sleep, digestion, routine, and emotional tone together sometimes reveals a lever that a single appointment never had time to find. This is not a promise. Many people continue to have difficult evenings. But the search itself is reasonable, and it is not a betrayal of good medical care.

You haven't failed. You've just been seen through the same lens

If you are reading this, you have probably already been through the loop. There was the first appointment where someone said the word "dementia" and then, gently, "Alzheimer's." There was the cognitive testing, the blood work to rule out thyroid disease and B12 deficiency, the imaging. There was a cholinesterase inhibitor, and perhaps memantine added later. There were the sleep aids tried and abandoned because they made her more confused or more unsteady. There was the advice — keep her hydrated, keep her calm, keep the routine — which is good advice and also, somehow, not enough at six o'clock in the evening.

The loop plateaus for a real reason. Standard treatment for Alzheimer's disease targets the cognitive trajectory — the slow slope of memory and function — and it does so with modest effect. It was never designed to address the daily rhythm of agitation, and it was never designed to look at the body as a system whose evenings are shaped by light exposure, meal timing, pain, and sleep architecture. One mainstream explanation is that the suprachiasmatic nucleus, the brain's master clock in the hypothalamus, is among the structures affected early in Alzheimer's disease, so the internal signal that organizes wakefulness and rest weakens; the result is a fragmented circadian rhythm, with daytime drowsiness, night-time wakefulness, and a late-afternoon window in which confusion and agitation climb (Volicer et al., 2001). That is a physiological story, not a moral one. It also happens to be a story that other traditions have been telling, in their own language, for a very long time.

The missing door is not another specialist. It is several at once.

Here is what is strange about the modern arrangement: the neurologist sees the brain, the geriatrician sees the medications, the sleep physician sees the night, the dietitian sees the plate, and the family sees all of it and is asked to hold it together alone. Nobody sits in the same room, at the same time, with the same person, and asks how these pieces interact. That is the door that has not been opened. It is not a door to a miracle. It is a door to a second opinion that is actually several opinions, held up against one another. On Rebirthealth, advisors from different medical systems review the same case independently and then peer-review each other's proposals — which is a structurally different thing from asking one more doctor the same question.

Four fields. How each one actually looks at you

Modern medicine

The person from modern medicine looking at you is looking at a neurodegenerative disease with a known biology and a measurable trajectory — and, at the evening hour, at a circadian and environmental problem layered on top of it —

they would pursue: the timing and severity of the agitation, the sleep–wake pattern across a full week, whether there is pain (arthritis, dental, urinary), constipation, urinary tract infection, or a new medication; they would check for delirium superimposed on dementia, review the anticholinergic burden of the drug list, and ask about light exposure, caffeine, alcohol, and nap length. They would want to know whether the evening distress is agitation, fear, or psychosis, because the answer changes the approach.

The direction of adjustment is to remove reversible contributors — infection, pain, constipation, sedating or activating drugs — and to stabilize the day–night rhythm with bright morning light, structured activity, and a consistent bedtime, using medication sparingly and only when non-drug measures have been tried.

The evidence here is real but modest. Bright light therapy in the morning has been studied for agitation and circadian rest–activity rhythm in dementia, with small-to-moderate benefits in some trials and inconsistent results across others (Forbes et al., 2014). Structured behavioral approaches — routines, environmental modification, caregiver training — are recommended as first-line in guidelines for behavioral symptoms of dementia before pharmacologic treatment (Kales et al., 2015). It should be noted that antipsychotics and benzodiazepines carry meaningful risks in older adults with dementia, including falls, sedation, and increased mortality, so the modern-medicine answer is often less medication, not more.

Traditional Chinese Medicine

The person from Traditional Chinese Medicine looking at you is looking at a pattern of disharmony expressed across the day — and, at dusk, at the question of whether the shen, the spirit housed in the heart, is unsettled because blood and yin are insufficient to anchor it —

they would pursue: the tongue and pulse, the quality of sleep, whether there is restlessness with dryness of mouth and eyes, whether the person is agitated and hot or withdrawn and cold, the state of digestion and stool, and the specific hour at which symptoms peak, since the traditional organ clock assigns evening hours to the heart and pericardium. They would ask about fear, startle, and night-time calling out.

The direction of adjustment is to nourish blood and yin, calm the shen, and harmonize digestion so the person is not being asked to sleep on an unsettled stomach — typically through dietary change, routine, and, in some traditions, herbal formulas.

The evidence is traditional and observational rather than definitive. Small trials of Chinese herbal formulas such as Danggui Shaoyao San and Suan Zao Ren Tang have reported improvements in agitation and sleep quality in dementia in some studies, but sample sizes are small and methodologies vary (Lin et al., 2018). It should be noted that herbal preparations can interact with cholinesterase inhibitors and other medications, and any herbal approach should be reviewed by a clinician who knows the full medication list — this tradition is a serious body of practice, not a substitute for the neurologist.

Ayurveda

The person from Ayurveda looking at you is looking at a constitution and a stage of life — vata predominance in old age, with its qualities of dryness, lightness, motion, and irregularity, which map closely onto restlessness, fragmented sleep, and anxiety at dusk —

they would pursue: the person's longstanding constitution and digestive habits, the state of the bowel (constipation is treated as central, not incidental), the timing and nature of meals, oil massage and oiling of the head and feet as a calming practice, the sensory environment, and the daily routine — sleep, wake, meals at consistent hours.

The direction of adjustment is to settle vata through warmth, oil, regularity, nourishing and easily digested food, and a calm, unhurried evening ritual — less stimulation, more grounding.

The evidence is preliminary. Small trials of Ayurvedic formulations and of oil massage (abhyanga) in dementia and in sleep disturbance have reported some benefit on agitation and sleep quality, but the literature is limited, often single-centre, and rarely blinded (Sharma et al., 2019). It should be noted that Ayurvedic herbal products vary widely in quality and can contain heavy metals in some preparations, so sourcing and clinician oversight matter; the most defensible parts of this tradition for a caregiver are the behavioural ones — routine, warmth, touch, and digestion.

Mind-body / Stress physiology

The person from mind-body and stress physiology looking at you is looking at a nervous system that has lost its predictable cues — and at the caregiver's nervous system, which is co-regulating with the patient's every single evening whether either of you intends it —

they would pursue: the household's emotional tone in the late afternoon, the caregiver's own stress and sleep, the presence of predictable ritual, the amount of noise and visual clutter, whether the person is being asked to do things that exceed their remaining capacity, and the physiological signals of arousal — breathing rate, muscle tension, startle response.

The direction of adjustment is to lower the whole household's arousal in the late afternoon — dimmer light, quieter sound, a predictable and pleasant ritual, gentle touch, slow breathing, and a caregiver who is themselves regulated — so the person is not being asked to self-soothe with a nervous system that no longer can.

The evidence supports the direction without promising the outcome. Caregiver-delivered behavioral and relaxation-based interventions have been associated with reduced agitation in some studies, and caregiver stress itself is consistently associated with worse behavioral symptoms in the person with dementia (Brodaty & Donkin, 2009). It should be noted that these are associations and modest effects, not cures, and that the burden on caregivers is real — a mind-body approach is not a way of asking you to try harder, but a way of lowering the temperature for everyone.

These four pairs of eyes have never looked at the same person at the same time.

Each has been looking at a different part of the same evening — the clock, the spirit, the constitution, the nervous system — and each has been doing so alone.

The unopened door may be the one that has not looked at you yet.

Four systems at a glance

Dimension	Modern Medicine	Traditional Chinese Medicine	Ayurveda	Mind-Body / Stress Physiology
What they look at	Neurodegeneration, circadian rhythm, reversible causes, medication burden	Pattern of disharmony, shen, digestion, hour of worsening	Constitution (vata), bowel, routine, sensory environment	Arousal, predictability, caregiver co-regulation
Core question	What is reversible, and what is the safest rhythm?	What is unsettled, and what would anchor it?	What would ground and warm this person?	What would lower the temperature for everyone?
Direction of adjustment	Remove triggers, stabilize day–night rhythm, minimize sedation	Nourish blood and yin, calm the spirit, harmonize digestion	Warmth, oil, regularity, easily digested food	Dim light, quiet, ritual, touch, slow breathing
Evidence level	Moderate for behavioral and light approaches; strong for risk of sedatives	Traditional, small trials, limited blinding	Traditional, preliminary small trials	Moderate for caregiver-based behavioral approaches
Best as	First-line medical review and safety	Adjunct, with medication review	Adjunct, behavioural core	Household-wide support and routine

Important: This complements, not replaces, your current care. Do not stop or change any medication without your mother's doctor.

Frequently Asked Questions

Why does my mom get worse in the evening and better in the morning?

The most accepted explanation is that Alzheimer's disease affects the suprachiasmatic nucleus, the brain's master clock, weakening the internal signal that organizes wakefulness and rest (Volicer et al., 2001). The result is a fragmented circadian rhythm: daytime drowsiness, night-time wakefulness, and a late-afternoon window when confusion and agitation climb. Fatigue, hunger, low light, and the accumulated stimulation of the day all add to it. It is a physiological pattern, not a sign that she is "giving up" or that the day's care has failed.

Is sundowning a sign that she is dying or that the end is near?

No. Sundowning is common in Alzheimer's disease and fluctuates; it is not, by itself, a marker of imminent decline. It can be worse during illness, after a move, or with a urinary tract infection or constipation, and it can improve when those are treated. That said, any sudden change in behaviour should be checked by a doctor, because a new or abrupt worsening can signal delirium from an infection, pain, or a medication — which is treatable.

Could a medication be making the evenings worse?

Possibly. Sedatives, antipsychotics, anticholinergics, and some pain medications can worsen confusion and agitation in older adults, and the timing of doses matters. This is exactly the kind of question a geriatrician or pharmacist review can answer. Do not stop or change anything yourself — ask for a formal medication review, and bring the full list, including supplements and over-the-counter sleep aids.

Does bright light in the morning actually help?

In some people, yes, modestly. Morning bright-light exposure has been studied for agitation and circadian rhythm in dementia, with small-to-moderate benefits in some trials and inconsistent results in others (Forbes et al., 2014). It is low-risk and worth trying: a walk outside in the morning, or a light box used under guidance. It is not a cure, and it will not work for everyone.

Can Chinese medicine or Ayurveda help her evenings?

Some small trials report improvements in agitation and sleep with herbal formulas and with oil massage, but the evidence is preliminary, samples are small, and blinding is rare (Lin et al., 2018; Sharma et al., 2019). Herbal products can interact with her medications, and some Ayurvedic preparations have been found to contain heavy metals. These traditions are worth exploring with a qualified practitioner who knows her full medication list — as an adjunct, not a replacement.

What can we do in the hour before the difficult time?

Lower the temperature of the whole house. Dim the lights, turn off the television, reduce noise and clutter, and build a predictable ritual — a warm drink, a hand massage, familiar music, a short walk, the same chair at the same time. Check for hunger, thirst, pain, and a full bladder or bowel. Keep your own voice slow and low. The goal is not to prevent the evening from happening; it is to make the evening less frightening for her and less exhausting for you.

Is it wrong to want more than one opinion?

No. It is reasonable to want the whole picture seen. The risk is not in seeking other perspectives; the risk is in abandoning good medical care for a single promised cure. Keep the neurologist, keep the medication review, and add other lenses alongside — carefully, and with someone coordinating.

What to do next

Start with what is reversible, then widen the lens — in that order.

1. Book a medication and reversible-cause review. Ask her doctor to check for pain, constipation, urinary tract infection, and any drug that could be worsening her evenings. Bring the full list, including supplements.

2. Change the evening environment for two weeks and keep a simple log. Note the hour symptoms start, what she ate, her bowel movements, light, noise, and sleep. Patterns often appear that no single appointment had time to see.

3. Let more than one lens look at her specific case. Post the details — the hour, the pattern, the medications, what you have already tried — and let advisors from different traditions review it independently and peer-review each other at Rebirthealth. You are not looking for a miracle. You are looking for the questions nobody has asked yet.

Important: This article is intended to broaden your understanding and help you ask better questions. It is not a replacement for professional medical care, and it should not be used to delay diagnosis or treatment. Always consult your mother's physician before changing medications, supplements, or care routines, and seek urgent care for any sudden worsening of confusion, fever, or distress.

References

1. Volicer L, Harper DG, Manning BC, Goldstein R, Satlin A, 2001. Sundowning and circadian rhythms in Alzheimer's disease. American Journal of Psychiatry.

2. Forbes D, Blake CM, Thiessen EJ, Peacock S, Hawranik P, 2014. Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia. Cochrane Database of Systematic Reviews.

3. Kales HC, Gitlin LN, Lyketsos CG, 2015. Assessment and management of behavioral and psychological symptoms of dementia. BMJ.

4. Lin PW, Chan WC, Ng BF, Lam LC, 2018. Efficacy of aromatherapy and Chinese herbal medicine for behavioral and psychological symptoms of dementia: a review. International Psychogeriatrics.

5. Sharma H, Chandola HM, Singh G, Basisht G, 2019. Utilization of Ayurveda in health care: an approach for prevention, health promotion, and treatment of disease. Journal of Alternative and Complementary Medicine.

6. Brodaty H, Donkin M, 2009. Family caregivers of people with dementia. Dialogues in Clinical Neuroscience.