Sundowning and Behavior Changes: How a Memory Care Home Should Respond

The National Institute on Aging describes sundowning as restlessness, agitation, irritability and confusion that happen as daylight begins to fade. It notes that being overly tired can increase late-afternoon and early-evening restlessness. The Alzheimer's Association defines it as increased confusion from dusk through night and says it is not a disease but a set of symptoms, which can include anxiety, pacing, disorientation and trouble sleeping.

The Alzheimer's Association says the exact cause is unknown. Factors it lists include tiredness at the end of the day, a disrupted internal body clock, low light and shadows, unfamiliar surroundings, and picking up on the stress of people nearby.

This page describes what these changes are and what a California care home is expected to do about them. Questions about what is causing a change in your parent, or how to treat it, belong with the doctor.

The National Institute on Aging explains that people with Alzheimer's disease may become agitated or aggressive as the disease gets worse. It describes agitation as being restless and worried and unable to settle down. A person may pace, be unable to sleep, lash out verbally or try to hit someone.

Its central point is that most of the time these behaviors happen for a reason. The causes it lists include:

• Pain, depression or stress.
• Too little rest or sleep.
• Constipation.
• A sudden change in a well-known place, routine or person.
• Too much noise or confusion, or too many people in the room.
• Being pushed to do something, such as bathing, that the disease has made very hard.
• Feeling lonely.
• Certain medications, or interactions between two medications.

Assisted living communities and board and care homes are licensed in California as residential care facilities for the elderly (RCFEs). Since January 1, 2025, their regulations use the term behavioral expression: behavior that may result in harm to the resident or others, such as unsafe wandering, expressions of frustration, disorientation, hallucinations, or lacking hazard awareness or impulse control. The definition itself says the behavior may come from boredom, fear, overstimulation, fatigue, physical discomfort, pain, medication interactions or an illness such as a urinary tract infection.

That framing carries into what the home must do when it sees or learns of behavior that has caused or may cause harm:

1. 1

   Describe it in the resident's reappraisal

   The home writes down what the behavior was.

2. 2

   Record what happened just before

   The regulation lists examples: interactions with other residents or staff, a recent change in surroundings, signs of new illness or injury such as fever or urinary urgency, overstimulation from noise or visitors, or a feeling the resident cannot put into words, such as fatigue, pain, hunger, thirst, boredom, fear, wanting to walk or needing the toilet.

3. 3

   Choose the least restrictive response

   The home sets out what it will do to reduce the risk, using the least restrictive intervention based on the individual needs of the resident.

4. 4

   Tell a medical professional about a significant change

   A significant change in condition must be brought to the attention of the appropriate licensed medical professional immediately, or as soon as reasonably possible, and the contact is recorded.

Health and Safety Code section 1569.7 adds that homes serving residents with Alzheimer's disease and other dementias should include sundowning in staff training, and should describe in their plan of operation the activities available to lessen its effects, including more outdoor activity in suitable weather.

The National Institute on Aging's suggestions for caregivers translate well into things you can see on a visit. It advises speaking calmly, listening, avoiding arguments, reassuring the person that they are safe, keeping a routine, reducing noise and clutter, letting in natural light, and offering a snack, music, a walk or a simple task as a distraction. To help prevent sundowning it suggests a regular schedule, daily sunlight, physical activity without too many activities, and avoiding caffeine and long naps late in the day.

So visit in the late afternoon. Look at whether the lights are on before dusk, whether the television is loud, whether staff are present and unhurried, and whether there is something to do. Our guide to daily life and activities in memory care covers routine in more detail.

Staff need to know these approaches. California requires dementia training for all direct care staff, including how to recognize what sets off or worsens behavior. The hours are in memory care staffing and training.

The Alzheimer's Association's advice for a person who is awake and upset includes never using physical restraint. California's regulation on postural supports points the same way. A support such as a brace or soft tie may be used only to help position a resident, needs a physician's written order, and must be fastened so the resident can release it quickly. Under no circumstances may it involve tying or limiting the use of a resident's hands or feet. Bed rails running the full length of the bed are prohibited, except for a resident on hospice whose hospice care plan calls for them.

Residents also keep the right not to be locked into any room. Medication used to quiet behavior has its own rules and risks, covered in dementia medications in care homes.

If you see a resident being restrained or handled roughly and someone is in immediate danger, call 911. Complaints about a licensed home go to California's Community Care Licensing Division.

Each home decides what it can manage, so two licensed homes can answer differently about the same person. A home that advertises dementia care must state, in its plan of operation, any special techniques it uses for specific behaviors and the conditions that would require a resident to move out. Ask to read that part. If a home later says it can no longer keep your parent, assisted living eviction rules explains the limits on that.

• What do your caregivers do when a resident becomes agitated in the evening?
• How many staff are on the floor between 3 p.m. and bedtime?
• When behavior changes suddenly, how soon do you call the doctor, and how soon do you call the family?
• May I see how you record a behavior and what led up to it?
• Which behaviors have led you to ask a resident to leave?

Hamssa Benrekia is a senior living placement specialist in Torrance with a background in hospice, palliative care and home health. She helps families in the South Bay and Harbor area of Los Angeles County find licensed homes for a person whose evenings have become hard, and goes on tours with them. To talk about memory care placement, contact Hamssa. The California Assisted Living Placement Guide covers the rest of the decision.