Medications That Cause Sundowning: What Families Should Know
Can medications cause sundowning?
Some medications can make sundowning symptoms worse, but they are not necessarily the direct cause of sundowning. Medicines that increase confusion, sedation, agitation, sleep disruption, or delirium may make late-day behavioral changes more noticeable in an older adult with dementia. Medication classes that deserve particular attention include anticholinergic medicines, certain antihistamines and sleep aids, benzodiazepines, Z-drugs, antipsychotics, opioids, systemic corticosteroids, and some H2-blocking stomach medicines.
If sundowning started or became worse after a medication was added, stopped, increased, decreased, or moved to a different time of day, ask the person's doctor or pharmacist for a medication review.
What does sundowning actually mean?
Sundowning describes a pattern in which a person living with Alzheimer's disease or another form of dementia becomes more restless, agitated, irritable, or confused as daylight begins to fade. For some families, the change is mild. For others, evenings may bring pacing, anxiety, difficulty settling down, sleep disruption, resistance to care, or noticeably greater confusion.
Sundowning is not explained by one single trigger. Fatigue, disrupted sleep, changes in routine, pain, constipation, stress, an overstimulating environment, changes in daylight, medical problems, and medication effects may all contribute to behavioral changes.
Medications that may make sundowning worse
The phrase “medications that cause sundowning” is commonly searched, but the relationship is more nuanced. A medication may worsen cognition, trigger delirium, cause sedation, disturb sleep, or increase agitation. In a person who already experiences dementia-related late-day confusion, those effects can resemble or intensify sundowning.
The following medication groups are especially important to discuss with a physician or pharmacist when a new pattern of evening confusion appears.
Anticholinergic medicines can affect brain function and are associated with confusion and delirium risk in older adults. The total “anticholinergic burden” can become especially important when a person takes several medicines with these properties.
Examples that may warrant review: diphenhydramine, doxylamine, hydroxyzine, meclizine, promethazine, amitriptyline, paroxetine, oxybutynin, tolterodine, cyclobenzaprine, and other medicines with significant anticholinergic effects.
Families sometimes overlook over-the-counter products because they do not feel like “prescriptions.” Some first-generation antihistamines and nighttime sleep products contain medicines such as diphenhydramine or doxylamine, both of which have strong anticholinergic effects.
Check cold, allergy, nighttime pain, and “PM” products carefully because the same active ingredient can appear in several different brands.
Benzodiazepines can increase cognitive impairment, sedation, falls, and delirium risk in older adults. They may still have appropriate medical uses, so the goal is not to stop them abruptly but to review whether the medication, dose, timing, and ongoing need remain appropriate.
Examples include: lorazepam, alprazolam, clonazepam, diazepam, temazepam, oxazepam, and similar medicines.
Nonbenzodiazepine sleep medicines, sometimes called Z-drugs, can produce adverse effects similar to benzodiazepines in older adults, including delirium and falls. A sleep medicine that causes next-day grogginess or confusion can also complicate an already disrupted sleep-wake cycle.
Examples include: zolpidem, eszopiclone, and zaleplon.
Opioids can contribute to sedation and delirium in susceptible older adults. Pain itself can also worsen agitation, so medication review should focus on balancing adequate pain control with possible medication-related cognitive effects rather than simply removing treatment.
Combining opioids with benzodiazepines can create additional safety risks and deserves careful clinical review.
Antipsychotics may sometimes be prescribed for specific psychiatric conditions or severe behavioral symptoms, but they require particular caution in dementia. The AGS Beers Criteria advises against routine use for dementia-related behavioral problems unless non-drug approaches have failed or are not possible and the person poses a substantial risk of harm.
Examples include: haloperidol, risperidone, olanzapine, quetiapine, aripiprazole, and others.
Oral or injectable corticosteroids can contribute to delirium or behavioral changes in susceptible older adults. When these medicines are medically necessary, clinicians may consider the lowest appropriate dose and shortest appropriate duration while monitoring for mental-status changes.
The AGS Beers Criteria also flags several H2-receptor antagonists for older adults who have or are at high risk for delirium.
Examples include: cimetidine, famotidine, and nizatidine.
Why can a medication problem look like sundowning?
Medication effects do not always appear immediately after a pill is taken. Sedation, drug accumulation, interactions, changes in sleep, dehydration, pain, reduced kidney function, or the combined effect of several medications may influence how alert and oriented an older adult feels later in the day.
That is why the pattern matters. A clinician may want to know whether the evening behavior began after a prescription change, whether it follows a particular dose, and whether the person is also confused at other times of day.
What should families review with the care team?
Bring every prescription, over-the-counter medicine, vitamin, supplement, sleep product, allergy medicine, and as-needed medication into the conversation.
- Did the confusion begin after starting a new medication?
- Was a dose recently increased, reduced, or moved to another time of day?
- Is the person using an OTC sleep, allergy, cold, or “PM” product?
- Are several medications causing sedation or affecting the central nervous system?
- Does the person take more than one medicine with anticholinergic properties?
- Could a medication interaction be contributing to the change?
- Are doses still appropriate for the person's current kidney function and overall health?
- Is pain, constipation, poor sleep, dehydration, infection, or another medical issue contributing to the behavior?
- Is there a safer medication, different dose, or different dosing time that the clinician considers appropriate?
Do not change medications without clinical guidance.
Discovering that a medication may contribute to confusion does not mean it should suddenly be discontinued. Some medications can cause withdrawal, rebound symptoms, uncontrolled pain, seizures, or other serious problems when stopped incorrectly.
Instead, contact the prescribing clinician or pharmacist. They can review the reason the medication is being used, whether the dose remains appropriate, possible interactions, alternative treatments, and whether any change should happen gradually.
“Could any prescription medicine, over-the-counter product, supplement, dose, interaction, or medication timing be contributing to this new evening confusion?”
New confusion should not automatically be blamed on dementia.
Sundowning usually describes a recurring late-day pattern. A sudden, rapidly fluctuating, or dramatic change in behavior or mental status can be different. Medication side effects, interactions, infection, pain, dehydration, constipation, and other medical problems may cause acute confusion.
Contact the person's health care professional promptly when confusion appears suddenly, becomes substantially worse than the person's usual pattern, or follows a recent medication change. Tell the clinician exactly what changed, when it began, and what medications or supplements the person is taking.
How home care can support a family managing sundowning.
Home care does not replace medical evaluation or medication management by the prescribing clinician. It can, however, help families create more consistency around the person's everyday routine and communicate meaningful changes to the appropriate care team.
Exploring home care for an older adult with memory changes?
Families supporting someone with dementia may need different levels of assistance over time. Dynamiks Home Care can help families explore senior home health care, home health aide support, respite care, skilled nursing, and other appropriate in-home services based on the person's needs.
Learn more about senior and adult home health care in Florida, explore in-home respite care, or review Dynamiks Home Care services.
Questions about medications and sundowning.
What medications can cause sundowning?
There is not one established list of medications that directly causes sundowning. However, medicines that increase confusion, sedation, agitation, sleep disruption, or delirium may worsen sundowning-like symptoms. Important medication classes to review include anticholinergics, first-generation antihistamines, benzodiazepines, Z-drug sleep medications, antipsychotics, opioids, systemic corticosteroids, and certain H2 blockers.
Can Benadryl make sundowning worse?
Diphenhydramine, the active ingredient in many Benadryl products, has strong anticholinergic properties and can cause confusion and other cognitive side effects in older adults. Families caring for someone with dementia should discuss its use with the person's physician or pharmacist rather than assuming an over-the-counter medicine is risk-free.
Can sleeping pills make dementia confusion worse?
Some sleep medications can increase confusion, sedation, falls, or delirium in older adults. Benzodiazepines and Z-drugs such as zolpidem, eszopiclone, and zaleplon are among the medication classes that deserve careful review in older adults with cognitive impairment.
Can anxiety medication make sundowning worse?
Some anxiety medications, particularly benzodiazepines, can increase sleepiness, cognitive impairment, falls, and delirium risk in older adults. That does not mean the medication is inappropriate for every person. A clinician should weigh the reason for treatment, dose, benefits, risks, and possible alternatives.
Can pain medicine cause evening confusion?
Opioid pain medicines can contribute to delirium or sedation in susceptible older adults. At the same time, untreated pain can also worsen agitation. Pain treatment should therefore be reviewed with a clinician rather than stopped without guidance.
Should I stop a medication if sundowning gets worse?
No prescribed medication should be stopped solely because it appears on a medication-risk list. Contact the prescribing clinician or pharmacist. Some medicines require gradual dose changes, and abruptly stopping them can create additional health risks.
How do I know if it is sundowning or delirium?
Sundowning generally describes a recurring pattern of increased confusion or agitation later in the day. Delirium is an acute change in attention and mental status that may fluctuate and can be triggered by illness, medication effects, or other medical problems. Sudden or significantly worsening confusion deserves prompt medical evaluation.
What information should I give the doctor?
Bring a complete list of prescription medicines, over-the-counter products, supplements, and as-needed medicines. Note recent medication or dose changes, when the confusion begins, sleep patterns, fluid and food intake, pain, bowel changes, illness symptoms, and any change from the person's normal behavior.
Medical Sources
- National Institute on Aging. Coping With Agitation, Aggression, and Sundowning in Alzheimer's Disease. National Institute on Aging
- National Institute on Aging. Managing Sleep Problems in Alzheimer's Disease. National Institute on Aging
- National Institute on Aging. Cognitive Health and Older Adults. National Institute on Aging
- American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. View the criteria
Supporting a loved one with dementia or evening confusion?
Dynamiks Home Care can help your family explore appropriate in-home support for an older adult, including senior home care, home health aide services, respite care, skilled nursing, and care coordination based on the person's needs, location, staffing, payer requirements, and approved plan of care.
