Four o'clock in the afternoon and she is a different person. Agitated, pacing, asking for her mother, certain she has to get to work. By ten in the morning she was fine. By four the next afternoon she is not again.

Families describe this to us the same way almost every time: it is like a switch flips. There is a name for it, and there are things that change it. Not a cure, but a real reduction in how bad the evenings get.

What is sundowning?

The Alzheimer's Association describes it as increased confusion that people living with Alzheimer's and dementia may experience from dusk through the night. It is not a separate disease and it is not the person being difficult. It is a pattern in the timing of the confusion.

Practically, it shows up as agitation, pacing, repetitive questions, suspicion, wanting to leave, or an insistence on getting somewhere they no longer need to be. The content varies. The clock is the consistent part.

Why does it happen in the late afternoon?

The exact cause is not known. The Alzheimer's Association says it may occur due to disease progression and changes in the brain. What is better understood is the list of things that make it worse, and most of them are fixable.

• Exhaustion. A day of holding it together is tiring in a way that is hard to see from outside. By late afternoon the reserve is gone.
• Low light. As the light drops, shadows appear that the brain cannot interpret. A coat on a hook becomes a person. This is one of the most direct causes and one of the easiest to remove.
• A disrupted body clock. Sleepy in the day, awake at night. Once that flips it reinforces itself.
• Your own stress. The Alzheimer's Association lists sensing stress in the caregiver as a contributing factor. If you are bracing for four o'clock, they can feel it, and that becomes part of the trigger.
• Unmet basic needs. Hunger, needing the toilet, pain. None of which they may be able to name.

What should I do in the moment when it starts?

Reduce the input and stop trying to reason.

• Turn the lights on before it gets dim, not after. The Alzheimer's Association puts it plainly: keep the home well lit in the evening to help reduce the person's confusion. Close the curtains at the same time, so the dark windows are not part of the room.
• Turn things off. Television, radio, the dishwasher, the conversation in the next room. Evening stimulation makes it worse, and a house at dinner time is usually full of it.
• Do not argue with the content. If she has to get to work, the answer is not that she retired in 1998. The answer is that the car is not there yet, sit down, here is a cup of tea.
• Go to something familiar and calming. Music they have known for fifty years, or a film they have seen a hundred times. The Alzheimer's Association suggests identifying these in advance rather than searching for one mid episode.
• Lower your own voice and slow down. Not a technique so much as the only thing that works.

What can I change during the day to make the evening better?

This is where the actual gains are. The evening is downstream of the day.

• Same times every day. Waking, meals, bed. A predictable day is the single biggest structural fix.
• Daylight, outdoors, early. Real sunlight resets the body clock in a way indoor lighting does not.
• Move the hard things to the morning. Appointments, bathing, anything demanding. Scheduling a shower for five in the afternoon is scheduling a fight. If bathing is already the hard part, we wrote about that separately: how to get someone with dementia to shower.
• Cut the caffeine, alcohol and nicotine. The Alzheimer's Association names all three as things that affect the ability to sleep. An afternoon coffee is an easy thing to keep doing without connecting it to eight in the evening.
• Keep a note of what happened before. The Alzheimer's Association suggests making notes about what happens before sundowning events and trying to identify triggers. Most families who do this for two weeks find something specific: a particular visitor, a program on the television, the time the heating comes on.

Should they be napping?

If they are not sleeping at night, no, or at least less. The Alzheimer's Association advises restricting daytime naps for people with nighttime sleep difficulty.

This is worth being honest about, because the afternoon nap is often the only two hours the person caring for them gets. Taking it away to fix the night makes the day unsurvivable. That trade is usually the point at which families start looking at bringing someone in for a few hours, and it is a reasonable reason to.

When is it not sundowning?

This matters, because the label can hide something treatable.

A sudden change, over days rather than months, is not a pattern, it is an event. The Alzheimer's Association points to conditions including urinary tract infections and sleep apnea as things that can make sleep problems worse, and recommends contacting the doctor when non drug approaches are not working.

In older adults a urinary tract infection can present as confusion and agitation with no pain and no fever at all. Families miss this constantly, because the symptom looks exactly like the dementia getting worse. If the change arrived quickly, call the doctor before you redesign the evening routine.

New or suddenly worse confusion, agitation or hallucinations are worth a same week call to the doctor. Pain, infection, dehydration and a recent medication change can all present this way, and all of them are treatable.

Does having an aide in the evening actually help?

Two reasons it often does, and we would rather say which ones.

The routine becomes the same every day. A visit at the same hour, same person, same order of things, is exactly the structure the advice above asks for, and it is very hard to hold on your own for months on end.

You stop being the one in the room at the worst hour. The Alzheimer's Association lists caregiver stress as something the person picks up on. If four to seven is the hardest stretch of your day, your tension is now part of the trigger, and you cannot talk yourself out of that. Handing those three hours to someone else can break the loop.

Our rate is $45 an hour for one to eight hours a day. A late afternoon block is a short visit rather than a long shift, and here is what that works out to at real schedules.

Where to start in Massachusetts

Before you pay anybody, call MassOptions on 1-800-243-4636 . They route you to your regional Aging Services Access Point for a free in home assessment, which tells you what the state will cover. Some families find a portion or all of it is.

If you are weighing the cost against the alternatives, we set the numbers out in can I afford Alzheimer's care at home in Massachusetts, and if you are close to hiring, these are the questions worth asking first.

Care Remedy Inc, 100 TradeCenter Suite G-700, Woburn, MA 01801. Call 781-957-8076. Our home health aides support people living with dementia at home across Greater Boston, the South Shore and the Pioneer Valley, including evening and overnight hours.

Sources: Alzheimer's Association, Sleep Issues and Sundowning. This article is general caregiving guidance and not medical advice. Any sudden change in confusion, sleep or behavior should go to the person's doctor.