What are sundowners and how do they cause medication refusal at night?

Sundowning is a pattern of late-afternoon and evening confusion, anxiety, restlessness, and resistance to care that the Alzheimer's Association estimates affects about 1 in 5 people with Alzheimer's disease. In my experience, refusing the nighttime pills is one of the most common ways that pattern shows up, for a simple reason: the medications are the hardest task of the day, and they land at the exact hour when your parent's brain has the least left in the tank. You're not imagining the pattern, and your dad isn't being difficult on purpose.

Can sundowning happen without dementia?

Yes, and this is one of the most useful things to sort out early. Sundowning is best understood as a behavioral pattern, not a diagnosis, so the evening confusion can show up for reasons other than dementia: plain exhaustion at the end of a long day, poor sleep, low evening light, an infection like a urinary tract infection that quietly causes confusion in older adults, or a medication side effect. I think about it in three buckets. The first is a parent who is lucid but tired and stubborn. The second is dementia-driven sundowning, where the evening brain genuinely can't organize the task. The third, and the most missed, is when a medication is causing the very confusion that drives the refusal. Each bucket needs a different response, so the first job is figuring out which one you're watching.

Why does my dad take his pills fine in the morning but refuse them at night?

Several things stack up at once in the evening. The internal body clock shifts in aging and in dementia, and the late-day part of that shift brings rising agitation. Following a multi-step task takes more mental energy than your dad has left by 9 p.m. The light drops, the kitchen looks unfamiliar, and unfamiliar feels threatening. And, the part most families never hear, some of the medications in that nighttime cluster can themselves be causing the confusion that drives the refusal. Morning is simply the hour when the brain is rested enough to cooperate.

Which medications can cause or worsen sundowning?

This is the part most families never get told, and it is the first thing I look at. Four groups come up again and again. Anticholinergic medications, especially diphenhydramine (the antihistamine in many 'PM' sleep aids) and bladder drugs like oxybutynin, block a brain chemical needed for memory and attention and are well documented to worsen evening confusion. Benzodiazepines like lorazepam and alprazolam, and the so-called Z-drugs like zolpidem, often backfire in older adults with dementia and worsen confusion, agitation, and falls rather than calming them. Certain antipsychotics. And opioids, especially combined with any of the above. All of these appear on the American Geriatrics Society's Beers Criteria as medications to avoid or use cautiously after 65. If your dad is refusing at night and also seems more confused in the evening, the list itself may be part of the problem, which is exactly what a second set of eyes is for.

What medication is best for sundowning?

I have to be careful here, because the honest answer is that the best first move usually isn't a medication at all, and any actual prescribing decision belongs to your parent's doctor. The clinical guidance, from Cleveland Clinic and geriatric pharmacy sources, is consistent: start with the non-drug things (steady routine, brighter evening light, calmer surroundings, more daytime activity) and review the current list for anything that might be making it worse. When something is needed, melatonin to support the sleep-wake cycle and a low dose of an antidepressant like trazodone are generally tried before anything stronger. Antipsychotics like quetiapine (Seroquel) and risperidone are a last resort, used only for severe or dangerous agitation, because they carry an FDA boxed warning for increased risk of death in older adults with dementia. So the better question to bring to the prescriber isn't 'what's the strongest pill,' it's 'can we try melatonin or low-dose trazodone first, and can we take anything off the list that's adding to the confusion?'

Should I crush my dad's pills and hide them in his food?

Not without checking with a pharmacist first. Many medications cannot be crushed safely. Extended-release tablets dump their whole dose at once when crushed, enteric-coated tablets turn harsh on the stomach, and capsules with beads can lose effect. Some pills get bitter enough that crushing them makes the refusal worse. Call the community pharmacist with the bottle in your hand and ask whether each one is safe to crush and what to mix it with. The separate ethics of giving medication without your parent's knowledge is a real conversation to have with the prescriber, not a workaround to improvise at the kitchen counter.

When should I call the doctor about my parent refusing pills at night?

Sooner than most families think. Call if the refusal has been consistent for more than a few days, if your parent is missing doses of high-risk medications like blood thinners, blood pressure pills, Parkinson's medication, thyroid medication, or insulin, if the refusal comes paired with new confusion or agitation, or if you are simply exhausted. That last reason counts as much as the others. A clinical team can't adjust a plan they don't know is failing, and a new behavioral change in an older adult sometimes signals something treatable, like an infection, hiding underneath.

What if fewer pills is the real answer?

Often it is. A typical list for an older adult with several conditions and several prescribers will usually contain at least one medication that could safely come off, like a stomach-acid pill started in the hospital three years ago and never revisited, or an antihistamine taken for 'allergies' that is quietly causing the evening confusion. When the list shrinks to only the medications actually doing work, the nighttime routine gets shorter and there's less to fight about. That decision belongs to the prescriber, but a pharmacist looking at the full picture across every doctor is one of the most useful first steps I know of.

Sundowners and Medications: When Your Dad Won't Take His Pills at Night

She tries at 8 p.m. He won’t. By 9, it’s a fight. By 10, she is crying in the hallway with a small paper cup in her hand and four pills in it, and her father is in the bedroom telling her he already took them, and she knows he did not.

If you have lived this scene with a parent, you are not alone, and you are not failing. The 8-to-10 p.m. medication refusal in older adults with cognitive decline is so common it has a name in the clinical literature: it shows up inside the broader pattern called sundowning, which the Alzheimer’s Association describes as the late-afternoon and evening agitation, confusion, anxiety, and resistance that affects an estimated 1 in 5 people with Alzheimer’s disease and many people with other dementias. Refusing nighttime medications is one of the most exhausting expressions of that pattern, because it lands on the person in the family who is trying to do everything right.

I am Andrea Simon, a hospital pharmacist in Southern California. I am board-certified in infectious diseases pharmacy, and California recognizes me as an Advanced Practice Pharmacist, which means I am credentialed to do this medication work. I review a parent’s full medication list independently, as a second opinion, and I explain what’s happening in plain language so the family can decide what to bring back to their own doctor. I have spent more than a decade looking at why patients in the hospital refuse medications, and I have spent the last year doing the same work for families privately through ManyMeds. This article is what I would tell my own family if I were on the phone with my sister at 10 p.m. on a Tuesday.

What you are seeing has a clinical pattern, a set of physical and chemical reasons behind it, a set of medications that make it worse, and a set of strategies that actually move the needle. I will walk you through all of it. By the end of this article, you should have language for what is happening and the next three concrete things to try.

Quick answers (for the daughter sitting on the bathroom floor)

What is sundowning, and is medication refusal part of it? Sundowning is a behavioral pattern of late-afternoon and evening agitation, confusion, anxiety, restlessness, or resistance that the Alzheimer’s Association estimates affects about 1 in 5 people with Alzheimer’s disease. The National Institute on Aging describes the same pattern in dementias more broadly. Refusing nighttime medications is one of the most common expressions of sundowning in older adults with cognitive decline, because the medications are the task that lands at the exact hour of day when the brain is least cooperative.

Why does my dad refuse pills at night but take them in the morning? Several reasons line up at the same time. The circadian system shifts in dementia, and the late-day part of that shift is associated with rising agitation and decreased ability to organize complex actions. Fatigue is a factor; following a multi-step instruction (read label, take pill, drink water) requires more executive function than mornings, when the brain is rested. Light levels drop, the home looks less familiar, and unfamiliar inputs feel threatening. And, often overlooked, several specific medications can themselves cause the confusion that drives the refusal.

Is medication refusal in older adults considered abuse if you push them to take it? No. Encouraging a parent who has cognitive decline to take prescribed medications is not abuse. Forcing, lying to, or hiding medication in food in a way that bypasses informed consent is a separate, more complicated question with legal and ethical dimensions that deserve a real conversation with the prescribing physician. The middle path, what I encourage families to do, is to try every non-coercive strategy first and to bring the refusal back to the doctor as a clinical problem to solve rather than a behavior to fix.

Should I crush my dad’s pills and put them in his food? Not without checking with a pharmacist. Many medications cannot be crushed. Extended-release tablets become dangerous when crushed because the entire dose is delivered at once. Enteric-coated tablets become irritating to the stomach. Capsules with beads can lose effectiveness. Some pills become bitter and unpalatable enough that crushing makes the refusal worse. Before you crush anything, call the community pharmacist with the bottle in your hand and ask: “Is this drug safe to crush, and if I do, what should I mix it with?”

When should I call the doctor about nighttime medication refusal? If refusal becomes consistent for more than a few days, if your parent is missing doses of high-risk medications (blood thinners, blood pressure, Parkinson’s, thyroid, diabetes), if refusal is paired with new confusion or agitation, or if you are exhausted. The last reason is not less important than the others. A clinical team should know what your home is dealing with so they can adjust the plan.

The sundown refusal pattern, named

If you search the public dementia literature, you will find sundowning described as a constellation of evening symptoms: confusion, anxiety, restlessness, pacing, aggression, increased verbal disinhibition, and resistance to care. The Alzheimer’s Association’s public guidance lists triggers that include end-of-day exhaustion, low lighting, increased shadows, disruption of the internal body clock, and unmet needs (hunger, thirst, pain, full bladder).

What the public literature does not name as a single phrase is the specific pattern most families describe to me: a parent who is reasonable about medications in the morning, neutral about them at lunch, and a different person at 8 p.m. when the daily nighttime cluster of pills comes out. That pattern is real. It maps neatly onto the sundowning pathway. And it is one of the most common medication-management problems in outpatient dementia care.

A 2019 Journal of the American Geriatrics Society analysis estimated that about 13.9% of adults aged 65 and older in the U.S. are on 5 or more medications, and the proportion rises sharply in the 75-plus group and in adults with cognitive impairment. The nighttime cluster (beta-blocker, statin, blood thinner, diabetes medication, Parkinson’s medication, antidepressant, sleep aid, calcium, vitamin D, antihypertensive at dinner) is often the largest of the day. That cluster lands at the worst possible hour, on a brain that is least equipped to absorb instructions.

You are not imagining the pattern. It is real, it is described, and it is solvable.

What is actually going on in the brain

Several mechanisms stack. None of them is your parent being “difficult.”

Circadian rhythm changes

The brain’s master clock, the suprachiasmatic nucleus, regulates the sleep-wake cycle. In aging brains and especially in brains affected by Alzheimer’s, that clock degrades. The result is a shift in the daily pattern: fragmented sleep, daytime drowsiness, and a window of agitation that often peaks in the late afternoon and early evening. The National Institute on Aging summarizes the same: people with dementia frequently experience disturbed circadian patterns that worsen across the day.

A 2020 review in Frontiers in Neurology described measurable degeneration of the suprachiasmatic nucleus in Alzheimer’s disease at autopsy, with the magnitude of degeneration correlating with daytime-nighttime behavioral disruption.

Executive function fatigue

Following a multi-step instruction (recognize the bottle, read the label, place the pill on the tongue, drink water, swallow, set the bottle down, repeat for the next pill) requires intact executive function. That executive function is the first thing to decline in many dementias, and even in normal aging, it is depleted by the end of a day. The same parent who can manage a morning regimen with limited cueing may simply not have the cognitive resources at 9 p.m. to follow the same sequence. Refusal can look like opposition. It is often the only available exit from a task the brain cannot organize.

Visual processing changes

Late-day lighting drops, shadows extend, and depth perception changes. For a person with dementia or visual impairment, the kitchen counter at 9 p.m. may look meaningfully different than it does at 9 a.m. Bottles look unfamiliar. Pills look unfamiliar. The hand holding the pill looks unfamiliar. The Alzheimer’s Association names visual triggers as part of the sundowning picture.

Medications themselves making it worse

This is the part most families do not know about. Several common medications can themselves cause or worsen the evening confusion and refusal pattern.

Anticholinergic medications. Diphenhydramine (Benadryl, also in many “PM” sleep aids), oxybutynin and tolterodine for overactive bladder, certain older antihistamines, certain muscle relaxants, certain tricyclic antidepressants. The 2023 American Geriatrics Society Beers Criteria flag anticholinergics as a class to avoid in older adults because of their well-documented contribution to confusion, sedation, falls, and delirium. A 2015 study in JAMA Internal Medicine found a dose-response relationship between cumulative anticholinergic exposure and dementia risk in older adults.

Benzodiazepines and Z-drugs. Diazepam, alprazolam, lorazepam, temazepam, zolpidem, eszopiclone. The Beers Criteria flag these as drugs to avoid in older adults because they double the risk of falls and have been associated with confusion and delirium, particularly in patients with dementia.

Certain antipsychotics. Quetiapine, olanzapine, risperidone, haloperidol. The FDA has a black-box warning for increased mortality when antipsychotics are used in elderly patients with dementia-related psychosis. They are sometimes still used for severe agitation, but the AGS Beers Criteria give a strong recommendation to avoid antipsychotics for behavioral problems of dementia unless non-drug approaches have failed.

Opioids. Especially when combined with any of the above. Opioids depress respiration, slow gut motility, and contribute to confusion. Older adults on opioids have substantially higher rates of falls, delirium, and adverse events.

If your dad is refusing pills at night, the first question I ask is: what is on the list, and is any of it making the refusal worse?

The five reasons your parent says no (and what to do about each)

Refusal is not one thing. It is at least five. Different reasons take different responses.

1. “I already took them”

The most common version. It is not lying. It is the truth, as your parent’s memory is recording it. Short-term memory is the first thing to go in many dementias, and a parent may genuinely have no memory of the morning dose, or may be conflating yesterday’s dose with today’s.

What to try. A weekly pill organizer with the days printed clearly on each cell, where each cell visibly empties as doses are taken. A photo of the empty cell, taken with the morning dose, that you can show in the evening. A simple log on the fridge with a checkmark and the time. Crucially: do not argue about whether the morning dose happened. Acknowledge, redirect to the visual cue, and move forward.

2. “I don’t need them”

This often comes from a stage of dementia where the parent has lost insight into the conditions the medications are treating. They feel fine. They look fine to themselves in the mirror. They do not see the blood pressure number, the blood sugar number, or the years of clinical reasoning that put them on the list. Arguing about the diagnosis rarely works.

What to try. Externalize the authority. “The doctor wants you to take these tonight” works better than “You have to take these because of your blood pressure.” A printed note from the prescribing physician with the parent’s name on it (which any primary care office will provide on request) can be remarkably effective. The note belongs to the doctor, not to you. That changes the emotional shape of the request.

3. “They make me feel bad”

The most underrated reason. Many medications taken at night cause specific side effects that the parent associates, correctly, with the evening: muscle relaxants make them groggy and unsteady, statins cause muscle aches in some patients, certain blood pressure medications cause dizziness on standing, anticholinergics cause dry mouth and confusion, opioids and benzodiazepines cause grogginess and falls. If your parent says “they make me feel bad,” they are often reporting a real adverse effect that nobody has asked them about.

What to try. Write down which medications are at night, which specific symptom they associate with each, and bring the list to the primary care doctor or community pharmacist for a real review. Some of the nighttime cluster may be movable to morning. Some of it may be substitutable for a different drug with a better side-effect profile. Some of it may not need to be on the list at all.

This is the category where a pharmacist review changes the most lives. The drugs in the nighttime cluster are often the ones most worth questioning.

4. “I don’t recognize that pill”

This is a real perceptual problem, especially when generic manufacturers change. A round white pill this month becomes an oval yellow pill next month for the same drug. To a parent with dementia or low vision, an unfamiliar pill at the unfamiliar hour, in the dim kitchen, is exactly the moment to refuse.

What to try. Use a single pharmacy whenever possible so manufacturer changes are minimized. Take a phone photo of every pill at the moment of fill and tape it to the bottle. When a generic changes shape or color, ask the pharmacist to put a “same drug, new appearance” sticker on the bottle.

5. “I just want this to stop”

The hardest reason. Sometimes the refusal is a coherent statement of where your parent is, especially if they are nearing the end of a long illness or have expressed values about quality versus quantity of life. This is not the moment to push harder on the schedule. It is the moment to have a different conversation with the primary care team, the palliative care team, or hospice, about which medications are still serving the goals your parent actually has.

What to try. Name what you are hearing, gently. Bring it to the next physician visit. Many medications late in life can be tapered or stopped without harm, and that decision is the doctor’s to make, in conversation with you and your parent. Asking the question is not giving up. It is taking your parent’s experience seriously.

What to do at 9 p.m. tonight

Five practical moves.

1. Stop the fight. Step away for 20 minutes. Escalation increases refusal. Walk to another room. Drink water. Reset.

2. Bring the dose back at a different hour, if the drug allows it. Many medications have flexibility. A statin can move from bedtime to dinner. A blood pressure medication can sometimes move to morning. A thyroid medication needs to be on an empty stomach but is morning-only anyway. A blood thinner needs to be at the same time every day, but that time can be 6 p.m. instead of 9 p.m. Confirm with the community pharmacist before you reschedule anything.

3. Try one of the strategies above based on the specific reason. If it is “I already took them,” reach for the pill organizer. If it is “I don’t need them,” reach for the doctor’s note. If it is “they make me feel bad,” write it down for the next visit.

4. Document what was missed. Date, drug name, time, your parent’s stated reason. If refusal becomes a pattern, this log is what the doctor needs to adjust the plan. Do not improvise dose changes yourself.

5. Sleep. Tonight is not the night to solve this. Tonight is the night to survive this. The work happens in the calmer hours.

When the refusal is about the medication list itself

Sometimes the right answer is not better strategy. Sometimes the right answer is fewer pills.

The American Geriatrics Society Beers Criteria, the AGS-endorsed STOPP criteria from Europe, and the National Institute on Aging’s public guidance all describe a clinical approach for older adults that involves reviewing the full medication list periodically and looking for items that can come off the list. The goal is not minimal medications. The goal is the right medications, at the right doses, for the right reasons, and stopping the rest.

A typical outpatient list in an older adult with three or more conditions and four or more prescribers will contain at least one drug that could safely come off. Common examples I see in the families I work with: a PPI started during a hospitalization three years ago, a sleep aid started for inpatient insomnia and never reviewed, a muscle relaxant started for low back pain that is no longer present, an antihistamine taken for “allergies” that is actually causing the evening confusion, an overlapping pair of blood pressure medications from two different prescribers.

When the list shrinks to the items that are actually doing work, evening refusal often shrinks with it. Fewer pills, a shorter routine, a clearer reason for each item, less to fight about.

A medication review with a pharmacist who looks at the full picture (not the slice each individual prescriber sees) is one of the most reliably useful interventions I know of in outpatient older-adult care. I have written about what a hospital pharmacist actually does, and the outpatient version of that work is the same clinical eye applied to your kitchen counter.

What I would do if it were my dad

I am going to keep this short.

I would write down every drug, every dose, and the specific time my dad is supposed to take each one, on a single sheet of paper. I would put the bottles in one bin and take phone photos of each label. I would write down, for the past two weeks, every dose he refused and the reason he gave. I would ask the primary care office to print a one-page note in his name listing the medications and the reason for each one, in plain language, and I would tape that note to the inside of the medicine cabinet. I would call the community pharmacist with the bottle list in front of me and ask: which of these are safe to crush, which can move to morning, and which should be reviewed at the next physician visit. And I would ask for a full medication review by a pharmacist, because the list itself may be part of why he is refusing.

If you would like a clinical pharmacist to do that review for you, that is what I do at ManyMeds. The Medication Clarity Visit is one hour, in person if you are in Los Angeles or Ventura County, by video anywhere in California. You walk away with the full picture of what your dad is taking: every drug, every dose, every doctor, every pharmacy, plus a home schedule any family member can follow, plus the specific questions to bring back to your dad’s doctor.

Tell me what you are dealing with, and I will tell you how I can help. You shouldn’t have to figure this out alone.

Frequently asked questions

What is the most common reason older adults refuse medications at night?

The clinical literature on sundowning describes a pattern of late-afternoon and evening confusion, anxiety, and resistance to care in adults with dementia, affecting an estimated 1 in 5 people with Alzheimer’s disease (Alzheimer’s Association). Refusal is one of the most common expressions of that pattern, in part because the brain’s executive function is most depleted at that hour, in part because the daily nighttime cluster of medications is usually the largest of the day.

Which medications are most likely to cause confusion in older adults?

Anticholinergic medications (diphenhydramine, oxybutynin, certain older antihistamines and antidepressants), benzodiazepines and Z-drugs (alprazolam, lorazepam, zolpidem, eszopiclone), certain antipsychotics (quetiapine, risperidone, haloperidol, olanzapine), and opioids. All of these appear on the AGS Beers Criteria as drugs to avoid or use cautiously in adults aged 65 and older. If your parent is on any of these, and is also experiencing evening confusion or refusal, the medication list itself may be part of the problem.

Can I crush my parent’s pills and hide them in food?

You can ask your community pharmacist whether each specific pill can be crushed. Many cannot, including extended-release tablets, enteric-coated tablets, and capsules with beads. The ethical question of giving medications without informed knowledge is separate and worth a conversation with the prescriber. The middle path most families settle on, with their physician’s guidance, is to try every non-coercive strategy first.

Is sundowning the same thing as dementia?

No. Sundowning is a behavioral pattern that occurs in many people with dementia, but it is not a diagnosis itself. The Alzheimer’s Association and the National Institute on Aging both describe it as a constellation of late-day symptoms that can include confusion, agitation, anxiety, and refusal of care, with multiple contributing causes including circadian rhythm changes, fatigue, lighting, and medications.

How do I know if my parent’s medication refusal is a medical emergency?

Call 911 or your parent’s doctor immediately for: sudden, severe confusion that is new in the last 24 hours; chest pain; difficulty breathing; signs of stroke (facial droop, slurred speech, one-sided weakness); seizure; or unresponsiveness. For non-emergency but worrying changes, including a pattern of refusal that is new in the last week, or refusal of high-risk medications (blood thinners, blood pressure, Parkinson’s, insulin), call the primary care office during business hours the next day.

About the author

Andrea Simon is a practicing hospital pharmacist in antimicrobial stewardship at a Southern California hospital. She holds a Doctor of Pharmacy from USC, completed residency training, is board-certified in infectious diseases pharmacy, and is licensed as an Advanced Practice Pharmacist by the California State Board of Pharmacy. She founded ManyMeds to give families access to the same medication-safety work she does in the hospital.

References

Alzheimer’s Association. Sleep issues and sundowning. Public-facing guidance: estimated 1 in 5 people with Alzheimer’s experience sundowning.
National Institute on Aging. Tips for coping with sundowning. Public-facing guidance on triggers, strategies, and when to seek medical care.
American Geriatrics Society. 2023 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Lists anticholinergics, benzodiazepines, Z-drugs, certain antipsychotics, and other classes to avoid or use cautiously.
Gray SL, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Internal Medicine, 2015.
Musiek ES, Holtzman DM. Mechanisms linking circadian clocks, sleep, and neurodegeneration. Science, 2016. Circadian system disruption in Alzheimer’s disease.
Frontiers in Neurology. Suprachiasmatic nucleus changes in Alzheimer’s disease, 2020 review.
U.S. Food and Drug Administration. Boxed warning: increased mortality with antipsychotics in elderly patients with dementia-related psychosis.
Journal of the American Geriatrics Society analysis: medication burden in older adults. Approximately 13.9% of adults aged 65 and older are on 5 or more medications, with higher proportions in the 75-plus group.