How to manage sundown agitation in patients?

From the Guidelines

Managing sundown agitation in patients requires a multifaceted approach that prioritizes environmental modifications, behavioral interventions, and judicious use of medication, with the goal of minimizing morbidity, mortality, and improving quality of life. To manage sundown agitation effectively, it is essential to establish a consistent daily routine that includes regular meal times, activities, and sleep schedules to reduce confusion and anxiety. Creating a calm environment by adjusting lighting, reducing noise, and removing potential triggers can also help alleviate agitation. Encouraging familiar activities in the late afternoon and early evening, such as listening to soothing music or looking at family photos, can provide comfort and reassurance.

When agitation occurs, gentle redirection and reassurance should be used instead of confrontation. Ensuring the patient's basic needs are met, such as addressing hunger, thirst, pain, or the need to use the bathroom, is crucial in preventing escalation of agitation. For more severe cases, medications may be considered, but their use should be cautious and closely monitored. Low-dose antipsychotics like quetiapine (12.5-50mg) or risperidone (0.25-1mg) can be effective for short-term management of severe agitation, as suggested by 1. Additionally, melatonin (1-5mg) may help regulate sleep-wake cycles, although its use in sundowning specifically may not be directly addressed in the provided evidence.

It's also important to consider the potential side effects and interactions of these medications, as highlighted in 1, which discusses the use of midazolam and lorazepam in the management of delirium, emphasizing the need for careful dosing and monitoring due to risks such as increased falls and paradoxical agitation. The guidance from 1 further supports the cautious use of medications like haloperidol, risperidone, olanzapine, and quetiapine fumarate in the management of delirium, suggesting a tailored approach based on the patient's estimated life expectancy and the severity of delirium.

Given the complexity of sundown agitation and the variability in patient responses to different interventions, a personalized approach that combines non-pharmacological strategies with, when necessary, carefully selected and monitored medication use is likely to offer the best outcomes in terms of reducing morbidity, mortality, and enhancing quality of life.

From the Research

Management of Sundown Agitation

To manage sundown agitation in patients, several strategies can be employed:

• Identification and treatment of any physiologic factors contributing to the agitation 2
• Use of low doses of specific neuroleptics 2
• Nonpharmacological interventions such as:
  • Restriction of daytime sleep 2
  • Exposure to bright lights during the day 2
  • Mild activity schedules 2
• Validation therapy and reality orientation to improve the individual's quality of life 3

Pharmacological Interventions

Some studies have investigated the use of pharmacological interventions for managing sundown agitation:

• Risperidone has been compared to other antipsychotics such as haloperidol, olanzapine, and quetiapine, with mixed results 4
• The evidence for the use of risperidone in managing sundown agitation is of very low quality, and high-quality pragmatic RCTs are needed to draw clear recommendations 4

Clinical Relevance and Pathophysiological Determinants

Sundowning is a common manifestation among persons with dementia, and its occurrence and phenotypic characteristics may be influenced by diverse neurobiological, psychosocial, and environmental determinants 5

• The syndrome is associated with several adverse outcomes, including institutionalization, faster cognitive worsening, and greater caregiver burden 5
• There is a need for a better understanding of the pathophysiological determinants of sundowning to develop effective therapeutic approaches 5

Nonpharmacological Interventions

Nonpharmacological interventions can play a crucial role in managing sundown agitation:

• Strategies that improve the individual's quality of life, such as frequent and sufficient reality orientation and validation therapy, can be effective in reducing agitation 3
• Nurses should increase the use of validated techniques to manage acute agitation and prevent harm to the patient and personnel 3