What are alternative medications for managing sundowners syndrome?

Alternative Medications for Managing Sundowning Syndrome

Quetiapine is the preferred medication for managing sundowning syndrome in patients with dementia, with a recommended starting dose of 25mg orally at bedtime and a maximum target dose of 200mg/day in divided doses. 1

Understanding Sundowning Syndrome

Sundowning syndrome is characterized by the emergence or worsening of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, evening, or at night in persons with dementia 2. Its prevalence ranges from 1.6% to 66% of patients with dementia 3, and it significantly impacts patient wellbeing and caregiver burden.

First-Line Approach: Non-Pharmacological Interventions

Before initiating medication, always implement non-pharmacological strategies:

• Ensure adequate lighting to reduce shadows and improve orientation
• Maintain consistent caregivers to reduce anxiety
• Provide structured daily routines
• Address basic needs (hunger, thirst, pain, toileting)
• Ensure proper sleep hygiene
• Rule out sensory deficits that may contribute to disorientation

These approaches should be continued alongside any medication regimen 1.

Pharmacological Options

First-Line Medication Options:

1. Quetiapine:

   • Starting dose: 25mg orally at bedtime
   • Maximum target dose: 200mg/day in divided doses
   • Advantages: Lower extrapyramidal side effects compared to typical antipsychotics
   • Monitor for: Sedation, orthostatic hypotension, metabolic effects 1

2. Risperidone:

   • Starting dose: 0.25mg/day
   • Maximum dose: 2mg/day (lower in elderly)
   • Particularly effective for agitation with aggressive features
   • Monitor for: Extrapyramidal symptoms, increased stroke risk 1

3. Olanzapine:

   • Starting dose: 2.5mg/day
   • Maximum dose: 10mg/day
   • Monitor for: Sedation, metabolic effects, falls 1

Second-Line Options:

1. Haloperidol:

   • Dose: 0.5-1mg orally at night and every 2 hours when required
   • Maximum: 5mg daily
   • Best for acute, severe agitation
   • Higher risk of extrapyramidal side effects 1

2. Lorazepam (for anxiety component):

   • Dose: 0.25-0.5mg orally four times daily as needed
   • Maximum: 2mg in 24 hours for elderly patients
   • Caution: Not recommended for long-term use due to risks of cognitive impairment, falls, and dependence 1

3. Melatonin:

   • Useful for circadian rhythm regulation
   • May help with sleep-wake cycle disturbances underlying sundowning
   • Evidence supports its use in non-24-hour sleep-wake rhythm disorders 4

Special Considerations

Elderly Patients:

• Require lower doses of antipsychotics
• More susceptible to side effects
• Avoid long-term benzodiazepine use due to increased risk of falls, cognitive impairment, and dependence 1

Monitoring Requirements:

• Follow-up within 1-2 weeks after medication changes
• Assess for side effects, therapeutic response, and emergence of other psychiatric symptoms
• Regular reassessment of medication need within 3-6 months
• Monitor for metabolic side effects with atypical antipsychotics 1

Stepwise Treatment Algorithm

1. Identify and address underlying causes of agitation/restlessness

   • Rule out delirium, pain, infection, medication side effects
   • Ensure basic needs are met

2. Implement non-pharmacological interventions as described above

3. If symptoms persist, initiate pharmacological therapy:

   • For mild-moderate symptoms: Start with quetiapine 25mg at bedtime
   • For symptoms with prominent anxiety: Consider adding lorazepam short-term
   • For severe agitation with aggression: Consider risperidone

4. Titrate medication based on response and tolerability:

   • Increase dose gradually every 3-7 days until symptom control or maximum dose reached
   • If inadequate response after 2-4 weeks at maximum tolerated dose, switch to alternative agent

5. Regular reassessment:

   • Attempt dose reduction or discontinuation after 3-6 months of stability
   • Continue non-pharmacological approaches throughout treatment

Common Pitfalls to Avoid

• Using benzodiazepines as first-line or long-term therapy in elderly patients
• Failing to rule out reversible causes of agitation before starting medication
• Inadequate monitoring for medication side effects
• Not implementing non-pharmacological approaches alongside medications
• Using excessive doses in elderly patients, increasing risk of adverse effects
• Not reassessing the need for continued medication therapy

By following this evidence-based approach to managing sundowning syndrome, clinicians can effectively address symptoms while minimizing risks associated with pharmacological interventions.