Management of Sundowning Syndrome in an Elderly Hospitalized Patient
Nonpharmacologic interventions that simulate normal circadian sleep/wake cycles should be the first-line approach for managing sundowning-related agitation in elderly hospitalized patients, with pharmacologic options reserved for refractory cases.
Initial Assessment and Nonpharmacologic Interventions
Environmental Modifications
- Maintain consistent daily schedule with structured activities
- Ensure adequate exposure to bright light during daytime hours 1, 2
- Minimize noise and stimulation during evening hours
- Keep room well-lit until bedtime to reduce shadows and confusion
- Provide familiar objects and orientation cues (clock, calendar)
Sleep Hygiene Optimization
- Restrict daytime napping, particularly after 2:00 PM 3
- Establish consistent sleep and wake times
- Ensure comfortable room temperature
- Reduce caffeine intake, with no caffeine after 4:00 PM 3
- Schedule mild physical activity during daytime hours 2
Reorientation Techniques
- Frequent reorientation to time, place, and situation
- Cognitive stimulation during daytime hours 3
- Encourage family visits during periods of increased agitation
- Use clear, simple communication
Pharmacologic Management (If Nonpharmacologic Approaches Fail)
First-Line Options (For Persistent Agitation)
- Quetiapine: Consider low-dose (12.5-25 mg) for refractory agitation 3, 4
- Preferred over other antipsychotics due to lower risk of extrapyramidal symptoms
- Monitor for orthostatic hypotension, sedation
Alternative Options (If First-Line Fails)
- Haloperidol: 0.5 mg orally at night and every 2 hours when required (maximum 5 mg/24h) 4
- Reduce dose in elderly patients (0.25-0.5 mg)
- Monitor for QT prolongation and extrapyramidal symptoms
Important Cautions
- Avoid benzodiazepines as initial treatment for delirium/sundowning 3
- Consider adding lorazepam (0.25-0.5 mg, maximum 2 mg/24h) only for severe agitation refractory to antipsychotics 4
- FDA warning: Increased mortality in elderly patients with dementia-related psychosis treated with antipsychotics 5
Monitoring and Follow-Up
Daily Assessment
- Document pattern and timing of agitation episodes
- Assess effectiveness of interventions
- Monitor for medication side effects:
- Extrapyramidal symptoms
- Sedation level
- Orthostatic hypotension
- QT prolongation (if on antipsychotics)
Addressing Underlying Causes
- Evaluate for and treat potential contributing factors:
- Pain or discomfort
- Infection (particularly UTI)
- Constipation
- Medication side effects
- Metabolic disturbances
Special Considerations
For Chronic Sundowning (As Reported by Wife)
- Develop consistent daily routine that can be continued after discharge
- Consider consultation with sleep medicine specialist if persistent
- Educate family on environmental modifications and behavioral techniques
Pitfalls to Avoid
- Restraint use (physical or chemical) without attempting nonpharmacologic approaches
- Excessive sedation that may worsen confusion and increase fall risk
- Ignoring the circadian component of sundowning behavior 6, 7
- Overlooking potentially reversible causes of delirium
By implementing these structured interventions that support normal circadian rhythms while holding Zyprexa (olanzapine), you can effectively manage sundowning-related agitation while minimizing risks associated with pharmacologic interventions in elderly patients.