Would a 93-year-old woman with new onset sundowning benefit from medication to manage behaviors or slow dementia progression?

Management of Sundowning in a 93-Year-Old Woman with Dementia

For a 93-year-old woman with new onset sundowning, non-pharmacological approaches should be the first-line treatment, as there is no medication proven to slow dementia progression or effectively manage sundowning symptoms without significant risks. 1

Understanding Sundowning

Sundowning syndrome is characterized by the emergence or worsening of neuropsychiatric symptoms (NPS) such as agitation, confusion, anxiety, and aggressiveness in late afternoon, evening, or at night in persons with dementia 2. These symptoms can significantly impact quality of life for both patients and caregivers.

First-Line Approach: Non-Pharmacological Interventions

Environmental and Behavioral Modifications

• Implement the DICE approach (Describe, Investigate, Create, Evaluate) to manage neuropsychiatric symptoms 1
• Establish structured daily routines with predictable activities to reduce confusion and anxiety 1
• Ensure adequate exposure to bright light during daytime (2 hours in the morning at 3,000-5,000 lux) to help regulate circadian rhythms 1
• Reduce nighttime light and noise to create a favorable sleep environment 1
• Increase daytime physical and social activities to promote better sleep-wake cycles 1
• Address any underlying pain or discomfort that may be contributing to agitation 1, 3

Caregiver Education and Support

• Educate caregivers that behaviors are not intentional but are symptoms of the disease 1
• Improve communication techniques (calmer tones, simpler single-step commands, light touch to reassure) 1
• Avoid negative interactions (harsh tone, complex multi-step commands, open-ended questioning) 1

Second-Line Approach: Consider Medical Causes

• Investigate potential underlying medical causes of sundowning:
  • Pain or discomfort 1, 3
  • Urinary tract infections or other infections 1
  • Dehydration or constipation 1
  • Iron deficiency (low transferrin saturation percentage has been associated with nighttime agitation) 3
  • Sleep disorders such as Restless Legs Syndrome (RLS) 3

Third-Line Approach: Limited Pharmacological Options

Important Warning

• The FDA has issued a black box warning that antipsychotic medications increase the risk of death in elderly patients with dementia 4

If Non-Pharmacological Approaches Fail:

• Consider melatonin, though evidence is inconsistent. One trial showed a trend toward improvement with 10 mg dose, but not with 2.5 mg 1
• Selective serotonin reuptake inhibitors (SSRIs) may be considered for disinhibition and compulsive behaviors, but use with caution as they can worsen RLS symptoms 5, 3
• Atypical antipsychotics should only be considered as a last resort for severe behavioral disturbances with clear risk of harm, with close monitoring for adverse effects 5, 6
• Cholinesterase inhibitors and memantine have not shown consistent positive effects for behavioral symptoms in dementia 5, 6

Common Pitfalls to Avoid

• Relying primarily on pharmacological approaches when non-pharmacological strategies should be first-line 5, 6
• Using medications with significant anticholinergic effects, which can worsen cognitive symptoms 6
• Failing to monitor for medication side effects, which can sometimes worsen behavioral symptoms 6
• Using antipsychotics without careful consideration of the significant mortality risk in elderly patients with dementia 4
• Overlooking potentially treatable causes of agitation such as pain, infection, or iron deficiency 1, 3

Monitoring and Follow-up

• Evaluate response to interventions within 30 days 6
• For patients on psychotropics, conduct close follow-up to monitor for adverse effects 6
• Consider tapering or discontinuing pharmacological treatments after 6 months of symptom stabilization 6