How is sundowning managed?

Managing Sundowning in Dementia

Begin with non-pharmacological interventions as first-line treatment, specifically bright light therapy during daytime hours combined with restriction of daytime sleep and structured activity schedules, reserving low-dose neuroleptics only for severe cases that fail behavioral approaches. 1, 2

Understanding Sundowning

Sundowning refers to the emergence or worsening of neuropsychiatric symptoms—including agitation, confusion, anxiety, and aggressiveness—occurring specifically in the late afternoon, early evening, or at night in patients with dementia. 3, 2 The prevalence ranges widely from 1.6% to 66% of dementia patients, reflecting both the common nature of this syndrome and challenges in consistent diagnosis. 4

Pathophysiological Basis

The syndrome appears mediated by three primary mechanisms:

• Circadian rhythm disruption from degeneration of the suprachiasmatic nucleus of the hypothalamus, leading to decreased melatonin production 1, 2
• Sleep architecture disturbances, including REM sleep disruption and episodes of sleep apnea 1
• Environmental and psychosocial factors that interact with impaired cognition 2

First-Line Treatment: Non-Pharmacological Interventions

Bright Light Therapy

• Expose patients to bright light during daytime hours to help restore circadian rhythmicity and reduce evening behavioral disturbances 2
• This intervention directly addresses the underlying pathophysiology of suprachiasmatic nucleus degeneration 2

Sleep-Wake Cycle Management

• Restrict daytime sleep to consolidate nighttime sleep and reduce evening confusion 1
• Implement mild activity schedules during the day to promote appropriate sleep-wake patterns 1
• These behavioral modifications are more efficacious than pharmacotherapy but require intensive caregiver involvement 4

Environmental Modifications

• Address any physiologic factors that may be contributing to agitation (pain, infection, medication side effects, constipation, urinary retention) 1
• Optimize the evening environment to reduce confusion and anxiety 3

Second-Line Treatment: Pharmacological Approaches

Only proceed to pharmacological management after non-pharmacological interventions have been attempted and proven insufficient. 1, 4

Medication Options (in order of preference):

1. Acetylcholinesterase inhibitors for patients with Alzheimer's dementia who are not already on these agents 2

2. Melatonin to address the underlying circadian rhythm dysfunction and decreased melatonin production 2

3. Low-dose neuroleptics (antipsychotics) for severe agitation, using the lowest effective dose 1, 2

   • These carry significant risks including increased mortality, stroke, and cognitive decline in elderly dementia patients
   • Reserve for cases where behavioral interventions have failed and safety is at immediate risk

4. N-methyl-d-aspartate receptor antagonists (memantine) may provide benefit in moderate-to-severe dementia 2

Critical Pitfalls to Avoid

• Do not use sedatives as first-line treatment—pharmacotherapy with sedatives can be effective but is associated with severe side effects including falls, increased confusion, and paradoxical agitation 4
• Avoid polypharmacy—many medications can worsen confusion and contribute to sundowning 1
• Do not ignore sleep-disordered breathing—screen for and treat sleep apnea, which may be contributing to the syndrome 1
• Never assume sundowning is inevitable—always identify and treat reversible physiologic causes first 1

Treatment Algorithm

1. Identify and treat physiologic factors (infection, pain, medication effects, metabolic disturbances) 1
2. Implement bright light therapy during daytime + restrict daytime napping + structured activity schedule 1, 2
3. Reassess after 2-4 weeks—if insufficient improvement, consider adding melatonin or acetylcholinesterase inhibitor (if not already prescribed) 2
4. Reserve low-dose antipsychotics only for severe, refractory cases where safety is compromised and behavioral interventions have definitively failed 1, 2

Monitoring and Follow-Up

• Track behavioral symptoms throughout the 24-hour day, not just during evening hours, to accurately assess treatment response 5
• Monitor for medication side effects closely, particularly sedation, falls, and worsening cognition 4
• Provide ongoing caregiver education and support, as behavioral interventions require sustained caregiver involvement 4
• Reassess the treatment plan regularly, as the underlying dementia will progress and management needs may change 3