How do you manage acute sundowners syndrome in a hospitalized patient?

Management of Acute Sundowning in Hospitalized Patients

For acute sundowning in hospitalized patients, immediately administer intravenous haloperidol as first-line pharmacological therapy, as it is rapidly acting, rarely produces hypotension, and can be given safely to cardiac patients with agitation and delirium. 1

Immediate Assessment and Environmental Modifications

• Identify and eliminate precipitating factors first, including medications known to induce delirium such as lidocaine, mexiletine, procainamide, atropine, cimetidine, and meperidine 1
• Assess for underlying medical causes including hypoxia, infection, metabolic derangements, and pain that may be triggering or worsening agitation 1
• Modify the care environment immediately: ensure the patient area is well-lit during daytime hours, reduce noise and stimulation in the evening, maintain a consistent sleep-wake schedule, and provide a calm, welcoming environment with professional staff 1, 2
• Implement barrier nursing in a side room when possible to reduce environmental triggers and nosocomial infection risk 1

Pharmacological Management Algorithm

First-Line: Haloperidol

• Administer intravenous haloperidol for acute agitation and delirium, as it is rapidly acting and safe in hospitalized patients, including those with cardiac conditions 1
• Haloperidol rarely produces hypotension or requires assisted ventilation, making it ideal for the acute hospital setting 1

Second-Line: Benzodiazepines (Use with Extreme Caution)

• If haloperidol is contraindicated or ineffective, consider lorazepam 0.5-1 mg in elderly or debilitated patients (maximum 2 mg/24 hours due to increased fall risk and sensitivity) 3
• For standard adults, lorazepam 2-3 mg/day divided into 2-3 doses with the largest dose at bedtime may be used 3
• Limit benzodiazepine use to 1-2 weeks maximum to avoid tolerance, addiction, depression, and cognitive impairment 3
• Monitor closely for paradoxical agitation, which occurs in approximately 10% of patients treated with benzodiazepines 3
• Use scheduled dosing rather than PRN for consistent therapeutic effect 3

Critical Medication Avoidance

• Do not use routine anxiolytics prophylactically, as studies show no difference in anxiety, blood pressure, heart rate, or chest discomfort compared to placebo 1
• Avoid mixed agonist-antagonist opioids, tramadol, and codeine due to neurotoxicity risk and limited dose titration 4

Non-Pharmacological Interventions (Implement Simultaneously)

• Restrict daytime sleep and maintain mild activity schedules to preserve circadian rhythm 2
• Provide exposure to bright lights during daytime hours to help regulate the deteriorated suprachiasmatic nucleus function that underlies sundowning 5, 2
• Liberalize visiting rules to allow family presence, as studies demonstrate no harmful physiological effects and may reduce agitation 1
• Ensure adequate pain control using multimodal analgesia including scheduled acetaminophen and NSAIDs if not contraindicated, as untreated pain worsens delirium 4

Monitoring and Safety

• Monitor sedation scores, respiratory rate, and level of consciousness continuously when using sedating medications 4
• Have naloxone immediately available if opioids are being used for pain management 4
• Assess for clinical deterioration with regular vital signs and targeted assessments to identify underlying conditions requiring treatment 1
• Document all interventions and monitor patterns to identify triggers and effective strategies 1

Common Pitfalls to Avoid

• Do not assume sundowning only occurs at sunset - studies show agitation peaks may occur in early morning and mid-afternoon related to environmental variables beyond time of day 6
• Do not overlook treatable medical causes including sleep apnea, REM sleep disturbances, infection, or metabolic derangements that may be driving the behavior 2
• Avoid chronic benzodiazepine use beyond the acute episode, as this leads to dependence and worsening cognitive impairment 3
• Do not use physical restraints as first-line management - focus on environmental modification and appropriate pharmacotherapy 1