What are the management strategies for sundowning (a phenomenon characterized by confusion and agitation in the late afternoon or early evening)?

From the Guidelines

Sundowning management should prioritize non-pharmacological approaches, focusing on establishing consistent daily routines, creating a calm environment, and engaging the person in familiar activities, as these methods have been shown to be effective in reducing symptoms and improving quality of life 1.

Non-Pharmacological Management

To manage sundowning, it is essential to:

• Establish consistent daily routines with regular sleep-wake cycles, meals, and activities to reduce confusion
• Create a calm environment by reducing noise, dimming lights in the evening, and using nightlights to prevent disorientation
• Engage the person in familiar activities during late afternoon and early evening when symptoms typically worsen
• Limit caffeine and sugar intake after lunch, and ensure adequate exposure to bright light during daytime hours to help regulate circadian rhythms

Pharmacological Management

For pharmacological management, low-dose antipsychotics like risperidone (0.25-0.5mg) or quetiapine (25-50mg) may be used short-term for severe agitation, but should be avoided when possible due to increased stroke and mortality risk in elderly patients with dementia 1. Additionally, melatonin (1-5mg) taken 1-2 hours before bedtime can help regulate sleep cycles, and cholinesterase inhibitors like donepezil (5-10mg daily) may reduce sundowning symptoms by improving cognitive function.

Key Considerations

When managing sundowning, it is crucial to:

• Address the neurobiological factors contributing to sundowning, including disrupted circadian rhythms, decreased sensory processing abilities, and neurotransmitter imbalances that occur with dementia progression
• Prioritize high-quality, person-centered care, including psychosocial interventions, as the first line of prevention and treatment for behavioral and psychological symptoms of dementia (BPSD) 1
• Use medication as a carefully monitored, short-term, last resort in specific cases, due to the attendant increased risk of adverse effects, including falls, stroke, and death 1

From the Research

Sundowning Management

• Sundowning refers to episodes of agitated behavior that are more frequent or severe at night, often occurring in patients with dementia 2.
• The management of sundowning is challenging due to the lack of comprehensive studies on its treatment, with fewer than 20 studies explicitly mentioning temporal dimensions of behavioral outcome 2.
• Despite the limited research, some studies suggest that selective serotonin reuptake inhibitors (SSRIs) may be useful in managing sundowning, although their effectiveness has not been specifically investigated in randomized controlled trials 3, 4, 5.
• SSRIs, such as sertraline, have been shown to increase cortical excitability in patients with major depressive disorders, which may have implications for their use in managing sundowning 6.
• The pathophysiological determinants of sundowning are complex and influenced by neurobiological, psychosocial, and environmental factors, making it essential to develop personalized treatment approaches 3.
• Non-pharmacological strategies, such as environmental modifications and behavioral interventions, may also be effective in managing sundowning, although more research is needed to support their use 3.