What medication can be used to reduce agitation in an elderly patient with sundowning behavior and dementia, who is not responding to non-pharmacological interventions such as having a bedside sitter and is pulling out their Foley (urinary) catheter at night?

Management of Sundowning with Foley Catheter Removal in Elderly Patients

Immediate First-Line Pharmacological Recommendation

For an elderly patient with sundowning behavior who is pulling out their Foley catheter despite having a bedside sitter, start low-dose haloperidol 0.5-1 mg orally at 2-4 PM (before symptoms typically worsen) and again at bedtime, with a maximum of 5 mg daily, only after addressing reversible medical causes. 1

Critical Pre-Medication Assessment (Must Complete First)

Before initiating any medication, you must systematically investigate and treat these reversible causes that commonly drive nocturnal agitation:

• Remove the Foley catheter if at all possible - urinary retention from the catheter itself is a major contributor to agitation and pulling behavior 1
• Assess and treat pain aggressively - this is the most common driver of behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Check for urinary tract infection - especially common with indwelling catheters and a major trigger for sundowning 1
• Evaluate for constipation and fecal impaction - frequently overlooked causes of nocturnal agitation 1
• Review ALL medications - discontinue anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1
• Check for dehydration, hypoxia, and metabolic disturbances 1

Pharmacological Management Algorithm

Step 1: Acute Severe Agitation (Immediate Danger)

Haloperidol 0.5-1 mg orally or subcutaneously is the first-line medication when non-pharmacological interventions have failed and the patient poses imminent risk of harm 1

• Start with 0.5 mg in frail elderly patients 1
• Maximum 5 mg daily in elderly patients 1
• Time the dose strategically: Give 2 mg at 2 PM (before sundowning typically begins) and 2 mg at bedtime to target afternoon/evening symptoms 1
• Monitor ECG for QTc prolongation 1
• Watch for extrapyramidal symptoms (tremor, rigidity, bradykinesia) 1

Critical Safety Warning: All antipsychotics increase mortality risk 1.6-1.7 times higher than placebo in elderly dementia patients - this must be discussed with the patient's surrogate decision maker before initiating treatment 1

Step 2: If Haloperidol Fails or Is Not Tolerated

Risperidone 0.25 mg at bedtime is the preferred alternative antipsychotic 1

• Start at 0.25 mg once daily at bedtime 1
• Target dose: 0.5-1.25 mg daily 1
• Risk of extrapyramidal symptoms increases above 2 mg/day 1
• Better tolerated than haloperidol in some patients 2

Quetiapine 12.5 mg twice daily is a second-line alternative 1

• More sedating, which may be beneficial for nighttime agitation 1
• Higher risk of orthostatic hypotension and falls 1
• Maximum 200 mg twice daily 1
• Monitor for QT prolongation 3

Step 3: For Chronic Agitation (After Acute Crisis Stabilized)

Transition to an SSRI for long-term management once acute dangerous agitation is controlled 1

• Citalopram 10 mg/day (maximum 40 mg/day) - well tolerated, some patients experience nausea and sleep disturbances 1
• Sertraline 25-50 mg/day (maximum 200 mg/day) - well tolerated with less effect on metabolism of other medications 1
• Requires 4-8 weeks for full therapeutic effect 1
• Evaluate response at 4 weeks using quantitative measures 1
• If no clinically significant response after 4 weeks at adequate dose, taper and discontinue 1

Step 4: Alternative for Chronic Management

Trazodone 25 mg/day (maximum 200-400 mg/day in divided doses) if SSRIs fail or are not tolerated 1

• Use caution in patients with premature ventricular contractions 1
• Risk of orthostatic hypotension and falls (30% in real-world studies) 1
• More sedating, which may help with nighttime symptoms 1

What NOT to Use

Avoid benzodiazepines (including lorazepam, diazepam) as first-line treatment 1

• Increase delirium incidence and duration 1
• Cause paradoxical agitation in approximately 10% of elderly patients 1
• Risk of tolerance, addiction, cognitive impairment, and respiratory depression 1
• Only indicated for alcohol or benzodiazepine withdrawal 1

Avoid typical antipsychotics (other than haloperidol) as first-line therapy 1

• 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1

Do not use cholinesterase inhibitors to prevent or treat acute agitation 1

• Associated with increased mortality when newly prescribed for delirium 1
• May help with chronic sundowning in dementia with Lewy bodies, but not for acute management 4

Non-Pharmacological Interventions (Implement Simultaneously)

• Ensure adequate lighting during late afternoon and evening hours when sundowning typically worsens 1
• Use calm tones, simple one-step commands, and gentle touch for reassurance 1
• Provide structured daily routines with consistent timing 1
• Reduce excessive noise during evening hours 1
• Allow adequate time for the patient to process information before expecting a response 1

Monitoring and Duration Strategy

• Evaluate response daily with in-person examination 1
• Use the lowest effective dose for the shortest possible duration 1
• Attempt to taper antipsychotics within 3-6 months to determine if still needed 1
• Monitor for side effects: extrapyramidal symptoms, falls, sedation, metabolic changes, QT prolongation, cognitive worsening 1
• Approximately 47% of patients continue receiving antipsychotics after discharge without clear indication - avoid inadvertent chronic use 1

Common Pitfalls to Avoid

• Do not continue antipsychotics indefinitely - review need at every visit and taper if no longer indicated 1
• Do not use antipsychotics for mild agitation - reserve for severe symptoms that are dangerous or cause significant distress 1
• Do not add multiple psychotropics simultaneously - increases risk of adverse effects without demonstrated additive benefit 1
• Do not forget to reassess the Foley catheter indication - removing it may resolve the pulling behavior entirely 1