What is the best medication for an elderly patient with dementia experiencing sundowning and anxiety?

Best Medication for Sundowning and Anxiety in Elderly Dementia Patients

Start with cholinesterase inhibitors (donepezil 5-10 mg daily or rivastigmine 1.5-6 mg twice daily) as first-line pharmacological treatment after exhausting non-pharmacological interventions, and add an SSRI (citalopram or sertraline) only if comorbid depression or anxiety significantly contributes to symptoms. 1, 2

Treatment Algorithm

Step 1: Exhaust Non-Pharmacological Interventions First

Non-pharmacological approaches must be implemented before any medication, as the American Academy of Sleep Medicine provides a STRONG recommendation AGAINST sleep-promoting medications in elderly dementia patients due to significantly increased risks of falls, cognitive decline, confusion, and mortality. 1

Key non-pharmacological interventions include:

• Bright light therapy (3,000-5,000 lux for 2 hours in the morning over 4 weeks) to consolidate nighttime sleep and reduce agitated behavior 1
• Consistent daily routines for exercise, meals, and bedtime to regulate disrupted circadian rhythms 1
• Schedule activities earlier in the day when the patient is most alert, avoiding late afternoon overstimulation 1
• 50-60 minutes of total daily physical activity distributed throughout the day 1
• Reduce nighttime light, noise, and household clutter 1
• Use distraction and redirection techniques (repeat, reassure, redirect) rather than confrontation 1

Step 2: Initiate Cholinesterase Inhibitors as First-Line Pharmacological Treatment

If not already prescribed, cholinesterase inhibitors should be the first medication considered, as they treat both cognitive symptoms and behavioral/psychopathologic symptoms including sundowning. 1, 2

Donepezil dosing:

• Start 5 mg daily for 4-6 weeks
• Increase to 10 mg daily if tolerated 1

Rivastigmine dosing:

• Start 1.5 mg twice daily with food
• Increase by 1.5 mg twice daily every 4 weeks as tolerated
• Maximum 6 mg twice daily
• Take with food to reduce gastrointestinal side effects 1, 2

Galantamine dosing:

• Start 4 mg twice daily with meals for 4 weeks
• Increase to 8 mg twice daily 2

Step 3: Add SSRI if Depression/Anxiety Contributes to Evening Symptoms

If anxiety or depression significantly contributes to sundowning behaviors, add an SSRI as they have minimal anticholinergic effects. 1, 2

Preferred SSRIs for elderly dementia patients:

• Citalopram (10-40 mg daily) - well-tolerated in this population 1, 3
• Sertraline - minimal anticholinergic effects 1, 2

One Cochrane meta-analysis found SSRIs significantly reduced agitation compared to placebo (mean difference -0.89 on CMAI scores, 95% CI -1.22 to -0.57), and SSRIs were reasonably well tolerated with no difference in withdrawal rates due to adverse events. 4

Avoid fluoxetine in older adults due to its long half-life and side effects. 3

Step 4: Reserve Atypical Antipsychotics ONLY for Dangerous Behaviors

Atypical antipsychotics should be reserved only for severe, dangerous symptoms (delusions, hallucinations, severe psychomotor agitation, combativeness) that have not responded to all other measures. 1, 2

The FDA has issued a black box warning regarding increased risk of death when antipsychotics are used for dementia-related behavioral disturbances. 2, 5 Elderly patients with dementia-related psychosis treated with antipsychotic drugs have a 1.6 to 1.7 times increased risk of death compared to placebo. 5

If absolutely necessary:

• Risperidone starting 0.25 mg at bedtime (maximum 2-3 mg daily) 1
• Olanzapine starting 2.5 mg at bedtime (maximum 10 mg daily) 1

The American Geriatrics Society strongly recommends avoiding antipsychotics in older adults with dementia due to increased mortality risk. 3

Critical Medications to AVOID

Melatonin: The American Academy of Sleep Medicine provides a WEAK recommendation AGAINST melatonin in elderly dementia patients, as high-quality trials show no improvement in total sleep time, with potential harm including detrimental effects on mood and daytime functioning. 1

Benzodiazepines (including clonazepam): The American Geriatrics Society recommends strictly avoiding benzodiazepines due to high risk of falls, confusion, worsening cognitive impairment, and listing on the Beers Criteria as potentially inappropriate. 1 The American Academy of Sleep Medicine makes a STRONG recommendation AGAINST sleep-promoting medications including benzodiazepines for irregular sleep-wake rhythm disorder in demented elderly patients. 2

Anticholinergic medications: These cause CNS impairment, delirium, slowed comprehension, and worsen cognitive function in dementia. 2

Combination of light therapy and melatonin: The American Academy of Sleep Medicine recommends against this combination in demented elderly patients. 1

Medication Management Principles

• Start with the lowest possible dose and increase slowly while monitoring for side effects 1, 2
• After behavioral symptoms are controlled for 4-6 months, attempt periodic dose reduction to determine if continued medication is necessary 1, 2
• Investigate and address underlying medical issues such as pain, infection, constipation, or medication side effects that can worsen evening agitation before adding medications 1
• Monitor for adverse effects: SSRIs commonly cause nausea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, and sweating 6

Common Pitfalls to Avoid

• Do not jump to antipsychotics first - they carry significant mortality risk and should be reserved only for dangerous behaviors unresponsive to all other interventions 1
• Do not ignore underlying medical issues such as pain, infection, constipation, or medication side effects that can worsen evening agitation 1
• Do not use sleep-promoting medications as the American Academy of Sleep Medicine strongly recommends against them due to increased falls, cognitive decline, and mortality 1, 2
• Do not use melatonin as evidence shows no benefit and potential harm in this population 1