How should sundowning be managed in an elderly patient (≥65 years) with dementia?

Management of Sundowning in Elderly Patients with Dementia

Implement morning bright light therapy as the primary intervention for sundowning in dementia patients, using white broad-spectrum light at 2,500-5,000 lux positioned approximately 1 meter from the patient for 1-2 hours daily between 9:00-11:00 AM for 4-10 weeks, while strictly avoiding sleep-promoting medications including benzodiazepines and hypnotics due to significantly increased risks of falls, cognitive decline, and mortality. 1, 2

Non-Pharmacological Interventions: First-Line Treatment

Bright Light Therapy (Primary Intervention)

• Use white broad-spectrum light at 2,500-5,000 lux intensity, positioned approximately 1 meter (30-34 inches) from the patient's eyes, for 1-2 hours daily between 9:00-11:00 AM, continued for 4-10 weeks. 1, 2
• This intervention improves behavioral symptoms including wandering, violent behavior, restlessness, and delirium, even though total sleep time may not significantly increase. 1
• Light therapy consolidates nighttime sleep, decreases daytime napping, reduces agitated behavior, and increases circadian rhythm amplitude. 1
• The American Academy of Sleep Medicine provides a WEAK FOR recommendation for light therapy, acknowledging very low quality evidence but recognizing that most caregivers would choose this intervention over no treatment. 1

Environmental and Behavioral Modifications

• Maximize daytime sunlight exposure and increase structured physical and social activities during daytime hours to strengthen sleep-wake cycles. 1, 2
• Implement 50-60 minutes of total daily physical activity distributed throughout the day, including 5-30 minute walking sessions. 3
• Reduce nighttime light and noise exposure while maintaining adequate lighting to prevent confusion—avoid excessive brightness that disrupts sleep. 1, 2, 3
• Establish consistent times for exercise, meals, and bedtime to provide temporal cues that regulate disrupted circadian rhythms. 1, 3
• Schedule activities earlier in the day when the patient is most alert, avoiding overstimulation in late afternoon. 3
• Use distraction and redirection techniques (repeat, reassure, redirect) when agitation begins rather than confrontation. 3

Medical Evaluation Before Any Pharmacological Treatment

Systematically investigate and treat underlying medical triggers before considering any medication. 2

• Evaluate for urinary tract infections, pneumonia, other infections, pain, dehydration, constipation, and urinary retention. 2
• Review all medications to identify and discontinue anticholinergic agents such as diphenhydramine, oxybutynin, and cyclobenzaprine that worsen confusion and agitation. 2

Pharmacological Options: Only After Non-Pharmacological Failure

Critical Medications to AVOID

The American Academy of Sleep Medicine provides a STRONG AGAINST recommendation for sleep-promoting medications in elderly dementia patients due to significantly increased risks of falls, cognitive decline, confusion, and mortality that outweigh any potential benefits. 1, 2, 3

• Strictly avoid benzodiazepines, traditional hypnotics (including trazodone), and other sleep-promoting medications. 1, 2
• These medications increase risks of adverse events including falls, worsening cognition, and death in this population. 1

Melatonin: Not Recommended

The American Academy of Sleep Medicine provides a WEAK AGAINST recommendation for melatonin in elderly dementia patients with irregular sleep-wake rhythm disorder. 1, 2, 4, 3

• High-quality trials show no improvement in total sleep time with melatonin. 1
• Potential harm includes detrimental effects on mood and daytime functioning. 2, 4, 3
• Evidence is inconsistent, with one trial showing no significant differences at 2.5 mg, though a trend toward improvement was seen at 10 mg. 1
• Do not combine light therapy with melatonin in demented elderly patients. 3

Important caveat: While guidelines recommend against melatonin, one older research study reported improvement in sleep quality and suppression of sundowning with 6-9 mg melatonin daily in AD patients. 5 However, this conflicts with higher-quality guideline evidence and should not guide practice.

First-Line Pharmacological Option (If Necessary)

SSRIs such as citalopram 10 mg/day or sertraline 25-50 mg/day are the preferred first-line pharmacological option for chronic agitation without psychotic features. 2, 3

• These have minimal anticholinergic effects and are reasonably well tolerated. 3
• A Cochrane meta-analysis found SSRIs significantly reduced agitation compared to placebo. 3
• Common side effects include nausea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, and sweating. 3

Cholinesterase Inhibitors

If not already prescribed, initiate a cholinesterase inhibitor for cognitive symptoms, as these can also reduce behavioral and psychopathologic symptoms including sundowning. 3

• Donepezil: Start 5 mg daily for 4-6 weeks before increasing to 10 mg daily. 3
• Rivastigmine: Start 1.5 mg twice daily with food, increasing every 4 weeks to maximum 6 mg twice daily. 3

Antipsychotics: Last Resort Only

Reserve atypical antipsychotics only for severe, dangerous symptoms (delusions, hallucinations, severe psychomotor agitation, combativeness) that have not responded to all other measures. 2, 3

• Risperidone 0.25 mg once daily at bedtime, with target dose of 0.5-1.25 mg daily (maximum 2-3 mg daily). 2, 3
• Olanzapine starting 2.5 mg at bedtime (maximum 10 mg daily). 3
• These medications carry significant mortality risk and increased risk of extrapyramidal symptoms, tardive dyskinesia, and other adverse effects. 2, 3
• Start with the lowest possible dose and increase slowly while monitoring for side effects. 3

Monitoring and Reassessment

• Evaluate response to interventions within 30 days using quantitative measures such as the Cohen-Mansfield Agitation Inventory or NPI-Q. 2
• After behavioral symptoms are controlled for 4-6 months, attempt periodic dose reduction to determine if continued medication is necessary. 2, 3
• Review medication necessity at every visit to avoid unnecessary continuation of antipsychotics. 2

Common Pitfalls to Avoid

• Do not jump to antipsychotics first—they should be reserved only for dangerous behaviors unresponsive to all other interventions. 3
• Do not ignore underlying medical issues such as pain, infection, constipation, or medication side effects that can worsen evening agitation. 3
• Do not use typical antipsychotics like haloperidol due to increased risk of tardive dyskinesia and mortality. 2
• Avoid tacrine due to hepatotoxicity requiring frequent monitoring. 3