What medication is appropriate for treating sundowning-related agitation in an older adult with dementia?

Medication for Sundowning Agitation in Dementia

For sundowning-related agitation in older adults with dementia, start with non-pharmacological interventions—especially morning bright-light therapy—and reserve medications only for severe, dangerous agitation; if medication becomes necessary, SSRIs (citalopram or sertraline) are first-line, with low-dose antipsychotics (risperidone or haloperidol) reserved only for severe psychotic features or imminent risk of harm after all other measures fail. 1

Step 1: Non-Pharmacological Interventions (Mandatory First-Line)

Morning bright-light therapy is the primary evidence-based intervention. Provide 2 hours of bright light at 3,000–5,000 lux positioned approximately 1 meter from the patient's eyes between 9:00–11:00 AM, continued for 4–10 weeks. 1 This consolidates nighttime sleep, reduces daytime napping, decreases agitated behavior, and increases circadian rhythm amplitude. 1

Environmental and Activity Modifications

• Maximize daytime sunlight exposure (at least 30 minutes daily) and increase supervised physical and social activities during daylight hours to strengthen sleep-wake cycles. 1
• Reduce nighttime light and noise while maintaining sufficient illumination to prevent confusion—avoid excessive brightness that disrupts sleep. 1
• Establish consistent daily schedules for exercise, meals, and bedtime to supply temporal cues that regulate disrupted circadian rhythms caused by suprachiasmatic nucleus degeneration. 1
• Schedule activities earlier in the day when the patient is most alert, avoiding overstimulation in late afternoon when sundowning typically peaks. 1
• Implement 50–60 minutes of total daily physical activity distributed throughout the day, including 5–30 minute walking sessions. 1

Communication and Safety Strategies

• Use the "three R's" approach (repeat, reassure, redirect) when agitation begins rather than confrontation. 1
• Simplify all tasks and break complex activities into steps with clear instructions, using calm tones and simple one-step commands. 1
• Remove environmental hazards including slippery floors, throw rugs, and obtrusive electric cords that become more dangerous when evening confusion worsens. 1
• Implement scheduled toileting or prompted voiding to reduce incontinence-related agitation. 1

Step 2: Identify and Treat Reversible Medical Causes

Before any medication, systematically investigate and treat:

• Pain (a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort) 2
• Infections (urinary tract infections, pneumonia) 2
• Metabolic disturbances (hypoxia, dehydration, electrolyte abnormalities, hyperglycemia) 2
• Constipation and urinary retention 2
• Medication side effects, especially anticholinergic agents (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen agitation 2

Step 3: Pharmacological Treatment (Only After Non-Pharmacological Failure)

First-Line: SSRIs for Chronic Agitation

If not already prescribed, initiate a cholinesterase inhibitor (donepezil 10 mg daily or rivastigmine up to 6 mg twice daily), as these medications can reduce behavioral and psychopathologic symptoms including sundowning. 1 Start low and titrate slowly: donepezil 5 mg daily for 4–6 weeks before increasing to 10 mg; rivastigmine 1.5 mg twice daily with food, increasing every 4 weeks to maximum 6 mg twice daily. 1

For chronic agitation without psychotic features, SSRIs are preferred first-line pharmacological treatment:

• Citalopram: Start 10 mg/day, maximum 40 mg/day 2
• Sertraline: Start 25–50 mg/day, maximum 200 mg/day 2

SSRIs significantly reduce overall neuropsychiatric symptoms, agitation, and depression in dementia patients, with minimal anticholinergic effects. 1, 2 Assess response within 4 weeks of adequate dosing; if no clinically significant response, taper and withdraw. 2

Second-Line: Antipsychotics (Only for Severe, Dangerous Symptoms)

Reserve atypical antipsychotics only for severe, dangerous symptoms (delusions, hallucinations, severe psychomotor agitation, combativeness) that have not responded to other measures. 1

Before initiating any antipsychotic, discuss with the patient (if feasible) and surrogate decision maker:

• Increased mortality risk (1.6–1.7 times higher than placebo) 2
• Cardiovascular effects (QT prolongation, dysrhythmias, sudden death) 2
• Cerebrovascular adverse reactions 2
• Falls risk 2

If absolutely necessary:

• Risperidone: Start 0.25 mg at bedtime, maximum 2–3 mg daily (extrapyramidal symptoms increase above 2 mg/day) 1, 2, 3
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg daily (less effective in patients over 75 years) 1, 2
• Haloperidol: 0.5–1 mg orally or subcutaneously for acute severe agitation, maximum 5 mg daily in elderly patients 2

Use the lowest effective dose for the shortest possible duration, with daily in-person examination to evaluate ongoing need. 2 After behavioral symptoms are controlled for 4–6 months, attempt periodic dose reduction to determine if continued medication is necessary. 1

Critical Medications to AVOID

Melatonin: WEAK AGAINST Recommendation

The American Academy of Sleep Medicine suggests AVOIDING melatonin as treatment for irregular sleep-wake rhythm disorder in older people with dementia (weak recommendation against, low-quality evidence). 1, 4 High-quality trials show no improvement in total sleep time, with potential harm including detrimental effects on mood and daytime functioning. 1, 4

Do not combine light therapy with melatonin in demented elderly patients. 1

Sleep-Promoting Medications: STRONG AGAINST Recommendation

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, 4

Benzodiazepines: Strictly Avoid

The American Geriatrics Society recommends strictly avoiding benzodiazepines, including clonazepam, due to high risk of falls, confusion, worsening cognitive impairment, and listing on the Beers Criteria as potentially inappropriate. 1, 2 Benzodiazepines increase delirium incidence and duration, cause paradoxical agitation in approximately 10% of elderly patients, and risk respiratory depression, tolerance, and addiction. 2

Typical Antipsychotics: Avoid as First-Line

Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to association with 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients. 2 Do not use tacrine—it is no longer first-line due to hepatotoxicity requiring frequent monitoring. 1

Monitoring and Reassessment

• Evaluate response within 4 weeks of initiating pharmacological treatment using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q). 2
• Monitor for side effects: extrapyramidal symptoms, falls, metabolic changes, QT prolongation, cognitive worsening. 2
• Daily in-person examination to evaluate ongoing need for antipsychotics and assess for adverse effects. 2
• Attempt taper within 3–6 months to determine if medication is still needed; approximately 47% of patients continue receiving antipsychotics after discharge without clear indication. 2

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 continue antipsychotics indefinitely—review the need at every visit and taper if no longer indicated. 2
• Do not use antipsychotics for mild agitation—reserve them for severe symptoms that are dangerous or cause significant distress. 2