What is Sundowning?
Sundowning, or "sundown syndrome," is not a disease itself but a collection of symptoms that occur in individuals with dementia, typically in the late afternoon and early evening. These symptoms can include increased confusion, anxiety, restlessness, agitation, and even aggression. The exact cause is unknown, but theories suggest it may be related to a disruption of the internal body clock (circadian rhythm) caused by damage to brain cells from dementia. Changes in light and shadows as evening approaches can also be disorienting and frightening, further exacerbating the symptoms.
What is Quetiapine (Seroquel)?
Quetiapine, also known by the brand name Seroquel, is an atypical antipsychotic medication. It was originally developed and FDA-approved for the treatment of schizophrenia, bipolar disorder, and major depressive disorder. Like other antipsychotics, it works by altering the activity of certain chemicals in the brain, including dopamine and serotonin, to help regulate mood, behavior, and thought processes.
The Off-Label Use of Quetiapine for Sundowning
Using quetiapine for sundowning is considered an "off-label" use, meaning it is not an FDA-approved treatment for this condition. However, some clinicians may prescribe it to manage severe agitation, hallucinations, or anxiety that accompanies sundowning, especially when non-drug interventions have failed or for specific types of dementia. For example, quetiapine is sometimes considered a safer antipsychotic option for individuals with Lewy body dementia or Parkinson's disease, as other antipsychotics can worsen motor symptoms.
Serious Risks Associated with Quetiapine for the Elderly
Despite its potential use in certain circumstances, the prescription of quetiapine for elderly patients with dementia, including for sundowning, comes with serious health warnings. The FDA has issued a "black box" warning highlighting the risks of atypical antipsychotics in this population.
Increased Risk of Stroke and Mortality
Studies have shown that older adults with dementia treated with antipsychotic medications have an increased risk of stroke and a higher risk of death compared to those not taking these drugs. The risk is particularly elevated soon after starting the medication.
Adverse Side Effects
Beyond the most serious risks, quetiapine can cause a range of other adverse effects in elderly patients that can be particularly dangerous:
- Increased Risk of Falls: The drug can cause sedation, dizziness, and motor instability, increasing the risk of falls and related fractures.
- Cognitive Decline: Quetiapine can potentially accelerate cognitive decline, which is a major concern for those already suffering from dementia.
- Other Side Effects: These can include orthostatic hypotension (a drop in blood pressure when standing), weight gain, and symptoms that mimic Parkinson's disease, such as tremors and stiffness.
First-Line Alternatives: Non-Pharmacological Interventions
Given the significant risks associated with medication, the standard of care for managing sundowning begins with non-pharmacological interventions. These strategies aim to address environmental and behavioral triggers that contribute to the symptoms.
Behavioral Modifications and Environmental Changes
- Maintain a routine: A consistent daily schedule for meals, waking, and bedtime can provide a sense of security and reduce confusion.
- Increase daytime activity: Engaging in light exercise or activities during the day can promote better nighttime sleep.
- Limit daytime napping: Long or late-afternoon naps can disrupt the sleep-wake cycle.
- Ensure proper lighting: Maximize natural light exposure during the day and use good indoor lighting in the evening. As dusk approaches, close curtains to minimize confusing shadows.
- Reduce evening stimulation: Lower background noise, turn off loud TVs, and create a calm, relaxing environment in the evenings.
Complementary Therapies
- Light therapy: Controlled exposure to bright light during the day can help reset the body's circadian rhythm.
- Music therapy: Calming, familiar music can reduce agitation and provide a pleasant distraction.
- Aromatherapy: The use of certain essential oils, such as lavender, may promote a calming effect.
Comparison of Treatment Approaches for Sundowning
| Feature | Pharmacological (e.g., Quetiapine) | Non-Pharmacological Interventions |
|---|---|---|
| Effectiveness | Can reduce severe agitation, but with limited specific evidence for sundowning. Effects can be moderate at best. | Highly effective as first-line treatment. Focuses on addressing underlying triggers rather than just symptoms. |
| Risks/Side Effects | High risk, including black box warnings for increased mortality, stroke, and falls in dementia patients. | Minimal to no side effects. Safe and focuses on comfort and routine. |
| Mechanism | Alters brain chemistry to sedate or manage psychosis. | Addresses environmental cues, sensory input, and routines to minimize agitation triggers. |
| Appropriate Use | Reserved for severe, unmanageable symptoms or specific conditions like Lewy body dementia, after all other options fail. | Should always be the first course of action due to safety and effectiveness. |
A Concluding Note on Safety
While quetiapine is sometimes used to treat behaviors associated with sundowning, it is not a routine or safe first-line treatment for elderly patients with dementia. The risks of adverse effects, including increased mortality and stroke, are significant and well-documented. Healthcare providers, caregivers, and families should exhaust all non-pharmacological strategies before considering such a medication, and any decision should be made in careful consultation with a healthcare professional who understands the specific needs and risks for the individual. For more detailed information on managing sundowning and dementia-related behaviors, consult reliable resources like the Alzheimer's Association [https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior].
