Understanding Sundowning and Its Causes
Sundowning, or "late-day confusion," refers to a state of increased confusion, anxiety, agitation, and aggression that occurs in the late afternoon and evening in individuals with dementia. The exact cause is not fully understood, but it is believed to be linked to disruptions in the body's internal clock, or circadian rhythm, as well as fatigue, and environmental factors like shadows or low light. The symptoms can be distressing for both the affected individual and their caregivers, leading to sleep problems, stress, and reduced quality of life.
The Importance of Non-Pharmacological Strategies
Before considering medication, healthcare providers emphasize non-drug, or behavioral, interventions as the primary approach for managing sundowning. These strategies focus on establishing a stable, calming environment and include:
- Maintaining a consistent daily routine with regular meal and sleep times.
- Ensuring exposure to bright light during the day to help regulate the sleep-wake cycle.
- Limiting naps and caffeine intake, especially in the afternoon.
- Creating a calm, low-stimulation environment in the evening, with minimal noise and a soothing atmosphere.
- Increasing physical activity during the day to promote better sleep at night.
Only when these non-pharmacological methods fail to control severe, distressing symptoms should medication be considered, and always with a careful assessment of risks and benefits.
Pharmacological Options for Managing Sundowning
There is no single medication specifically designed for sundowning, and any drug used is often considered an "off-label" treatment, with the notable exception of brexpiprazole (Rexulti). Treatment is typically personalized based on the patient's specific symptoms and overall health.
1. Atypical Antipsychotics
- Function: These medications, such as risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa), are used to manage severe agitation, aggression, and hallucinations.
- Risks: Atypical antipsychotics carry a U.S. FDA black box warning for elderly patients with dementia-related psychosis due to an increased risk of death, often related to cardiovascular issues or infection. They also pose risks of stroke and significant side effects like sedation, movement disorders, and weight gain. They must be used at the lowest effective dose for the shortest duration possible.
- FDA-Approved Exception: Brexpiprazole (Rexulti) is the only atypical antipsychotic that has received FDA approval specifically for the treatment of agitation associated with Alzheimer's dementia.
2. Antidepressants
- Function: Trazodone (Desyrel) is a sedating antidepressant often prescribed off-label in low doses to help with sleep disturbances and agitation associated with sundowning.
- Risks: Trazodone has fewer serious side effects than antipsychotics but can still cause dizziness, orthostatic hypotension (a drop in blood pressure when standing), and daytime sleepiness. It can also cause problems if combined with other sedating drugs.
3. Melatonin
- Function: This naturally occurring hormone helps regulate the sleep-wake cycle. Melatonin supplements are sometimes used to help reset the circadian rhythm in individuals experiencing sleep disruption due to sundowning.
- Risks: Melatonin is generally considered safer than many prescription drugs, but its effectiveness can vary. It is important to use pharmaceutical-grade supplements and discuss dosage with a doctor. Side effects are usually mild and may include daytime sleepiness, dizziness, or headache.
4. Acetylcholinesterase Inhibitors
- Function: These drugs, including donepezil (Aricept) and rivastigmine (Exelon), are primarily used to treat the cognitive symptoms of Alzheimer's disease. In some individuals, they can also help manage behavioral symptoms, potentially by stabilizing brain chemistry.
- Considerations: Their effect on sundowning symptoms is inconsistent and they may sometimes worsen agitation or insomnia in certain patients.
5. Other Considerations
- Anti-anxiety medications (Benzodiazepines): Drugs like lorazepam (Ativan) are generally avoided in older adults with dementia due to the high risk of increased confusion, sedation, and falls. They are used cautiously and typically for short-term, severe crises only.
- Cannabinoids: Preliminary research on cannabinoids like dronabinol for agitation has shown some potential, but evidence is limited and more studies are needed. Use is not widely recommended due to cognitive and functional side effect concerns in the elderly.
Medication Comparison
| Medication Class | Primary Use for Sundowning | Main Risks/Considerations | General Efficacy for Sundowning |
|---|---|---|---|
| Atypical Antipsychotics | Severe agitation, aggression, hallucinations | FDA black box warning, increased mortality risk, sedation | High for severe symptoms, but significant risk |
| Antidepressants (e.g., Trazodone) | Sleep disturbances, mild-moderate agitation | Dizziness, orthostatic hypotension, daytime sleepiness | Moderate, useful for sleep-related issues |
| Melatonin | Sleep-wake cycle disruption | Generally mild side effects, variable effectiveness | Variable, often works best with light therapy |
| Cholinesterase Inhibitors | Cognitive symptoms of dementia | Inconsistent effect on sundowning; can sometimes worsen agitation | Inconsistent for sundowning behaviors |
| Benzodiazepines | Acute, severe agitation (short-term) | High risk of sedation, confusion, falls; generally avoided | Short-term effect, but high risk |
How a Physician Determines Treatment
When a physician decides to use medication, they follow a systematic approach:
- Thorough Assessment: The doctor will first rule out other potential medical issues contributing to the behavior, such as a urinary tract infection (UTI), pain, or medication side effects.
- Start Low, Go Slow: The principle is to use the lowest possible dose and to titrate slowly. The goal is to manage symptoms without causing unnecessary sedation or adverse effects.
- Monitoring and Evaluation: The patient is closely monitored for both therapeutic effects and side effects. The treatment plan is regularly reviewed, and the medication may be adjusted or discontinued if not effective or if side effects are significant.
- Combining with Non-Drug Approaches: Medication is almost always used in conjunction with behavioral strategies, not as a standalone solution.
- Educating Caregivers: Caregivers are educated on the purpose, risks, and expected outcomes of the medication, empowering them to monitor the patient effectively and communicate with the healthcare team.
Conclusion
There is no one-size-fits-all answer to what medication is used for sundowning in the elderly. The management of sundowning is a complex process that relies heavily on a multi-faceted approach. While various pharmacological options exist, they are typically considered after non-drug interventions have been exhausted and are used cautiously due to potential side effects, particularly in frail older adults. A collaborative approach involving the patient, caregivers, and a physician is essential for finding the most effective and safest management strategy. For more information on managing behavioral symptoms in dementia, consult a resource like the Alzheimer's Association.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Consult a healthcare professional for diagnosis and treatment.
