What is Sundowning?
Sundowning, also known as sundown syndrome, is a group of behavioral and psychological symptoms that occur in the late afternoon, early evening, or at night among individuals with dementia. Symptoms can include increased agitation, confusion, restlessness, anxiety, and even aggression as daylight fades. This shift in behavior is often tied to disruptions in the person's circadian rhythm, or internal body clock, which regulates sleep and wakefulness. Environmental factors, such as shadows appearing as the sun sets, can increase confusion and trigger these distressing behaviors.
First-Line Approaches: Non-Pharmacological Strategies
Before turning to medication, healthcare professionals and caregivers prioritize non-drug approaches to manage sundowning behaviors. These interventions focus on environmental adjustments and behavioral strategies aimed at reducing triggers and promoting a sense of calm and predictability. The goal is to first address potential underlying causes and create a more soothing routine.
Effective Non-Drug Interventions
- Maintain a consistent daily routine. Predictable schedules for meals, bathing, and activities can provide comfort and reduce confusion.
- Regulate light exposure. Maximize exposure to natural light during the day, such as by sitting by a window or going for a walk, to help regulate the body's internal clock. As evening approaches, ensure rooms are well-lit to minimize shadows that can be confusing or frightening.
- Encourage daytime activity. Engage in light physical activity to help with restlessness and encourage better sleep at night.
- Create a calming evening environment. Reduce noise, turn off the TV, and play gentle music or nature sounds. Familiar objects and photos can also be reassuring.
- Avoid stimulants. Limit caffeine, sugar, and alcohol, especially late in the day.
- Distraction and reassurance. If agitation occurs, use distraction techniques like offering a favorite snack or looking at a photo album. Speak calmly and gently to reassure the person that they are safe.
When Is Medication Considered?
Medication is typically reserved for cases where non-pharmacological strategies are not effective, or when behaviors pose a risk to the individual or others. A doctor will carefully weigh the potential benefits against the risks, especially in older adults who may be more susceptible to side effects. The treatment process often involves a trial-and-error approach, starting with the lowest possible dose.
Types of Medicine for Sundowning
Atypical Antipsychotics
This class of drugs is often used for severe agitation, aggression, and hallucinations associated with sundowning. Brexpiprazole (Rexulti) is an atypical antipsychotic specifically FDA-approved for agitation related to Alzheimer's dementia. Other commonly used options include quetiapine (Seroquel) and risperidone (Risperdal). These medications carry significant risks, including an increased risk of stroke and death in older adults with dementia.
Melatonin
Melatonin is a hormone that regulates the sleep-wake cycle. Supplements are sometimes used to help regulate circadian rhythms and improve sleep quality in people with dementia. Some studies show potential benefits, but the evidence is not conclusive. It is often used in combination with light therapy.
Antidepressants
Sedating antidepressants, such as trazodone (Desyrel) and mirtazapine (Remeron), are often used off-label at bedtime to promote sleep. While some find relief, evidence regarding their effectiveness for agitation symptoms is mixed. Risks include increased falls and gastrointestinal distress.
Benzodiazepines
These tranquilizers, such as lorazepam (Ativan) and clonazepam (Klonopin), can be used for short-term relief of severe anxiety or agitation. However, they are generally avoided in older adults due to high risks of increased confusion, falls, and potential for dependence. They are considered a last resort and should be used with extreme caution.
Acetylcholinesterase (AChE) Inhibitors
Medications like donepezil (Aricept) and rivastigmine (Exelon), used to treat cognitive symptoms of dementia, may have some effect on behavioral symptoms, including sundowning. However, the evidence is mixed and some have reported worsening sleep or agitation with these medications.
Weighing the Options: A Comparison
| Feature | Pharmacological Approaches | Non-Pharmacological Approaches |
|---|---|---|
| Action Speed | Can be faster-acting for acute situations | Slower, requires consistency over time |
| Safety & Side Effects | Higher risk, especially in older adults (e.g., increased fall risk, confusion, stroke) | Lower risk; primarily focused on safety and environment |
| Long-Term Efficacy | Variable; often requires ongoing monitoring and reassessment | Offers long-term support for managing behavior by addressing triggers |
| Treatment Focus | Primarily symptom management | Addresses root causes (circadian rhythm, environment) |
| Application | Reserved for severe cases or when other methods fail | First-line, universally recommended strategy |
Monitoring and Collaboration with the Healthcare Team
Effective management of sundowning requires ongoing communication with the healthcare team. Before any medication is prescribed, a doctor will perform a thorough evaluation to rule out other potential causes for behavioral changes, such as pain, infections, or side effects from other medications. Caregivers should keep a detailed log of behaviors, including timing, potential triggers, and responses to interventions, to help the doctor make informed decisions about treatment.
Conclusion
Understanding what medicine is used for sundowning is a critical part of a comprehensive care plan. While pharmacological interventions, such as atypical antipsychotics, sedating antidepressants, or melatonin, may be necessary for severe symptoms, they are not a cure and come with risks. The best approach starts with careful observation and implementation of non-drug strategies, which can create a more predictable and calming environment. Always consult a healthcare professional to create a personalized plan and discuss the safest and most effective options for your loved one. For additional information on coping with dementia-related behaviors, visit the National Institute on Aging at www.nia.nih.gov.
