What is Sundowning Syndrome?
Sundowning, or sundown syndrome, is a common phenomenon in people with dementia characterized by a pattern of increased confusion, anxiety, restlessness, agitation, and irritability that begins in the late afternoon and continues into the night. While the exact cause is not fully understood, it is believed to be linked to disruptions in the brain's circadian rhythm (the body's internal clock) due to the underlying neurodegenerative disease. Environmental factors, such as decreased light and increased shadows, and other issues like fatigue, pain, or infection, can also trigger or worsen symptoms.
First-Line Treatment: Non-Pharmacological Strategies
Before considering medication, non-drug interventions are the recommended first step for managing sundowning. These strategies focus on creating a supportive and calming environment to help regulate the person's sleep-wake cycle and reduce anxiety.
- Maintain a Consistent Daily Routine: A predictable schedule for waking, meals, and bedtime provides a sense of security and familiarity, which can minimize confusion and anxiety.
- Maximize Daytime Activity: Regular physical activity, such as walks or simple exercises, can promote better sleep at night. Ensuring exposure to natural light during the day also helps regulate the circadian rhythm.
- Limit Evening Stimulation: Reduce noise, clutter, and activity in the late afternoon and evening. Calm, low-energy activities, such as listening to soft music or looking at a photo album, can help the person wind down.
- Adjust Lighting: As daylight fades, ensure indoor lighting is adequate to prevent shadows and reduce visual misperceptions that can cause fear or anxiety. Consider light therapy, which involves controlled exposure to bright light, especially in the morning.
- Check for Underlying Needs: Rule out potential triggers like hunger, thirst, pain, constipation, or a urinary tract infection, which can worsen behavioral symptoms.
When Medication is Necessary
If non-pharmacological strategies are not sufficient to manage severe or distressing sundowning behaviors, a healthcare professional may consider medication. It is crucial to approach this with caution and careful monitoring due to potential side effects in elderly individuals.
Melatonin
This is a hormone that regulates the body's sleep-wake cycle. Research suggests that low-dose melatonin supplements may help improve sleep quality and reduce sundowning agitation in some dementia patients. It is considered a relatively safe option with a mild side effect profile, though it is not effective for everyone.
Trazodone
An antidepressant with sedative properties, trazodone is often used off-label to treat sleep disturbances and insomnia associated with sundowning. It is generally better tolerated than some stronger sedatives, but can cause side effects like drowsiness, dizziness, and swelling.
Antipsychotic Medications
These are reserved for severe behavioral symptoms, such as agitation, aggression, hallucinations, or delusions, that do not respond to other treatments. Atypical antipsychotics like brexpiprazole (Rexulti), risperidone (Risperdal), and quetiapine (Seroquel) may be prescribed. However, these medications carry significant risks, including an increased risk of stroke and mortality in elderly individuals with dementia-related psychosis, and must be used with extreme caution. Brexpiprazole is the only atypical antipsychotic FDA-approved for agitation associated with Alzheimer's dementia.
Other Options
- Cholinesterase inhibitors (e.g., Donepezil): Primarily used to improve cognitive function in dementia, their effect on sundowning symptoms is mixed, and some studies even suggest they may worsen nighttime behaviors. Taking them in the morning may help mitigate potential sleep disruption.
- NMDA receptor antagonists (e.g., Memantine): Used for moderate to severe Alzheimer's, memantine may offer some benefits for aggression or psychosis with a more favorable side effect profile than antipsychotics.
- Benzodiazepines: Generally not recommended for sundowning due to high risks of dependence, increased confusion, sedation, and falls.
Comparison of Medications for Sundowning
| Medication Type | Primary Use in Sundowning | Key Benefits | Notable Risks/Side Effects |
|---|---|---|---|
| Melatonin | Sleep-wake cycle regulation | Can improve sleep quality and reduce agitation; relatively mild side effects | May not be effective for all individuals; possible daytime drowsiness |
| Trazodone | Sleep disturbances, insomnia | Can be effective for improving sleep; generally better tolerated than older sedatives | Drowsiness, dizziness, increased risk of falls, anticholinergic effects |
| Atypical Antipsychotics (e.g., Risperidone, Brexpiprazole) | Severe agitation, aggression, hallucinations | Potent reduction of severe behavioral symptoms; Brexpiprazole is FDA-approved for dementia agitation | Black box warning for increased stroke and mortality risk; sedation, extrapyramidal symptoms |
| Cholinesterase Inhibitors (e.g., Donepezil) | Cognitive symptom management | Possible minor effect on behavioral symptoms; treats underlying dementia | Mixed evidence; some studies suggest worsened nighttime behaviors or insomnia |
| Memantine | Moderate to severe Alzheimer's symptoms | Potential for reduced aggression or psychosis with fewer risks than antipsychotics | Gastrointestinal issues, dizziness, confusion |
Weighing Risks and Benefits
Determining the right course of treatment for sundowning requires a careful evaluation of the potential benefits and risks of any medication. For individuals with dementia, the trade-off between symptom control and potential side effects is a critical consideration. Powerful medications like antipsychotics, while effective for severe behaviors, carry significant risks that must be balanced against the distress and danger posed by the symptoms. The decision to use medication is a shared one between the prescribing physician, the caregiver, and, where possible, the patient, based on a comprehensive assessment of the individual's health, triggers, and the severity of their symptoms. Starting with the lowest effective dose for the shortest duration is standard practice.
Conclusion
There is no single definitive answer to what is the best medication for sundowning. The most effective approach is a personalized one, prioritizing non-pharmacological interventions like consistent routines, environmental modifications, and managing underlying health issues. When medication is deemed necessary, options range from supplements like melatonin for sleep to specific antidepressants like trazodone for sleep disturbances, and in severe cases, atypical antipsychotics for significant agitation and aggression. It is paramount to work closely with a healthcare provider to carefully weigh the risks and benefits of any medication and ensure the safest, most effective treatment plan is implemented for the individual with dementia.
For more information on non-drug approaches, consider resources from the Alzheimer's Association: https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior.
