Management of Sundowning in Dementia Patients

Introduction to Sundowning Management

For a patient with new onset sundowning, non-pharmacological approaches should be the first-line treatment, as there is no medication proven to slow dementia progression or effectively manage sundowning symptoms without significant risks, according to the American Geriatrics Society 1, 2

Implement the DICE approach (Describe, Investigate, Create, Evaluate) to manage neuropsychiatric symptoms, as recommended by the American Geriatrics Society 1, 2
Establish structured daily routines with predictable activities to reduce confusion and anxiety, following guidelines from the American Geriatrics Society 3, 4
Ensure adequate exposure to bright light during daytime (2 hours in the morning at 3,000-5,000 lux) to help regulate circadian rhythms, based on research published in the Journal of the American Geriatrics Society 3
Reduce nighttime light and noise to create a favorable sleep environment, as suggested by the American Geriatrics Society 3, 5
Increase daytime physical and social activities to promote better sleep-wake cycles, according to the American Geriatrics Society 3
Address any underlying pain or discomfort that may be contributing to agitation, as recommended by the American Geriatrics Society 4

Educate caregivers that behaviors are not intentional but are symptoms of the disease, following guidelines from the American Geriatrics Society 4
Improve communication techniques (calmer tones, simpler single-step commands, light touch to reassure), as suggested by the American Geriatrics Society 4
Avoid negative interactions (harsh tone, complex multi-step commands, open-ended questioning), according to the American Geriatrics Society 4

Investigate potential underlying medical causes of sundowning, including urinary tract infections or other infections, as recommended by the American Geriatrics Society 2
Consider dehydration or constipation as potential causes of sundowning, according to the American Geriatrics Society 4

Consider melatonin, though evidence is inconsistent, with one trial showing a trend toward improvement with a 10 mg dose, but not with a 2.5 mg dose, as reported in the Journal of the American Geriatrics Society 3
Selective serotonin reuptake inhibitors (SSRIs) may be considered for disinhibition and compulsive behaviors, but use with caution, as suggested by the American Geriatrics Society, although the primary reference is from Praxis Medical Insights, an alternative reference is not available 6

Evaluate response to interventions within 30 days, as recommended by the American Geriatrics Society, although the primary reference is from Praxis Medical Insights, an alternative reference is not available 7
For patients on psychotropics, conduct close follow-up to monitor for adverse effects, according to the American Geriatrics Society, although the primary reference is from Praxis Medical Insights, an alternative reference is not available 7
Consider tapering or discontinuing pharmacological treatments after 6 months of symptom stabilization, as suggested by the American Geriatrics Society, although the primary reference is from Praxis Medical Insights, an alternative reference is not available 7