Medication Management for Sundowning in Dementia

Initial Management Strategy

The American Geriatrics Society emphasizes that non-pharmacological interventions should be exhausted before considering medications for behavioral symptoms in dementia 3
Non-pharmacologic interventions, including environmental modifications and structured routines, should be the first-line approach for sundowning, as recommended by the American Family Physician 1, 2

Cholinesterase inhibitors, such as donepezil, rivastigmine, or galantamine, may improve behavioral symptoms including sundowning and should be considered as first-line pharmacologic therapy, according to the American Family Physician 1, 3
Rivastigmine dosing should start at 1.5 mg twice daily, increase by 1.5 mg twice daily every 4 weeks as tolerated to maximum 6 mg twice daily, and be taken with food to reduce gastrointestinal side effects, as recommended by the American Family Physician 1
Galantamine dosing should start at 4 mg twice daily with meals for 4 weeks, then increase to 8 mg twice daily, according to the American Family Physician 1
The FDA has issued a black box warning regarding increased risk of death when antipsychotics are used for dementia-related behavioral disturbances, and should only be used when patients pose serious risk of harm to themselves or others, and only for short-term duration, as stated by the Mayo Clinic Proceedings 4, 3
Selective serotonin reuptake inhibitors, such as citalopram or sertraline, are preferred for comorbid depression due to minimal anticholinergic effects, according to the American Family Physician 2, 3

The American Academy of Sleep Medicine makes a strong recommendation against sleep-promoting medications, including benzodiazepines, for irregular sleep-wake rhythm disorder in demented elderly patients, due to increased risks of falls, cognitive impairment, and other adverse outcomes 7, 5
Anticholinergic medications should be avoided as they cause CNS impairment, delirium, slowed comprehension, and worsen cognitive function in dementia, as stated by the Mayo Clinic Proceedings 4

The treatment algorithm should start with optimizing comorbid conditions, implementing comprehensive non-pharmacologic interventions, and initiating a cholinesterase inhibitor if not already prescribed, according to the American Family Physician 1, 2
If pharmacologic therapy becomes necessary, low-dose risperidone (0.5-1 mg/day) may be added for persistent severe agitation/aggression, with careful monitoring, as recommended by the American Family Physician 2
Geriatric dosing principles should be used, with monitoring for side effects and attempts to reduce doses after 4-6 months of behavioral control, according to the American Family Physician 2