Management of Sundowning in Dementia

Introduction to Sundowning Management

The American College of Physicians recommends avoiding Wellbutrin, Buspar, and Remeron as first-line treatments for sundowning in dementia patients, in favor of non-pharmacological interventions and evidence-based alternatives 1, 2

Bupropion is not recommended for sundowning or behavioral symptoms in dementia due to lack of evidence for efficacy and potential to increase agitation and confusion, as noted by the Mayo Clinic 3
Buspirone has no established role in treating sundowning or behavioral symptoms of dementia and lacks evidence from controlled trials in this population, contributing to polypharmacy burden without substantiated benefit, as reported by the Mayo Clinic 3
Mirtazapine may be considered only if comorbid depression is present, as it is among the safer antidepressants for dementia patients, but should not be used specifically for sundowning or sleep disturbances alone, according to Praxis Medical Insights 2, 1

Morning bright light therapy at 2,500-5,000 lux for 1-2 hours daily between 9:00-11:00 AM is recommended to regulate circadian rhythms and decrease evening agitation, as suggested by Praxis Medical Insights 1
Maximizing daytime sunlight exposure and reducing nighttime light and noise exposure is advised to consolidate nighttime sleep and reduce evening restlessness, according to Praxis Medical Insights 1
Increasing physical and social activities during daytime hours is recommended to consolidate nighttime sleep and reduce evening restlessness, as noted by Praxis Medical Insights 1, 2

If major depression is documented, initiating an SSRI (citalopram, escitalopram, or sertraline) as first-line treatment is recommended, as serotonergic antidepressants reduce overall neuropsychiatric symptoms including agitation, according to Praxis Medical Insights 2
Mirtazapine may be used as an alternative antidepressant if SSRIs are contraindicated or poorly tolerated, but only for documented depression, not for sleep or sundowning alone, as reported by Praxis Medical Insights 2
Antipsychotics should only be used for dangerous agitation or psychosis that poses risk to self or others, after comprehensive assessment and discussion of risks with family, and should be used at the lowest effective dose for the shortest duration, as recommended by the Mayo Clinic and the American Journal of Psychiatry 4, 5

Benzodiazepines are absolutely contraindicated due to high risk of falls, confusion, worsening cognitive impairment, and paradoxical agitation, as noted by the Mayo Clinic and Praxis Medical Insights 3, 1
Sleep-promoting medications (hypnotics, sedatives) are strongly discouraged as they increase falls, cognitive decline, and daytime hypersomnolence without meaningful benefit, according to Praxis Medical Insights 1
Anticholinergic medications should be minimized or eliminated, as they worsen cognition and behavioral symptoms, as reported by Praxis Medical Insights 1, 2

Wellbutrin and Buspar should be tapered and discontinued as they lack evidence for benefit in dementia with sundowning and contribute to polypharmacy burden, as recommended by the Mayo Clinic 3
Remeron should be continued only if treating documented major depression with demonstrated benefit; otherwise, taper over 2-4 weeks while implementing non-pharmacological interventions, according to the Mayo Clinic and Praxis Medical Insights 4, 2