Treatment options for sundowning in patients with dementia

Abstract

Objective. To review the evidence for the pharmacologic and non-pharmacologic management of sundowning in patients with dementia. Methods. Databases were searched using the terms sundown, circadian, chronobiological, biological clock, elderly, aged, geriatric, and senior. Studies selected for inclusion assessed potential interventions for the treatment of sundowning or nocturnal agitation. Results. A total of thirteen individual studies and two systematic reviews were evaluated. Study design and outcomes varied, but many measured sleep and nocturnal agitation. Non-pharmacologic interventions that may be of benefit include bright light therapy, music therapy, and aromatherapy. Pharmacologic therapies generally provided minimal benefit and were associated with safety concerns. Supportive evidence was found for the use of melatonin and antipsychotics. Evidence for antidepressants, donepezil, and dronabinol was weaker. Supportive evidence for the use of benzodiazepines was not found and thus cannot be recommended in elderly patients as they are more susceptible to their adverse effects. Conclusion. The number of studies on the management of sundowning is limited and the quality of evidence supporting its treatment is weak. Non-pharmacologic interventions are first line due to safety. Pharmacologic agents are recommended as second line treatment options, in particular antipsychotics and melatonin.