What Is the Best Medication for Sundowners?

Reviewed on 11/30/2022
A caregiver holding the hands of an elderly woman
There isn't one best medication used to treat sundowning in people with Alzheimer's disease. Treatment is individualized and may include medication as well as lifestyle modifications.

Sundowning (also called sundown syndrome) refers to changes in mood and behavior that often occur in the late afternoon or evening in people with Alzheimer's disease and similar conditions that affect brain function. 

Sundowning can occur at any stage, but it tends to peak in the middle stages of dementia and diminishes as the disease progresses and can affect quality of life for patients. 

Sundowning can may affect many as two-thirds of people with Alzheimer’s disease and other dementias.

There is no single best medication for sundowners. Treatment is individualized and what works for one person may not work for another. Treatment for sundowners may include: 

  • Bright light therapy
    • Increased lighting in the evening hours may help elderly patients with a neurologically compromised brain in orient to their surroundings
  • Melatonin
    • May reduce sundowning behavior, reduce nocturnal activity, decrease the time it takes to fall asleep, and improve quality of sleep
  • Acetylcholinesterase inhibitors
    • No clear evidence they help with sundowning behaviors, but these medications are commonly used to treat Alzheimer’s disease
    • In some patients it may improve some sundowning behaviors and in some, these drugs can worsen the condition
  • Antipsychotic medications
    • The most widely used class of medications to manage symptoms of sundowning, but there is limited information available on their effectiveness
  • Environmental intervention/behavioral modifications
    • Physical exercise
      • Can help with cognition and the rest-activity rhythm
    • Aromatherapy
      • One study found lavender oil administered in an aroma stream was somewhat effective in treating agitated behavior in patients with severe dementia
    • Music therapy
      • One study showed improvements in sundowning symptoms 
    • Everyone reacts differently and it may take trial and error to learn what works 
      • Plan and encourage activities during the day
        • Don’t plan too many activities as a full schedule can be exhausting 
      • Discourage napping or keep naps short and don’t nap late in the day
      • Schedule calming activities when agitation usually occurs and make early evening a quiet time of day
      • Maintain a routine
      • Reduce noise, clutter, or the number of people in the room
      • Adjust lighting
        • Let in natural light during the day and softer room lighting in the evening
      • Restrict sugary snacks and drinks and avoid caffeine at night
      • Avoid alcohol
      • Provide adequate lighting in the evening to help identify objects and people
      • Provide items of comfort like a favorite pillow or blanket
      • Distract the person with a favorite object or activity

Benzodiazepines and cannabinoids have been suggested as treatments for sundowning, but due to the significant negative side effects associated with these medications, they are not recommended for use to treat sundowning. 

What Are Symptoms of Sundown Syndrome?

Symptoms of sundowning (sundown syndrome) include: 

  • Aggression
  • Agitation
  • Delusions
  • Hallucinations
  • Paranoia
  • Increased disorientation
  • Wandering or pacing
  • Attempting to leave home
  • Becoming demanding
  • Impulsiveness
  • Difficulty understanding others
  • Problems with tasks that were done without difficulty earlier in the day
  • “Shadowing” (The person mimics or follows the caregiver, sometimes asking repetitive questions)
  • Difficulty sleeping and staying in bed

What Triggers Sundowning?

It's not always clear why sundowning (sundown syndrome) behaviors tend to occur in late afternoon and at night, but certain events or issues can trigger sundowning, such as:

  • Tiredness at the end of the day
    • May lead to an inability to cope with stress
  • Low lighting and more shadows 
    • Can create confusion and hallucinations, especially with things that look different when it is darker
  • Disruption of the Circadian rhythm (sleep/wake cycle) 
    • Patients are unable to distinguish day from night because of dementia 
  • Less or no activity in the afternoon as compared to the morning
    • Can lead to restlessness later in the day
  • Unmet needs such as hunger or thirst
  • Depression
  • Boredom
  • Pain
  • Side effects of medications that can cause restlessness or other movement disorders or affect cognition 
    • Antidepressants
    • Antipsychotics
    • Anti-Parkinsonian drugs
    • Anticholinergics 

How Do You Test for Sundown Syndrome?

  • Sundowning (sundown syndrome) is diagnosed with a patient history and the diagnosis is made based on the range of cognitive, affective, and behavioral symptoms that occur or worsen in late afternoon, at evening, or at night.
  • There are no laboratory tests, imaging studies, or electrophysiologic studies needed. 

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Reviewed on 11/30/2022
References
Image source: iStock Images

https://alzheimer.ca/en/help-support/im-caring-person-living-dementia/understanding-symptoms/restlessness-or-sundowning

https://www.nia.nih.gov/health/tips-coping-sundowning

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/

https://emedicine.medscape.com/article/292498-medication

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5187352/