When Calm Feels Out of Reach: CES for Dementia-Related Anxiety and Agitation

A resource for families, caregivers, and anyone supporting individuals impacted by dementia

FDA-Cleared for anxiety and insomnia

You're Not Imagining It

If you've watched a loved one become increasingly anxious, restless, or agitated — especially as the day goes on — you're not alone. Up to 90% of people with dementia experience behavioral and psychological symptoms¹,and agitation is among the most challenging for families and caregivers to manage. It can show up as pacing, restlessness, verbal outbursts, emotional distress, resistance to care, or an inability to settle — particularly in the late afternoon and evening hours, a pattern commonly known as "sundowning".

Circadian rhythm disruptions in individuals with dementia have been linked to decreased or dysregulated melatonin levels, and are thought to play a significant role in the development of sundowning behavior².

These moments are exhausting for caregivers and distressing for the person experiencing them. And yet, many families feel like they're out of options — medication is usually the only one on the table.

Caregiver supporting an older loved one at home

Older adult discussing a medication plan with a physician

The Problem with Relying on Medication

When behavioral symptoms become severe, medication is often the default response. While there are FDA-approved options for agitation associated with dementia, antipsychotics and anti-anxiety medications carry significant risks in older adults, including increased sedation, falls, confusion, and in some cases more serious outcomes⁶.

Most experts and leading medical organizations recommend that non-drug approaches be considered first⁷ — yet accessible, easy-to-use non-drug options remain limited for most families.

Sundowning Doesn't End When the Sun Goes Down

For many people with dementia, the agitation and anxiety of sundowning doesn't simply stop at bedtime — it bleeds directly into the night. People with dementia often produce lower levels of melatonin, especially in the evening, making it harder to fall asleep and stay asleep, and contributing to insomnia and nighttime restlessness³.

The result is a cycle that caregivers know all too well: a difficult late afternoon and evening, followed by a night of fragmented or absent sleep — which then worsens cognitive function and lowers the threshold for agitation the next day. Research has confirmed that agitation in people with dementia is directly linked to sleep disorders⁴, meaning the two problems don't just co-exist — they feed each other.

This is where the overlap between sundowning and insomnia becomes clinically meaningful. Both involve the same underlying disruption: a dysregulated nervous system, declining melatonin production, and a circadian rhythm that has lost its anchor. Studies have found that supporting melatonin production in people with dementia significantly improved sleep quality, decreased nighttime waking, and reduced agitated behavior — including sundowning⁵.

CES supports the body's natural production of melatonin, alongside serotonin and endorphins, while helping to lower cortisol and calm nervous system hyperarousal. These are precisely the mechanisms that become dysregulated in both sundowning and insomnia — which is why CES may offer something that few other non-drug interventions do: the potential to address both problems through a single, gentle daily session.

Anxiety Is Anxiety, Regardless of Its Cause

Dementia does not create a different kind of anxiety. It creates the same anxiety — the same nervous system dysregulation, the same cortisol spike, the same hyperarousal — in a person who has fewer cognitive resources to manage or communicate it. The brain structures involved in anxiety and agitation are the same ones CES is known to influence: the thalamus, the limbic system, and the reticular activating system, which governs arousal and sleep-wake cycles⁸.

CES is FDA-cleared for anxiety and insomnia. While these clearances are not specific to dementia-related anxiety, the underlying physiology that CES addresses — nervous system hyperarousal, disrupted sleep architecture, cortisol dysregulation, and imbalanced neurotransmitter levels — is the same physiology that drives agitation and sundowning in people with dementia. Research has also shown that CES clinically reduces symptoms of anxiety and may improve sleep quality in older adults⁹, suggesting that the benefits extend meaningfully into the aging population.

Why CES Is Worth Exploring

For caregivers looking for a safe, non-drug option to support a loved one with dementia-related anxiety, agitation, or sleep disruption, Calm Ultra CES offers several qualities that are difficult to find in a single intervention:

Drug-free — no sedation, no risk of dependency, no interactions with existing medications

Non-invasive — worn comfortably on the earlobes for a 30 or 45 minute session

Home-friendly — simple enough to use in any care setting, including at home or in a memory care facility

Calming by design — works by promoting alpha wave activity and supporting the body’s natural production of serotonin, melatonin, and endorphins, while lowering cortisol

Addresses both agitation and sleep — by working at the nervous system level, a single daily session may support both calmer evenings and more restful nights

Gentle — the microcurrent is painless

What to Expect and How to Approach It

CES is most effective with consistent, regular use — daily sessions tend to produce more sustained results than occasional use
Sessions are passive — your loved one simply sits or reclines while Calm Ultra CES is in use, making it accessible even for those with limited mobility or communication

As with any non-drug approach, results vary from person to person, and CES is not a cure for dementia or a replacement for medical care
We always recommend discussing any new intervention with your loved one’s physician or care team

NEUROVANA - CES & DEMENTIA CARE

CES and the Symptoms of Dementia

Cranial Electrotherapy Stimulation (CES) is an FDA-cleared medical device with nearly 50 years of clinical use. Below is a look at the neurochemical changes CES produces, and how those changes relate to two symptoms common in dementia: anxiety and sundowning.

Neurochemical Changes with CES

Brain Messenger	Changes after 1 CES session	What It Means
Serotonin	↑ 50%	Improves mood, increases pain tolerance, decreases insomnia.
Melatonin	↑ 25%	Supports sleep onset and circadian rhythm regulation.
Cortisol	↓ 18%	Reduces stress and anxiety, improves sleep, normalizes metabolism.
Norepinephrine	↑ 24%	Improves focus, regulates sleep/wake cycles.
Beta Endorphin	↑ 98%	Improves sense of well-being, helps regulate pain response.
Cholinesterase	↑ 8%	Allows muscles to relax.

Adapted from Kirsch, D. L., & Nichols, F. (2013). Cranial electrotherapy stimulation for treatment of anxiety, depression, and insomnia. Psychiatric Clinics of North America, 36(1), p. 171. Copyright © 2013 Elsevier.

FDA-Cleared for Anxiety

Dementia-Related Anxiety

What Causes Anxiety in Dementia?

Cause	What Happens	Why It Matters
Amygdala/Limbic Hyperactivity	As dementia progresses, damage to the hippocampus and amygdala — along with loss of top-down control from the prefrontal cortex — leaves the brain's threat-response system overactive and poorly regulated.	This produces excessive worry, fear, and restlessness that can be hard to reason away, since the brain regions responsible for calming the response are themselves impaired.
GABA System Dysfunction	GABA is the brain's primary "calming" neurotransmitter. In anxiety states, GABA signaling in the amygdala becomes underactive, weakening its ability to inhibit fear and threat responses.	Without enough inhibitory signaling, normal or even neutral situations can trigger a disproportionate anxiety response.
HPA-Axis / Cortisol Dysregulation	Chronic stress keeps the hypothalamic-pituitary-adrenal (HPA) axis activated, leading to persistently elevated cortisol.	Sustained cortisol elevation contributes to a body and brain that stay "on alert," making it harder to settle into a calm baseline state.

EXPLORATORY USE - NOT YET FDA-CLEARED SPECIFICALLY FOR SUNDOWNING

Sundowning

What Causes Sundowning?

Cause	What Happens	Why It Matters
Circadian Rhythm Breakdown	As dementia progresses, the brain's internal clock loses its ability to reliably distinguish day from night.	People experience confusion, restlessness, or agitation as evening approaches — their brain isn't getting a clear "day is ending" signal.
Serotonin Decline	Serotonin levels drop, which in turn reduces melatonin production.	Without the normal serotonin-to-melatonin handoff, the brain never gets the "wind down" signal it needs to transition toward sleep.
Nervous System Stuck in Alarm Mode	The autonomic nervous system remains activated in a stress/fight-or-flight state rather than settling in the evening.	This shows up as agitation, vocalization, resistance to care, and pacing — the hallmark behavioral symptoms of sundowning.

Sundowning has three known drivers; a failing internal clock, a serotonin/melatonin shortfall, and a nervous system stuck in alarm mode. As shown above, CES affects all three of these same pathways - which is why we believe it's worth exploring for sundowning. This is not an FDA-cleared indication — not because the science doesn't support it, but because no clearance application for sundowning has been pursued.

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Note for Healthcare Providers and Facility Administrators

If you are a healthcare provider, memory care administrator, or facility clinical director exploring non-pharmacological options for residents with dementia-related agitation, we would love to connect. Neurovana offers provider support, clinical guidance, and partnership options for facilities interested in integrating CES into their care model.

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How CES Works

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References

CES is FDA-cleared for anxiety and insomnia. The information on this page is for educational purposes and does not constitute medical advice. Please consult your loved one's physician before introducing any new treatment or intervention.