CES Case Series: How Cranial Electrotherapy Stimulation Reduced Dementia Related Anxiety And Insomnia in Sundowning Patients

Memory Care Residents

A report on residents at The Cottages Assisted Living & Memory Care, an Idaho-based senior living community, who began Cranial Electrotherapy Stimulation (CES) for dementia-related agitation and sundowning. Shared with permission from the facility and the residents involved. (Sundowning is increased confusion that people with dementia might experience from dusk through night.)

Prepared by Tauna Young, FNP-C – Founder & CEO, Neurovana

About CES and the Loading Phase

Cranial Electrotherapy Stimulation (CES) is a non-invasive, non-sedating treatment that delivers a very low-level electrical current through small ear clips. It is FDA-cleared for anxiety and insomnia. On the prescribing provider’s recommendation, every resident began with a one-month loading phase of twice-daily 30-minute CES Ultra sessions plus PRN for acute anxiety. The purpose of the loading phase was to help the brain settle into a calmer resting state, so that the benefits could then be maintained with less frequent sessions.

Executive Summary

This report summarizes the experience of eight residents at The Cottages Assisted Living & Memory Care whose care teams offered CES through a partnership with Neurovana. Residents began CES for dementia-related anxiety, agitation, sundowning, and insomnia. It is a descriptive report based on caregiver observations and provider check-ins, and improvement figures are caregiver estimates.

Across these eight residents, several themes emerged:

• Meaningful reductions in PRN anxiety medication use in several cases from every-other-day use to rare or zero use
• Significant improvement in sleep and sundowning – several residents who stayed awake into the early morning now go to bed on time and sleep through the night
• Caregiver-reported reduction in staff burden, with multiple caregivers independently describing the facility as calmer and easier to manage
• Benefits held when residents moved from twice daily to once daily after the first month
• No adverse effects reported for any resident, at any point
• Caregiver-estimated overall improvement of approximately 50% to 100%, varying by resident, symptom domain, and sometimes by shift
• Regular follow-up with the prescribing provider turned early obstacles into small adjustments.

After the loading phase, most residents were moved to once daily and maintained the same benefits. Two residents, E and B, chose to continue twice daily simply because they enjoy how relaxed it helps them feel.

One resident, H, passed away while receiving CES due to an unrelated terminal cancer diagnosis. CES was reported as helpful and well tolerated and was discontinued as she entered active decline.

Summary at a Glance

Resident A

A is an 84-year-old female with Alzheimer’s dementia who started CES for anxiety, exit-seeking, and sundowning that began around lunchtime and continued into the evening. At the start, caregivers rated her anxiety 9/10 at its worst, with daily pacing, wandering, clinging, resistance to care, and physical aggression (including biting) during acute episodes. She had been prescribed PRN for anxiety, which was administered every other day, on average.

Within 30–45 minutes of her first session, caregivers noted she was calmer and less shaky; by day two, her anxious hand-shaking had stopped. Day-shift staff estimated 50% improvement in week one, and she had not needed her PRN Ativan since the day after starting CES treatment. When the provider last checked in, 7 weeks after she started CES, she had not received any PRN since that one dose. By about two and a half weeks, she was more relaxed and cooperative across shifts, mealtime outbursts had stopped, and an elopement caused by a door left open by a delivery crew was uneventful – she did not fight when brought back. Staff estimated about 70% overall improvement.

It was like night and day difference. – a day-shift caregiver, on applying CES at A’s first signs of anxiety

By three and a half weeks, caregivers described her sundowning as completely resolved and her evening behavior as 100% improved. She had gone by far her longest PRN medication-free stretch, compared to a previous longest gap of seven days. She now attends evening dancing and Zumba with her daughter without exit-seeking, and the calmer house allowed staff to resume evening movie nights. After the first month she was moved to once daily plus PRN CES and has maintained the same benefits.

Resident B

B is a 95-year-old female with dementia, delusions (searching for family), exit-seeking, and daily sundowning. Her first session was a PRN on day one while she was actively agitated and trying to leave; caregivers reported she calmed almost instantly. By day three, sundowning symptoms had resolved, fall risk had dropped (she was no longer leaving without her walker), and PRN for anxiety and delusion previously used every 2–3 days, had stopped. By about one week, the delusions had stopped and she no longer felt a need to search for her family, which had driven her wandering. She is continuing twice daily use simply because she finds her CES sessions relaxing.

She’s just been more calm, more relaxed, the house is just smoother; she’s not making everyone so anxious.

Resident C

C is a 90-year-old female with dementia and the most shift-dependent course of any resident. The first days were a roller coaster: initially calming, then a brief anxiety spike on day two from the device’s flashing automatic-shutoff light, which repositioning the device behind her fully resolved. By about one week, evening and weekend staff reported she was less emotional, wandering less, and more engaged, while day staff still saw her as grouchy and resistant around the afternoon session. Staff traced this to her routine – she becomes upset around noon to 1pm that her daughter has not visited – rather than to CES. At about three weeks, the second session was moved from 3pm to 7pm, away from that window and closer to a time she is typically more cooperative. After the first month she moved to once daily and maintained her gains.

Resident D

D is a 91-year-old male with dementia, agitation, and daily sundowning.

At one week, he was already less aggressive and more upbeat. By two weeks he was falling asleep around 10pm and staying asleep (baseline: awake until 1–3am), with an estimated 80%-or-greater improvement in sleep and about 30% in sundowning distress. By three weeks he was more present and clear-minded, with no agitation even after two atypical late nights – a resilience not seen at baseline – his afternoon confusion had shifted later and was less distressing, and exit-seeking had stopped. Caregivers estimated 80–82% overall improvement. At about one month the team moved him to his preferred once-daily schedule plus PRN, and he has maintained the same benefits. Before CES, his exit-seeking had put him at risk of needing to be transferred to memory care; now that it has stopped, he is not expected to need that transfer.

He definitely hasn’t been showing those extreme behaviors as before, whereas before he was really kind of approaching that line – [regarding risk of needing transfer to memory care]

Resident E

E is a 78-year-old female whose primary concern is generalized anxiety, without significant dementia or sundowning. Before CES she had weeping episodes at least three to four times a week; after the first week, she had no further weeping episodes. By about two and a half weeks, caregivers described CES sessions as helping her process emotions rather than erupt, with an estimated 74–75% mood improvement. By four to five weeks her sleep was very regular, her energy was markedly better (she is now out of bed at least every other day, where she previously alternated overexertion with 2–3 days in bed), and emotional improvement was estimated at 80–85%. No change in cognition was reported or expected, as CES is not expected to affect the underlying dementia process. She is in maintenance and has chosen to continue twice daily simply because she enjoys how relaxed it helps her feel.

Resident F

F is an 83-year-old female with dementia, aggression, insomnia, and anxiety. Her main goal was an appropriate bedtime; at baseline she stayed awake until 3–4am, slept until noon or later, and hit and bit staff during morning care.

By two weeks, she was typically in bed by 9 pm, and her pattern of getting up 10–15 times after bedtime had resolved. By three weeks she was easier to wake (mild protesting instead of hitting or biting), eating more consistently (up from about two bites per meal), and possibly at lower fall risk. At about four weeks her bedtime goal was stable. With an estimated 80% overall improvement, she moved to once-daily CES plus PRN and has maintained her gains.

When they put the treatment on, she calms right down – on F’s response to CES sessions

Resident G

G is an 83-year-old female with dementia, insomnia, delusions, and agitation who had recently moved from assisted living to memory care. She had a fully inverted sleep-wake cycle – sleeping by day, then awake and active overnight, convinced she was a night-shift nurse, entering other residents’ rooms and asking nightly to get her car. In the first one to two weeks, staff applied CES whenever she woke overnight and consistently found it returned her to sleep, which became the standard approach. By two to three weeks, she was going to bed at a normal hour and sleeping through the night, which staff described as taking a huge burden off overnight care. Framing the device as her medicine, which her son had wanted her to try, improved her cooperation.

She began removing the ear clips about 10 minutes after application, which the team attributed to short-term memory impairment rather than distress; nighttime wakefulness stayed improved even with partial sessions. Her schedule was consolidated to one evening session around dinnertime, when she is reliably awake and cooperative. At about four weeks she developed a UTI and became acutely agitated, so sessions were not possible and CES was paused for about a week; it has resumed once daily plus PRN, and her gains have held.

Resident H

H was an 81-year-old female with dementia, anxiety, agitation, sundowning, and a history of breast cancer. Shortly before starting CES, a fall caused three broken ribs and a pelvic fracture, and a cancer recurrence was found. Very active before, she found it hard to sit still and was on numerous PRNs for sleep, anxiety, pain, and delusion.). In the first week caregivers reported a clear calming effect – it just relaxes her – with notable anxiety relief and an easier time settling for bed, which she had strongly resisted. By about three weeks her health had declined sharply and CES was largely paused; staff were advised it could still be used if it caused no distress. It was discontinued when she entered active dying, and she passed away a few days later. No adverse effects from CES were reported.

Impact on House Peace and Staff Burden

Across multiple caregivers and residents, staff independently described effects beyond the individual resident: calmer houses, residents who are easier to redirect and less likely to disturb others, and less intensive overnight supervision. Staff said they no longer needed to watch doors and residents as closely, that daily cares went more smoothly, and that calmer evenings allowed the house to resume shared activities such as evening movie nights.

The house has been overall more peaceful since the improvements to this pt and the other pt who is receiving this treatment… it helps staff tremendously with all the cares. – regarding D and E
The staff doesn’t have to watch the doors as closely or watch him as closely as before. – regarding D

Why Provider Follow-Up Matters

The prescribing provider followed up weekly for the first month and every two weeks during the second month. Going forward, follow-ups will likely be needed no more than once a month, and possibly less often. Each resident responded favorably, though some needed gentle support getting comfortable with sessions, since dementia can make it hard to remember why the device is being used. Nearly every early obstacle was solved at a check-in between the care team and the prescribing provider, usually with a small adjustment instead of a stop in treatment. Regular follow-up helped in several ways:

• Reinforcing staff education: PRN CES does not need nurse or provider sign-off and is a great first-line option for acute agitation before a pharmacological PRN, and consistent daily use helps maintain benefits. This education also helped staff feel empowered to administer CES sessions using their own judgment, because it is a safe, low-risk intervention.
• Troubleshooting delivery: small changes to device placement, electrodes, or session timing resolved early tolerance issues.
• Tailoring the schedule: session times were adjusted to fit each resident’s routine, and after the first month most residents moved to once daily plus PRN with the same benefits, while some chose to stay on twice daily simply because they enjoy their sessions.
• Interpreting mixed reports: differing estimates between shifts reflected routine and timing differences rather than an inconsistent treatment effect and gave staff useful information about what each resident needs.
• Adjusting to clinical changes: CES was briefly paused during an acute illness because the resident’s cooperation changed while she was ill, not because CES was harmful, and it resumed once she could cooperate again. For another resident, CES was discontinued as she declined prior to passing.

Closing

Across these eight residents, caregivers reported a consistent pattern: meaningful reduction in distressing dementia-related behaviors, substantial reductions in PRN medication use, improved sleep and sundowning, and a repeatedly reported reduction in staff burden, all without a single adverse event. After the first month, most residents moved from twice daily to once daily and maintained the same benefits. Regular provider follow-up was a consistent part of how those results were reached. We are grateful to the caregivers and administrators at The Cottages Assisted Living & Memory Care for generously sharing their experience with us and for the compassion and dedication they bring to caring for their residents.

Citations

1. The Cottages Assisted Living & Memory Care – Boise, Idaho 83714
2. CES Ultra – What Is CES?
3. CES Ultra – CES Ultra Benefits
4. Alzheimer’s Association® – Sleep Issues And Sundowning.