Sundowning

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (14/06/2019)

Original Editor - User:Akano Oluwadara Tomisin

Top Contributors - Akano Oluwadara Tomisin and Kim Jackson  

Introduction

Sundowning 2.jpg

Sundowning also known as sundown syndrome or late day confusion,[1] is a neurological condition that describes confusion and restlessness that occurs in the late afternoon or early evening in patients with Alzheimer's Disease and other forms of Dementia[2]. The symptoms can differ between individuals but often include:

  • Confusion
  • Anxiety
  • Aggression
  • Irritability
  • Not listening to advice
  • Acting suspicious
  • Pacing
  • Wandering

Although it is more common in people with Dementia it can be seen in older people who do not have Dementia[3], Symptoms tend to appear as the sun is setting and can last into the night but by morning they have usually disappeared..[4][5][6]

Causes of Sundowning

Some evidence indicates that sundowning behaviors tend to increase due to disruption of circadian rhythm, although the causes have not been proven objectively. In humans, a biochemical cascade is triggered as the sun sets which results in a reduction in the dopamine levels and an increase in melatonin production as the body goes to sleep. The opposite is the case in people with Dementia, the production of melatonin may be decreased,[1] which may interrupt other neurotransmitter systems. Also, a disruption within the suprachiasmatic nucleus (SCN) may occur due to the development of plaques and tangles that is associated with Alzheimer's disease.[6] The suprachiasmatic nucleus regulates sleep patterns by maintaining circadian rhythms, which are strongly associated with external light and dark cues. The kind of confusion that are mostly seen in sundown syndrome can be linked to the disruption that occurs within the suprachiasmatic nucleus . However, finding evidence to back this up is arduous, because an autopsy is needed to definitively diagnose Alzheimer's in a patient. Once an Alzheimer's patient has died, they have usually surpassed the level of dementia and brain damage that would be associated with sundowning. This hypothesis is, however, supported by the efficacy of melatonin, to decrease behavioral symptoms associated with sundown syndrome.

Other possible causes of sundowning include: fatigue, depression, unmet needs, pain, low lighting, difficulty separating dreams from realithy, presence of an infection such as urinary tract infection, boredom.

Symptoms of Sundowning

Different symptoms of sundowning have been identified, they include:

  • Increase in general confusion as natural light begins to fade and increased shadows appear.[4][7]
  • Agitation and mood swings.[4][5]
  • Mental and physical fatigue increase with the setting of the sun.[4][5]
  • Tremors may increase and become uncontrollable.
  • An individual may experience an increase in their restlessness while trying to sleep.[5]

Treatment of Sundowning

  • Reduction in confusion and agitation can be achieved in patients if a daily routine that the patient is comfortable with and a consistent sleeping schedule is maintained.[4]
  • Patients should be involved in doing more daily activities as this can help promote an earlier bed time and need for sleep.[4][5]
  • Over-napping should be discouraged. It can affect a good night sleep in patients. Physical activity should be encouraged as it is a treatment for Alzheimer's, and a way to encourage night sleep.[5]
  • Caffeine, brain stimulant, should be limited at night.[4][5]
  • Patients should be allowed to choose their own sleeping arrangements which they are comfortable with
  • the room of patients should not be left in utter darkness, dim light should be allowed to occupy the room to allay any confusion associated with an unfamiliar place.[5]
  • In the evening, stimulating activities and background noise should be reduced.
  • A strange or unfamiliar setting can be upset the patient, bring familiar items like photographs to create a more relaxed and familiar setting.
  • Play familiar gentle music in the evening or relaxing sounds of nature, such as the sound of waves.
  • Some evidence supports the use of melatonin to induce sleep.[6] It has also been suggested that a low dose of melatonin alone, or in combination with exposure to bright light during the day may help ease sundown syndrome.

Resources

  1. Sundowning: Late day confusion
  2. Tips for coping with sundowning

References

  1. 1.0 1.1 Khachiyants N, Trinkle D, Son S, Kim K. Sundown syndrome in persons with dementia: an update. Psychiatry investig, 2011; 8:275-87
  2. Burney-Puckett M. Sundown syndrome: etiology and management. Journal of psychosocial nursing and mental health services. 1996 May 1;34(5):40-3.
  3. Cipriani, G., Lucetti, C., Carlesi, C., Danti, S., & Nuti, A. (2015). Sundown syndrome and dementia. European Geriatric Medicine, 6(4), 375–380.doi:10.1016/j.eurger.2015.03.006 
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Smith G. Sundowning: Late-day confusion. Mayoclinic.com 2011
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Alzheimer's Association: Sleepelessness and Sundowning
  6. 6.0 6.1 6.2 de Jonghe A, Korevaar J, Munster B. Effectiveness of Melatonin treatment on circadian rhythm disturbances in dementia: Are there implications for delirium? A systematic Review. International Journal of Geriatric Psychiatry. 2010;25(12):1201-18
  7. Keller S. Sundwoning WedMD LLC, 2012