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== Introduction ==
== Introduction ==
[[File:Sundowning 2.jpg|thumb]]
[[File:Sundowning 2.jpg|thumb]]
Sundowning also known as sundown syndrome or late day confusion,<ref name=":0">Khachiyants N, Trinkle D, Son S, Kim K. Sundown syndrome in persons with dementia: an update. Psychiatry investig, 2011; 8:275-87</ref> 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. The symptoms can differ between individuals but often include:
Sundowning refers to a group of neuropsychiatric symptoms which develop late afternoon or during the evening and night time ( periods of diminishing daylight). It is commonly seen in individuals diagnosed with [[dementia]] or neurocognitive decline due to [[parkinson's]] or [[Alzheimer's Disease|alzheimer's]] disease  and in elderly institutionalized patients<ref name=":0">Khachiyants N, Trinkle D, Son S, Kim K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246134/ Sundown syndrome in persons with dementia: an update.] Psychiatry investig, 2011; 8:275-87</ref>.
* 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(ref), Symptoms tend to appear as the sun is setting and can last into the night but by morning they have usually disappeared..<ref name=":1">Smith G. Sundowning: Late-day confusion. Mayoclinic.com 2011</ref><ref name=":2">Alzheimer's Association: Sleepelessness and Sundowning</ref><ref name=":3">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</ref>


== Causes of Sundowning ==
Some of the common symptoms associated with sundowning include:<ref>Menegardo CS, Friggi FA, Scardini JB, Rossi TS, Vieira TD, Tieppo A, Morelato RL. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907707/ Sundown syndrome in patients with Alzheimer’s disease dementia.] Dementia & neuropsychologia. 2019 Dec 9;13:469-74.</ref>
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,<ref name=":0" /> 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.<ref name=":3" /> The suprachiasmatic nucleus regulates sleep patterns by maintaining circadian rhythms, which are strongly associated with external light and dark cues. A disruption within the suprachiasmatic nucleus would seem to be an area that could cause the types of confusion that are seen in sundowning. However, finding evidence for this is difficult, as 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 effectiveness of melatonin, a natural hormone, to decrease behavioral symptoms associated with sundowning.


Other possible causes of sundowning include: fatigue, unmet needs such as hunger or thirst, depression, pain, boredom, low lighting ,increased shadow, difficulty separating reality from dreams, presence of an infection such as urinary tract infection
* Confusion,  
* Anxiety,  
* Aggression,  
* Irritability
* Hallucination
* Pacing
* Changes in demeanour and affect
* Motor changes like restlessness, dyskinesia


== Symptoms of Sundowning ==
Sundowning can negatively impact patient safety and wellbeing and  results in considerable caregiver [[Burnout and wellbeing|burnout]], it also poses increased demands on the health care providers especially the nursing staff.<ref name=":1" />
Symptoms are not limited to but may include:
== Etiology of Sundowning ==
* Increased general confusion as natural light begins to fade and increased shadows appear.<ref name=":1" /><ref>Keller S. Sundwoning WedMD LLC, 2012</ref>
The etiology of Sundowning is complex and poorly understood.Changes in the normal circadian rhythm is one of the most common cause of sundowning  however other factors like medications, environmental changes, comorbidities all play a significant role in development of disruptive behaviours seen in sundowning  Some of the common factors are summarized in Table 1<ref name=":1" />.
* Agitation and mood swings.<ref name=":1" /><ref name=":2" />
* Mental and physical fatigue increase with the setting of the sun.<ref name=":1" /><ref name=":2" />
* Tremors may increase and become uncontrollable.
* An individual may experience an increase in their restlessness while trying to sleep. Restlessness can often lead to pacing and or wandering which can be potentially harmful for an individual in a confused state.<ref name=":2" />


[[File:Fmed-03-00073-t001.jpg|alt=|556x556px]]
== Treatment of Sundowning  ==
== Treatment of Sundowning  ==
* If possible, a consistent sleeping schedule and daily routine that the patient is comfortable with can reduce confusion and agitation.<ref name=":1" />
The treatment for sundowning requires a team based approach. Coordination between the health care providers, patient  and the family members is quintessential. The treatment can be broadly divided between Pharmacologic and Nonpharmacologic approaches.  
* If the patient's condition permits, having increased daily activity incorporated into their schedule can help promote an earlier bed time and need for sleep.<ref name=":1" /><ref name=":2" />
* Pharmacological Treatments:  The three groups of drugs that have shown some promise for the management of sundowning are: Melatonin supplementation, cholinesterase inhibitors  and antipsychotics<ref name=":1">[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907707/ Canevelli] M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, Bruno G. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907707/ Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches.] Frontiers in medicine. 2016 Dec 27;3:73.</ref>. However, more research is required.
* Check for over-napping. Patients may wish to take naps during the day, but unintentionally getting too much sleep will affect nighttime sleep. Physical activity is a  treatment for Alzheimer's, and a way to encourage night sleep.<ref name=":2" />
* Non Pharmacological Treatments: This should be the first line of treatment for the management of sundowning. These include [[Environmental Physiotherapy- Introduction|environmental]] modifications, [[Physical Activity|physical activity,]] alternate therapy like [[Music therapy and children with cerebral palsy|music]], [[acupuncture]], tai-chi , light therapy, consistent routines, caregiver education etc.
* Caffeine is a  (fast-working) brain stimulant, but should be limited at night if a night's sleep is needed.<ref name=":1" /><ref name=":2" />
* Caregivers could try letting patients choose their own sleeping arrangements each night, wherever they feel most comfortable sleeping, as well as allow for a dim light to occupy room to alleviate confusion associated with an unfamiliar place.<ref name=":2" />
* In the evening, try to reduce background noise and stimulating activities, including TV viewing, which can sometimes be upsetting.
* In a strange or unfamiliar setting, bring familiar items — such as photographs — to create a more relaxed, 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.<ref name=":3" /> Some research suggests that a low dose of melatonin — a naturally occurring hormone that induces sleepiness — alone or in combination with exposure to bright light during the day may help ease sundowning
 
== Resources  ==
#[https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511]
#[https://www.nia.nih.gov/health/tips-coping-sundowning]


== References  ==
== References  ==
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<references />
<references />
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics]]
[[Category:Conditions - Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Conditions]]

Latest revision as of 12:48, 30 December 2021

Original Editor - Akano Oluwadara TomisinAkano Oluwadara Tomisin

Top Contributors - Adhira Mahajan, Akano Oluwadara Tomisin and Kim Jackson  

Introduction[edit | edit source]

Sundowning 2.jpg

Sundowning refers to a group of neuropsychiatric symptoms which develop late afternoon or during the evening and night time ( periods of diminishing daylight). It is commonly seen in individuals diagnosed with dementia or neurocognitive decline due to parkinson's or alzheimer's disease and in elderly institutionalized patients[1].

Some of the common symptoms associated with sundowning include:[2]

  • Confusion,
  • Anxiety,
  • Aggression,
  • Irritability
  • Hallucination
  • Pacing
  • Changes in demeanour and affect
  • Motor changes like restlessness, dyskinesia

Sundowning can negatively impact patient safety and wellbeing and results in considerable caregiver burnout, it also poses increased demands on the health care providers especially the nursing staff.[3]

Etiology of Sundowning[edit | edit source]

The etiology of Sundowning is complex and poorly understood.Changes in the normal circadian rhythm is one of the most common cause of sundowning however other factors like medications, environmental changes, comorbidities all play a significant role in development of disruptive behaviours seen in sundowning Some of the common factors are summarized in Table 1[3].

Treatment of Sundowning[edit | edit source]

The treatment for sundowning requires a team based approach. Coordination between the health care providers, patient and the family members is quintessential. The treatment can be broadly divided between Pharmacologic and Nonpharmacologic approaches.

  • Pharmacological Treatments: The three groups of drugs that have shown some promise for the management of sundowning are: Melatonin supplementation, cholinesterase inhibitors and antipsychotics[3]. However, more research is required.
  • Non Pharmacological Treatments: This should be the first line of treatment for the management of sundowning. These include environmental modifications, physical activity, alternate therapy like music, acupuncture, tai-chi , light therapy, consistent routines, caregiver education etc.

References[edit | edit source]

  1. ↑ Khachiyants N, Trinkle D, Son S, Kim K. Sundown syndrome in persons with dementia: an update. Psychiatry investig, 2011; 8:275-87
  2. ↑ Menegardo CS, Friggi FA, Scardini JB, Rossi TS, Vieira TD, Tieppo A, Morelato RL. Sundown syndrome in patients with Alzheimer’s disease dementia. Dementia & neuropsychologia. 2019 Dec 9;13:469-74.
  3. ↑ 3.0 3.1 3.2 Canevelli M, Valletta M, Trebbastoni A, Sarli G, D’Antonio F, Tariciotti L, de Lena C, Bruno G. Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches. Frontiers in medicine. 2016 Dec 27;3:73.
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