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'''Original Editor '''- [[User:Akano Oluwadara Tomisin]]  
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== Introduction ==
== Introduction ==
[[File:Sundowning 2.jpg|thumb]]
[[File:Sundowning 2.jpg|thumb]]
Sundowning  refers to a group of neuropsychiatric symptoms experienced by individuals diagnosed with dementia or neurocognitive decline or seen in elderly institutionalized patients, which usually develops late afternoon, evenings or at night time.<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>Some of the common symptoms associated with sundowning include:<ref>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.
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<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>.


BibTeXEndNoteRefManRefWorks</ref>
Some of the common symptoms associated with sundowning include:<ref>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.
* Confusion
* Anxiety
* Aggression
* Irritability
* Yelling and Screaming
* Hallucination
* Pacing
* Wandering
The symptoms of sundowning are associated with considerable caregiver burnout and poses challenges to nursing care.<ref>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.</ref>


== Causes of Sundowning ==
BibTeXEndNoteRefManRefWorks</ref> Confusion, Anxiety, Aggression, Irritability ,Hallucination, Pacing, Wanderin, Changes in demeanour and affect,Motor changes like restlessness, dyskinesia
[[File:Fmed-03-00073-t001.jpg|thumb|<ref>Table 1 Etiology of Sundowning Syndrome (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.)</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">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> 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.  
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.<ref>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.</ref>
== Etiology of Sundowning ==
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.  


== Symptoms of Sundowning ==
Some of the common factors are summarized in Table 1.
Different symptoms of sundowning have been identified, they include:
[[File:Fmed-03-00073-t001.jpg|alt=|556x556px]]
* Increase in general confusion as natural light begins to fade and increased shadows appear.<ref name=":1">Smith G. Sundowning: Late-day confusion. Mayoclinic.com 2011</ref><ref>Keller S. Sundwoning WedMD LLC, 2012</ref>
Table 1 Table 1." Factors that have been associated with the pathophysiology and clinical occurrence of sundowning among persons with dementia" ( 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.
* Agitation and mood swings.<ref name=":1" /><ref name=":2">Alzheimer's Association: Sleepelessness and Sundowning</ref>
* 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.<ref name=":2" />


== Treatment of Sundowning  ==
== 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.<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.  
* Patients should be involved in doing more daily activities as this 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">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.</ref>.  However, more research is required.
* 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.<ref name=":2" />
* 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, taichi , light therapy, consistent routines, caregiver education etc<ref name=":1" />
* Caffeine, brain stimulant, should be limited at night.<ref name=":1" /><ref name=":2" />
* 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.<ref name=":2" />
* 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.<ref name=":3" /> 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  ==
#[https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511 Sundowning: Late day confusion]
#[https://www.nia.nih.gov/health/tips-coping-sundowning Tips for coping with sundowning]


== References  ==
== References  ==

Revision as of 03:53, 16 November 2021

Original Editor - User:Akano 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, Wanderin, 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. Table 1 Table 1." Factors that have been associated with the pathophysiology and clinical occurrence of sundowning among persons with dementia" ( 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.

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[4]. 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, taichi , light therapy, consistent routines, caregiver education etc[4]

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. BibTeXEndNoteRefManRefWorks
  3. ↑ 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.
  4. ↑ 4.0 4.1 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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