Sundowning

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Original Editor - User:Akano Oluwadara Tomisin

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

Introduction

Sundowning also known as sundown syndrome or late day confusion, 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:

• 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..

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, 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. 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

Symptoms of Sundowning

Symptoms are not limited to but may include:

• Increased general confusion as natural light begins to fade and increased shadows appear.
• Agitation and mood swings.
• Mental and physical fatigue increase with the setting of the sun.
• 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.

Treatment of Sundowning

• If possible, a consistent sleeping schedule and daily routine that the patient is comfortable with can reduce confusion and agitation.
• 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.
• 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.
• Caffeine is a (fast-working) brain stimulant, but should be limited at night if a night's sleep is needed.
• 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.
• 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. 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

1. [1]
2. [2]