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Sundowning....What is it?

Before we get into sundowning (or sundown syndrome) we must first briefly talk about where you may see it occur.

Alzheimer's is a neurodegenerative disorder that gets progressively worse over time. Certain symptoms occur early in the disease and some occur later. Common clinical features in the early stages of Alzheimer's can include a distinctive pattern of memory impairment where the individual has difficulty recalling recent episodes and events but access to long-term memory is less impaired. In the early to mid-stages of Alzheimer's, the individual may have some intermittent word finding difficulty and visuospatial difficulties. This can manifest itself in misplacing items or difficulty navigating in first unfamiliar and later in familiar terrain. Or having difficulty clearly expressing their thoughts or knowing a word and feeling like it is on the tip-of-their-tongue. The inability to recognize objects and faces is a later feature the disease, as is difficulty in performing motor tasks such as dressing. Word-finding becomes difficult, impairing spontaneous speech and comprehension. Patients at this point commonly have a change in personality and develop depression. This can lead to the emergence of behavioral disturbances, including agitation, aggression, wandering, and paranoia. Another symptom that can occur is sundowning......

What is sundowning?

Sundowning is a condition that often occurs with individuals who have moderate to advanced Alzheimer's dementia. Sundowning is commonly observed as the emergence or increase of neuropsychiatric symptoms in the late afternoon, evening or at night. It particularly occurs among cognitively impaired elderly individuals. These neuropsychiatric behaviors can represent a wide variety of symptoms such as confusion, disorientation, anxiety, agitation, aggression, pacing, wandering, screaming, and yelling. Some of these behaviors may not be specific to sundowning and can be the manifestation of dementia, delirium, Parkinson's disease, and/or sleep disturbances. However, what distinguishes sundowning from above mentioned conditions is that persons with sundown syndrome characteristically show disruptive behaviors specifically in the late afternoon, in the evening, or at night.

The severity of cognitive impairment in the individual may be one of the important predisposing factors in the development of a sundown syndrome. Researchers have suggested that sundowning may also be linked to the different seasons of the year with increased incidence in the fall or winter months due to a decrease in duration and amount of sunlight. Not all individuals with dementia have sundowning, but virtually all sundowning patients are experiencing dementia and they are likely delirious at the time of their sundowning episode. A major difference between sundowning and delirium will be that delirium tends to be relatively acute in onset, relatively brief (a matter of hours or days), and fluctuating in the course of the day.

What can family or caregivers do for sundowning?

Both non-pharmacologic and pharmacologic approaches have been considered in the treatment of patients with sundowning. The Alzheimer's Association recommends caregivers of persons who experience sundowning help the individual get plenty of rest, reduce stimulation during the evening hours and keep the home well-lit in the evening and early morning.

The prevention and treatment of sundowning has not yet been identified. As such, we must take a multifaceted approached when exploring the potential etiologic factors of sundowning syndrome (environmental, physiological, psychological). In addition, we must work at addressing modifiable factors with appropriate interventions in hope trying to reduce the clinical symptoms of sundowning. There has been limited data in current medical literature on effective methods of prevention of sundowning syndrome in dementia. However, there are several interventions that professionals have used to try to reduce the symptoms seen in this syndrome. These interventions have included:

· Behavioral modifications such as:

o Light therapy

o Music therapy

o Aromatherapy

o Caregiver education

o Multisensory stimulation

o Simulated presence therapy

o Following sleep hygiene routine

o Adherence to a structured daily schedule

o Physical exercise

If you notice an increase in sundowning, or any sudden behavioral changes, mention it to your loved one’s doctor. Sometimes, it can be the sign of another health problem, like a dehydration or a urinary tract infection (UTI), which can be treated.

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