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Chapters

0:00 Introduction
0:28 Symptoms of Sundowning
0:48 Who experiences Sundowning
1:20 Causes of Sundowning
1;51 How to manage Sundowning
2:24 Medications for Sundowning




Sundowning, or sundown syndrome,[1] is a neurological phenomenon associated with increased confusion and restlessness in people with delirium or some form of dementia. It is most commonly associated with Alzheimer's disease but also found in those with other forms of dementia. The term "sundowning" was coined by nurse Lois K. Evans in 1987 due to the timing of the person's increased confusion beginning in the late afternoon and early evening.[2][3] For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long term adverse outcomes.[4][5][6][7] Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia and seems to subside with the progression of the person's dementia.[4][5] People are generally able to understand that this behavioral pattern is abnormal. Research shows that 20–45% of people with Alzheimer's will experience some variation of sundowning confusion.[4][8] However, despite lack of an official diagnosis of sundown syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there is currently a wide range of reported prevalence.[2] The following social, economic, and physiological adverse outcomes are correlated with individuals affected by sundowning and their caregivers:

Long term admission to psychiatric care facilities.[7]
Prolonged hospital admission with recurrent visits that increase financial burden.[7]
Steeper cognitive decline in Alzheimer's disease.[7]
Decreased quality of life.[9]
Increased stress and burnout of caregivers due to the timing of sundowning symptom onset.[7]

Symptoms

Symptoms are not limited to but may include:

Increased general confusion as natural light begins to fade and increased shadows appear.[4][10]
Agitation,[10] and mood swings. Individuals may become fairly frustrated with their own confusion as well as aggravated by noise. Individuals being found yelling and becoming increasingly upset with their caregiver is not uncommon.[4][5]
Mental and physical fatigue increase with the setting of the sun. This fatigue can play a role in the individual's irritability.[4][5]
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.[5]
Hallucinations (visual and/or auditory) and paranoia can cause increased anxiety and resistance to care.[7]

Causes

While the specific causes of sundowning have not been empirically proven, some evidence suggests that circadian rhythm disruption increases sundowning behaviors.[11] In humans, sunset triggers a biochemical cascade that involves a reduction of dopamine levels and a shift towards melatonin production as the body prepares for sleep. In individuals with dementia, melatonin production may be decreased,[1] which may interrupt other neurotransmitter systems.

Other causes or precipitating factors that may lead to sundown syndrome may include hormonal changes, disturbances in REM sleep, individual and/or caregiver fatigue, inappropriate medication use, or being predisposed to behavioral disorders from chronic neurological diseases.[12] Resources in an institution's environment can also play a role as a symptom trigger. A reduced number of staff in the evening can attribute to more unmet needs and a lower threshold for agitation for individuals with sundown syndrome.[13]

Sundowning should be distinguished from delirium, and could be presumed to be delirium when it appears as a new behavioral pattern until a causal link between sunset and behavioral disturbance is established.[14] People with established sundowning and no obvious medical illness may be suffering from impaired circadian regulation, or may be affected by nocturnal aspects of their institutional environment such as shift changes, increased noise, or reduced staffing (which leads to fewer opportunities for social interaction). Delirium is generally an acute event that can span over a time period of hours to days.[1]

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