Understanding Sundowning Syndrome: Symptoms and Treatment

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Between 70 and 90 percent of individuals with Alzheimer’s Disorder eventually develop behavioral symptoms that will impact their lives and daily routines (Bedrosian & Nelson, 2013). These symptoms can include problems sleeping, restlessness, wandering, agitation, anger, hallucinations, and delusions (Bedrosian & Nelson, 2013). Some of the symptoms that individuals may experience may become worse in the evening; this is called sundowning. Sundowning, or “nocturnal delirium” is characterized by recurring behaviors that can be disruptive and have many causes (Bedrosian & Nelson, 2013). Individuals experiencing sundowning may experience an increase in the behavioral symptoms in the late afternoon or early evening, and their symptoms improve or disappear in the morning (Bedrosian & Nelson, 2013).

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Sundowning individuals are generally dementia patients, but even with normal cognitive functioning elderly can experience symptoms from time to time (Bedrosian & Nelson, 2013). Sundowning is believed to have been around for very many years, but it was first reported in clinical literature more than 70 years ago (Bedrosian & Nelson, 2013). Sundowning is difficult to define at times because it represents several neuropsychiatric symptoms that present themselves in a variety of neurological issues, like dementia (Evans & Grossberg, 2016). It is usually viewed as the sign of an underlying chronic disease, stress, or the combination of the two (Evans & Grossberg, 2016). The mechanisms surrounding the process of sundowning are still rather unspecified, but there are many contributing factors (Bedrosian & Nelson, 2013). Not only is sundowning associated with Alzheimer’s Disease, it is also associated with sleep disorders that are linked to aging (Evans & Grossberg, 2016). 10 to 25 percent of nursing home patients experience some sort of sundowning during the afternoon, with only 2.4 percent having diagnosed brain abnormalities (Evans & Grossberg, 2016). In 1993, colleagues discovered a seasonal effect in sundowning (Evans & Grossberg, 2016). Sundowning appears to be more experienced during the time of year where there is the shortest amount of daylight hours, such as winter (Evans & Grossberg, 2016). Sundowning is a descriptor, rather than an independent diagnosis although proposals of its addition to the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been made. Its etiology is not well known and it is often confused with delirium (Lebert, Pasquier & Petit, 1996).

The three main treatment approaches for treating sundowning involves improving the environment, minimizing comorbidities and using medications to improve symptoms and slowing the progression of Alzheimer Disease if that patient has the disease (Evans & Grossberg, 2016). The chronological age of 65 years old is what most countries have accepted to be the definition of an ‘elderly’ person ("Health Statistics," n.d.). The definition may be a little arbitrary but this is often associated with the time a person may retire and start collecting the pension that they have worked for ("Health Statistics," n.d.). Back in 1875, in Britain, the definition of old age was “any age after 50” ("Health Statistics," n.d.). There is no agreement or consensus on the age that a person becomes old, as the biological age of a person and the calendar date that an individual was born are not synonymous ("Health Statistics," n.d.). An aging individual that experiences sundowning also experiences exorbitant costs (Bedrosian & Nelson, 2013). There are costs that are placed on the caregivers, the distressed families, and quality of life (Bedrosian & Nelson, 2013). Family and caregivers are put at risk during the aggression and agitation that a patient experiences and quality of life are diminished by symptoms that compromise safety or lead to uncomfortable conditions and treatments (Bedrosian & Nelson, 2013). Sundowning is generally cited as the primary reason that families end up moving their loved one to a skilled nursing facility that can provide them the quality of care that they need medically and mentally (Bedrosian & Nelson, 2013). Sundowning is an important aging issue now because our world is on the cusp of research knowledge into discovering the etiology and physiology of the disorder (Bedrosian & Nelson, 2013). Over 38 percent of individuals over the age of 65 report that they have sleep disturbances, and there is a link between sleep disturbances and sundowning (Bedrosian & Nelson, 2013).

While there is still much to learn about this condition, we need to continue to establish plans and forming strategies to enable individuals that experience sundowning is able to do as much as possible independently (Fetherstonhaugh, Tarzia & Nay, 2013). It was noted that doing this allowed them to contribute to the build of their self-confidence and self-esteem; this allowed the individuals that were affected to continue to do the things that they found important to their quality of life and sense of self. (Fetherstonhaugh, Tarzia & Nay, 2013). Many individuals need to realize that support would be required as their symptoms progressed, or as their diagnosed condition progressed (Fetherstonhaugh, Tarzia & Nay, 2013). Caregivers must realize that the patients appreciate that their support is offered in subtle ways so that they are able to still feel some sense of control (Fetherstonhaugh, Tarzia & Nay, 2013).

In conclusion, sundowning is a condition of many factors that continue to elude complete understanding of its cause (Evans & Grossberg, 2016). Several interventions are currently available, but additional research needs to be done to conclusively pinpoint what causes sundowning as it should be considered a condition of its own during the aging process. More also needs to be done to attempt to understand the causes of sundowning to help grow awareness of the need for a better solution to provide more comfort to the individuals that experience this condition. There are more questions that need to be asked about this condition and the lasting impacts that it may have on the family, caregivers, and patients, especially if this is something that is indeed a part of other chronic diseases. Our elders deserve to still feel some sort of self-control and be involved in making the decisions in their care; the goal is to extend their quality of life.

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