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{{Short description|Neurological phenomenon}}
In ], '''sundowning''', also known as '''sundown syndrome''', is a ] involving the occurrence or increase of one or more abnormal behaviors in a ].<ref name="Volicer2001"/> Sundowning typically occurs during the late afternoon, evening, and night, hence the name. It occurs in persons with certain forms of ] and ], such as seen in ]. Although not widely surveyed, sundowning is estimated to occur in 45% of persons diagnosed with Alzheimer's disease.<ref>{{cite journal |author=Scarmeas N, Brandt J, Blacker D, ''et al.'' |title=Disruptive behavior as a predictor in Alzheimer disease |journal=Arch. Neurol. |volume=64 |issue=12 |pages=1755–61 |year=2007 |month=December |pmid=18071039 |doi=10.1001/archneur.64.12.1755 |url=}}</ref> A person who is sundowning may exhibit mood swings, become abnormally demanding, suspicious, upset or disoriented, and see or hear things that are not there in the late afternoon and evening. After ], sundowning is the second most common type of disruptive behavior in institutionalized persons with dementia.<ref>{{cite book
{{about|the psychological phenomenon}}
|author=U.S. Congress, Office of Technology Assessment
|title=Special care units for people with Alzheimer's and other dementias: Consumer education, research, regulatory, and reimbursement issues.
|issue=OTA-H-543
|publisher=Government Printing Office
|address=Washington DC
|year=1992
|url=http://books.google.com/books?id=0SXq4vuQM6oC
}}</ref> Sundowning often co-occurs with wandering, and the combination of these two syndromes is an important contributing factor to an emergency situation: ] at night. The cause of sundowning is unknown, but may be related to disturbed ].


'''Sundowning''', or '''sundown syndrome''',<ref name="Khachiyants_2011" /> is a neurological phenomenon wherein people with ] or some form of ] experience increased ] and restlessness beginning in the late afternoon and early evening. It is most commonly associated with ] but is also found in those with other forms of dementia. The term ''sundowning'' was coined by nurse Lois K. Evans in 1987 due to the association between the person's increased confusion and the setting of the sun.<ref name="Todd_2020">{{cite journal | vauthors = Todd WD | title = Potential Pathways for Circadian Dysfunction and Sundowning-Related Behavioral Aggression in Alzheimer's Disease and Related Dementias | journal = Frontiers in Neuroscience | volume = 14 | pages = 910 | date = 2020 | pmid = 33013301 | pmc = 7494756 | doi = 10.3389/fnins.2020.00910 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Evans LK | title = Sundown syndrome in institutionalized elderly | journal = Journal of the American Geriatrics Society | volume = 35 | issue = 2 | pages = 101–108 | date = February 1987 | pmid = 3805551 | doi = 10.1111/j.1532-5415.1987.tb01337.x | s2cid = 21234681 }}</ref>
==Cause==
Although the cause of sundowning is unknown, proposed causes include sensory deprivation from lower light conditions in the evening, and fatigue.{{Fact|date=August 2008}} Alzheimer's disease alters the normal daily cycle of changes in body temperature, and sundowning appears to be related to delay of those changes that normally occur in the evening.<ref name="Volicer2001">{{cite journal
|author=Volicer L, Harper DG, Manning BC, Goldstein R, Satlin A
|title=Sundowning and circadian rhythms in Alzheimer's disease
|journal=Am J Psychiatry
|volume=158
|issue=5
|pages=704–11
|year=2001
|month=May
|pmid=11329390
|doi=10.1176/appi.ajp.158.5.704
|url=http://ajp.psychiatryonline.org/cgi/content/full/158/5/704
}}</ref><ref>{{cite journal
|author=Satlin A, Volicer L, Stopa EG, Harper D
|title=Circadian locomotor activity and core-body temperature rhythms in Alzheimer's disease
|journal=Neurobiol. Aging
|volume=16
|issue=5
|pages=765–71
|year=1995
|pmid=8532109
|doi=10.1016/0197-4580(95)00059-N
}}</ref> Contributing factors may include ]s that can cause agitation or confusion,<ref>. Cleveland Clinic Regional Hospitals</ref> and ]s.{{Fact|date=January 2009}}


For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long-term adverse outcomes.<ref name="Smith_2011">{{cite web |url=http://www.mayoclinic.com/health/sundowning/HQ01463 |title=Sundowning: Late-day confusion | vauthors = Smith G |date=April 28, 2011|website=mayoclinic.com |publisher=] |access-date=August 30, 2016 }}</ref><ref name=alz>{{cite web |publisher=Alzheimer's Association |title=Sleeplessness and Sundowning |url=http://www.alz.org/care/alzheimers-dementia-sleep-issues-sundowning.asp }}</ref><ref name="de_Jonghe_2010">{{cite journal | vauthors = de Jonghe A, Korevaar JC, van Munster BC, de Rooij SE | title = Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review | journal = International Journal of Geriatric Psychiatry | volume = 25 | issue = 12 | pages = 1201–1208 | date = December 2010 | pmid = 21086534 | doi = 10.1002/gps.2454 | s2cid = 39214881 }}</ref><ref name="Canevelli_2016" /> 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.<ref name="Smith_2011" /><ref name=alz /> 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.<ref name="Smith_2011" /><ref>{{cite web|url=http://www.anzianievita.it/demenza-e-delirium/il-demente-e-la-sindrome-del-tramonto/|title=Il demente e la sindrome del tramonto|website=anzianievita.it|date=April 2, 2014|language=it|trans-title=The demented and the sunset syndrome}}</ref> However, despite lack of an official diagnosis of sundown syndrome in the ], there is currently a wide range of reported prevalence.<ref name="Todd_2020" />
==Prognosis==

In persons with early Alzheimer's disease, the presence of sundowning has been associated with faster decline in cognitive functions.<ref>{{cite journal
== Relevance ==
| author = Scarmeas N, Brandt J, Blacker D, ''et al.''
The following social, economic, and physiological adverse outcomes are correlated with individuals affected by sundowning and their caregivers:
| title = Disruptive behavior as a predictor in Alzheimer disease

| journal = Arch. Neurol.
* Long-term admission to psychiatric care facilities.<ref name="Canevelli_2016" />
| volume = 64
* Prolonged hospital admission with recurrent visits that increase financial burden.<ref name="Canevelli_2016" />
| issue = 12
* Steeper cognitive decline in Alzheimer's disease.<ref name="Canevelli_2016" />
| pages = 1755–61
*Decreased ].<ref name="Bedrosian_2013">{{cite journal | vauthors = Bedrosian TA, Nelson RJ | title = Sundowning syndrome in aging and dementia: research in mouse models | journal = Experimental Neurology | volume = 243 | pages = 67–73 | date = May 2013 | pmid = 22627081 | doi = 10.1016/j.expneurol.2012.05.005 | s2cid = 14990198 }}</ref>
| year = 2007
*Increased stress and burnout of caregivers due to the timing of sundowning symptom onset.<ref name="Canevelli_2016" />
| month = December

| pmid = 18071039
==Symptoms==
| doi = 10.1001/archneur.64.12.1755
Symptoms are not limited to but may include:
| url =
* Increased general confusion as natural light begins to fade and increased shadows appear.<ref name="Smith_2011" /><ref name=tips>{{cite web|title=Tips for Coping with Sundowning|url=http://www.nia.nih.gov/health/tips-coping-sundowning|access-date=2021-03-31|website=National Institute on Aging|language=en}}</ref>
| issn =
* Agitation<ref name=tips /> 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 caregivers are not uncommon.<ref name="Smith_2011" /><ref name=alz />
}}</ref>
* Mental and physical fatigue increase with the setting of the sun. This fatigue can play a role in the individual's irritability.<ref name="Smith_2011" /><ref name=alz />
* An individual may experience an increase in 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.<ref name="alz" />
*] (visual and/or auditory) and ] can cause increased anxiety and resistance to care.<ref name="Canevelli_2016">{{cite journal | vauthors = Canevelli M, Valletta M, Trebbastoni A, Sarli G, D'Antonio F, Tariciotti L, de Lena C, Bruno G | display-authors = 6 | title = Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches | journal = Frontiers in Medicine | volume = 3 | pages = 73 | date = December 2016 | pmid = 28083535 | pmc = 5187352 | doi = 10.3389/fmed.2016.00073 | doi-access = free }}</ref>

==Causes==

While the specific causes of sundowning have not been empirically proven, some evidence suggests that ] disruption increases sundowning behaviors.<ref>{{Cite journal|last1=Boronat|first1=Alexandre C.|last2=Ferreira-Maia|first2=Ana Paula|last3=Wang|first3=Yuan-Pang|date=2019|title=Sundown Syndrome in Older Persons: A Scoping Review|url=https://doi.org/10.1016/j.jamda.2019.03.001|journal=Journal of the American Medical Directors Association|volume=20|issue=6|pages=664–671.e5|doi=10.1016/j.jamda.2019.03.001|pmid=31043358 |s2cid=143423734 |issn=1525-8610}}</ref> In humans, ] triggers a biochemical cascade that involves a reduction of ] levels and a shift towards ] production as the body prepares for sleep. In individuals with dementia, melatonin production may be decreased,<ref name="Khachiyants_2011">{{cite journal | vauthors = Khachiyants N, Trinkle D, Son SJ, Kim KY | title = Sundown syndrome in persons with dementia: an update | journal = Psychiatry Investigation | volume = 8 | issue = 4 | pages = 275–287 | date = December 2011 | pmid = 22216036 | pmc = 3246134 | doi = 10.4306/pi.2011.8.4.275 }}</ref> which may interrupt other neurotransmitter systems.

Other causes or precipitating factors that may lead to sundown syndrome may include hormonal changes, disturbances in ], individual and/or caregiver fatigue, inappropriate medication use, or being predisposed to behavioral disorders from chronic neurological diseases.<ref name="Gnanasekaran_2016">{{cite journal | vauthors = Gnanasekaran G | title = "Sundowning" as a biological phenomenon: current understandings and future directions: an update | journal = Aging Clinical and Experimental Research | volume = 28 | issue = 3 | pages = 383–392 | date = June 2016 | pmid = 26243434 | doi = 10.1007/s40520-015-0431-3 | s2cid = 41480208 }}</ref> Resources in an institution's environment can also play a role as a symptom trigger. A reduced number of staff in the evening can be attributed to more unmet needs and a lower threshold for agitation for individuals with sundown syndrome.<ref name="Bachman_2016">{{cite journal | vauthors = Bachman D, Rabins P | title = "Sundowning" and other temporally associated agitation states in dementia patients | journal = Annual Review of Medicine | volume = 57 | issue = 1 | pages = 499–511 | date = January 2006 | pmid = 16409163 | doi = 10.1146/annurev.med.57.071604.141451 }}</ref>

Sundowning should be distinguished from ], 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.<ref>{{Citation|last1=Patti|first1=Laryssa|title=Change In Mental Status|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK441973/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=28723002|access-date=2021-08-02|last2=Gupta|first2=Mohit}}</ref> 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 hours to days.<ref name="Khachiyants_2011" />

===Disturbances in circadian rhythms===
It is thought that with the development of ] and ] associated with Alzheimer's disease there might be a disruption within the ] (SCN).<ref name="de_Jonghe_2010" /> The SCN is located in the hypothalamus and is associated with regulating 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 ] is needed to analyze this disruption properly. By the time a person experiencing Alzheimer's has died, they have usually surpassed the level of ] (and associated dementia) that would be associated with sundowning. This hypothesis is, however, supported by the effectiveness of ], a natural ], to decrease behavioral symptoms associated with sundowning. The pineal gland produces melatonin when signaled by the SCN to help maintain circadian rhythms. Melatonin supplementation can be administered to older adults as their natural hormonal production decreases over time.<ref name="Gnanasekaran_2016" />

] has also been observed to potentially have a key role in the regulation of circadian rhythm as research has shown that serotonergic agonism in the SCN results in "phase shifts" in portions of the light-dark cycle.<ref name="Todd_2020" /><ref>{{cite journal | vauthors = Daut RA, Fonken LK | title = Circadian regulation of depression: A role for serotonin | journal = Frontiers in Neuroendocrinology | volume = 54 | pages = 100746 | date = July 2019 | pmid = 31002895 | doi = 10.1016/j.yfrne.2019.04.003 | pmc = 9826732 }}</ref><ref>{{cite journal | vauthors = Ciarleglio CM, Resuehr HE, McMahon DG | title = Interactions of the serotonin and circadian systems: nature and nurture in rhythms and blues | journal = Neuroscience | volume = 197 | pages = 8–16 | date = December 2011 | pmid = 21963350 | doi = 10.1016/j.neuroscience.2011.09.036 | s2cid = 16015771 }}</ref> In addition to the effects on circadian rhythm, serotonin is also known to be involved in the regulation of aggression.<ref name="Todd_2020" /> Due to the serotonergic signaling deficiencies of Alzheimer's disease, it has been commonly reported that deficiencies in serotonin have been associated with worsening circadian rhythm or aggression.<ref name="Todd_2020" /><ref>{{cite journal | vauthors = Chakraborty S, Lennon JC, Malkaram SA, Zeng Y, Fisher DW, Dong H | title = Serotonergic system, cognition, and BPSD in Alzheimer's disease | journal = Neuroscience Letters | volume = 704 | pages = 36–44 | date = June 2019 | pmid = 30946928 | pmc = 6594906 | doi = 10.1016/j.neulet.2019.03.050 }}</ref>

=== Risk factors ===
Elderly people often experience multiple ] that may contribute to the phenomenon of sundowning syndrome through ].

* Neurological disorders: Alzheimer's disease, ], ], ], fronto-temporal dementia, subcortical dementia.<ref name="Bedrosian_2013" /><ref name="Gnanasekaran_2016" /><ref>{{cite journal | vauthors = Carter B, Justin HS, Gulick D, Gamsby JJ | title = The Molecular Clock and Neurodegenerative Disease: A Stressful Time | journal = Frontiers in Molecular Biosciences | volume = 8 | pages = 644747 | date = 2021-03-26 | pmid = 33889597 | pmc = 8056266 | doi = 10.3389/fmolb.2021.644747 | doi-access = free }}</ref>
* Neurobehavioral disorders: anxiety and ].<ref name="Gnanasekaran_2016" />
* Cerebrovascular disease risk factors: ], smoking, ].<ref name="Gnanasekaran_2016" />
*Genetic predisposition: presence of the ]4 allele has associations with sundown syndrome in people experiencing Alzheimer's disease.<ref name="Todd_2020" /><ref>{{Cite journal|last1=Gallagher-Thompson|first1=Dolores|last2=Brooks|first2=John O.|last3=Bliwise|first3=Donald|last4=Leader|first4=Julie|last5=Yesavage|first5=Jerome A.|date=1992|title=The Relations among Caregiver Stress, "Sundowning" Symptoms, and Cognitive Decline in Alzheimer's Disease|url=https://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.1992.tb01853.x|journal=Journal of the American Geriatrics Society|language=en|volume=40|issue=8|pages=807–810|doi=10.1111/j.1532-5415.1992.tb01853.x|pmid=1634724 |s2cid=19777495 }}</ref>


==Treatment== ==Treatment==
Treatment of sundown syndrome may vary based on when agitated behavior is observed throughout the day.<ref>{{cite journal | vauthors = McGaffigan S, Bliwise DL | title = The treatment of sundowning. A selective review of pharmacological and nonpharmacological studies | journal = Drugs & Aging | volume = 10 | issue = 1 | pages = 10–17 | date = January 1997 | pmid = 9111704 | doi = 10.2165/00002512-199710010-00002 | s2cid = 22395293 }}</ref>
Behavioural disturbance<!-- what about sundowning specifically? --> is often treated with ] medication such as ], ], or ]. However, these have significant side effects.{{Fact|date=August 2008}}<!-- possible source PMID 16050430, PMID 10840527 -->

=== Non-pharmacological treatments ===
*If possible, a consistent sleeping schedule and daily routine that a patient is comfortable with can reduce confusion and agitation.<ref name="Smith_2011" />
* If the person's condition permits, having increased daily activity incorporated into their schedule can help promote an earlier bedtime and need for sleep.<ref name="Smith_2011" /><ref name="alz" />
* Check for over-]ping. People 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.<ref name="alz" />
* ] is a (fast-working) brain stimulant, but should be limited at night if a night's sleep is needed.<ref name="Smith_2011" /><ref name="alz" /><ref name="tips" />
* Caregivers may try letting people choose their own sleeping arrangements each night, wherever they feel most comfortable sleeping, as well as allow for a dim light in the room to alleviate confusion associated with an unfamiliar place.<ref name="alz" />
*] can help regulate circadian rhythms. Older adults can struggle to receive consistent sunlight due to bedrest and institutional limitations.<ref name="Gnanasekaran_2016" /> Mood and spatial positioning improvements have been noted in people experiencing dementia with exposure to indoor light, but the evidence is currently inconclusive.<ref>{{cite journal | vauthors = Goudriaan I, van Boekel LC, Verbiest ME, van Hoof J, Luijkx KG | title = Dementia Enlightened?! A Systematic Literature Review of the Influence of Indoor Environmental Light on the Health of Older Persons with Dementia in Long-Term Care Facilities | journal = Clinical Interventions in Aging | volume = 16 | pages = 909–937 | date = 2017 | pmid = 34079240 | pmc = 8163627 | doi = 10.2147/CIA.S297865 | doi-access = free }}</ref>
*Reducing the amount of overwhelming noise in the late afternoon or early evening can help the transition to sleep.<ref name="Canevelli_2016" />
*], ], ], psychosocial support, caregiver education, multi-sensory stimulation, and ] are possible treatment pathways, but evidence is currently lacking in clinical practice.<ref>{{cite journal | vauthors = Ferrazzoli D, Sica F, Sancesario G | title = Sundowning syndrome: a possible marker of frailty in Alzheimer's disease? | journal = CNS & Neurological Disorders Drug Targets | volume = 12 | issue = 4 | pages = 525–528 | date = June 2013 | pmid = 23574165 | doi = 10.2174/18715273113129990065 }}</ref><ref>{{cite journal | vauthors = Abraha I, Rimland JM, Trotta FM, Dell'Aquila G, Cruz-Jentoft A, Petrovic M, Gudmundsson A, Soiza R, O'Mahony D, Guaita A, Cherubini A | display-authors = 6 | title = Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series | journal = BMJ Open | volume = 7 | issue = 3 | pages = e012759 | date = March 2017 | pmid = 28302633 | pmc = 5372076 | doi = 10.1136/bmjopen-2016-012759 }}</ref><ref>{{Citation|last1=Patti|first1=Laryssa|title=Change In Mental Status|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK441973/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=28723002|access-date=2021-07-31|last2=Gupta|first2=Mohit}}</ref>
*Exercising at consistent times daily has been proposed to improve circadian rhythm and reduce the symptoms of sundown syndrome in people with Alzheimer's and dementia.<ref name="Todd_2020" /> It has also been observed that people with Alzheimer's walking in the morning or afternoon hours had improvements in sundowning symptoms.<ref name="Todd_2020" /><ref>{{cite journal | vauthors = Shih YH, Pai MC, Lin HS, Sung PS, Wang JJ | title = Effects of walking on sundown syndrome in community-dwelling people with Alzheimer's disease | journal = International Journal of Older People Nursing | volume = 15 | issue = 2 | pages = e12292 | date = June 2020 | pmid = 31814316 | doi = 10.1111/opn.12292 | s2cid = 208956296 }}</ref>

=== Pharmacological treatments ===
* Some evidence supports the use of melatonin to induce sleep.<ref name="de_Jonghe_2010" /><ref name="Gnanasekaran_2016" /> The length of time required for a person to transition from fully awake to asleep has been shown to be more regular in melatonin users. Better memory and more positive emotional states have also been observed in people experiencing Alzheimer's disease.<ref>{{cite book | vauthors = Cardinali DP, Furio AM, Brusco LI, Liberczuk C | chapter = Melatonin Efficacy to Treat Circadian Alterations of Sleep in Alzheimer’s Disease|date=2006 | title = Sleep and Sleep Disorders|pages=111–120|place=Boston, MA|publisher=Springer US|language=en|doi=10.1007/0-387-27682-3_11|isbn=978-0-387-27681-6 }}</ref>
*Drug classes such as ], ], ] (AChIs), N-methyl D-aspartic acid antagonists (NMDA), ] (SSRIs), and ] ] have been used to treat sundowning, but their side effects limit their overall effectiveness in a risk versus benefit balance.<ref name="Gnanasekaran_2016" /><ref name="Staedt_2005">{{cite journal | vauthors = Staedt J, Stoppe G | title = Treatment of rest-activity disorders in dementia and special focus on sundowning | journal = International Journal of Geriatric Psychiatry | volume = 20 | issue = 6 | pages = 507–511 | date = June 2005 | pmid = 15920710 | doi = 10.1002/gps.1307 | s2cid = 8941229 }}</ref> Various side effects in the risk category include increased fall risk, vivid dreams, or nocturnal agitation.<ref name="Bachman_2016" />


== Research directions ==
==References==
There are several pathways in the pipeline for scientists seeking therapeutic options for sundowning syndrome.
{{reflist}}


* NADH cytochrome C reductase is an enzyme involved in the synthesis of neuron energy. Stress, hypometabolism, and oxidative damage may decrease physiologic reserve in the elderly and can lead to a decrease in neuron energy production and an increase in neuron damage.<ref name="Gnanasekaran_2016" />
==External links==
*] is an antioxidant that neutralizes oxidative free radicals that can cause cell death. The brain is vulnerable to oxidative free radicals because it receives 20% of the human body's oxygen supply. Finding a way to maintain the thioredoxin reductase pathway can decrease plaque formation and SCN degeneration.<ref name="Gnanasekaran_2016" />
{{Wiktionary|sundowning}}
*Inflammatory stress in mouse models can provide a pathway for studying neurodegeneration. It is hypothesized that neurodegeneration has a relationship with inflammatory ] such as ]. The role of cytokines in sundowning can improve our understanding of the pathology.<ref name="Gnanasekaran_2016" />
*
*Injection of ] ligands into the eye to stimulate the SCN through the ] is another possible treatment for sundown syndrome as a similar strategy has been thought to have potential with regards to therapy for mood-related disorders.<ref name="Todd_2020" /><ref>{{cite journal | vauthors = Bowrey HE, James MH, Aston-Jones G | title = New directions for the treatment of depression: Targeting the photic regulation of arousal and mood (PRAM) pathway | journal = Depression and Anxiety | volume = 34 | issue = 7 | pages = 588–595 | date = July 2017 | pmid = 28489327 | pmc = 5797474 | doi = 10.1002/da.22635 }}</ref><ref>{{cite journal | vauthors = Venner A, Todd WD, Fraigne J, Bowrey H, Eban-Rothschild A, Kaur S, Anaclet C | title = Newly identified sleep-wake and circadian circuits as potential therapeutic targets | journal = Sleep | volume = 42 | issue = 5 | pages = zsz023 | date = May 2019 | pmid = 30722061 | pmc = 6519911 | doi = 10.1093/sleep/zsz023 }}</ref>


== Controversy ==
{{-}}
In addition to sundown syndrome not being officially recognized in the DSM-5, there is also the thought that sundown syndrome may be a phenomenon of caretakers' perception of patient agitation in the early afternoon to evening.<ref name="Todd_2020" /> Some studies have observed sundown syndrome occurring at times other than sunset which may suggest the symptoms associated with sundown syndrome are time-dependent rather than occurring specifically at sundown.<ref name="Todd_2020" /><ref>{{cite journal | vauthors = Yesavage JA, Friedman L, Ancoli-Israel S, Bliwise D, Singer C, Vitiello MV, Monjan AA, Lebowitz B | display-authors = 6 | title = Development of diagnostic criteria for defining sleep disturbance in Alzheimer's disease | journal = Journal of Geriatric Psychiatry and Neurology | volume = 16 | issue = 3 | pages = 131–139 | date = September 2003 | pmid = 12967054 | doi = 10.1177/0891988703255684 | s2cid = 38287514 }}</ref>


== References ==
{{Mental-health-stub}}
{{disease-stub}} {{Reflist}}


{{Mental and behavioral disorders}} {{Mental and behavioral disorders}}
{{Authority control}}


] ]
] ]
] ]
] ]

Latest revision as of 23:46, 6 December 2024

Neurological phenomenon This article is about the psychological phenomenon. For other uses, see Sundowning (disambiguation).

Sundowning, or sundown syndrome, is a neurological phenomenon wherein people with delirium or some form of dementia experience increased confusion and restlessness beginning in the late afternoon and early evening. It is most commonly associated with Alzheimer's disease but is also found in those with other forms of dementia. The term sundowning was coined by nurse Lois K. Evans in 1987 due to the association between the person's increased confusion and the setting of the sun.

For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long-term adverse outcomes. 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. 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. 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.

Relevance

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.
  • Prolonged hospital admission with recurrent visits that increase financial burden.
  • Steeper cognitive decline in Alzheimer's disease.
  • Decreased quality of life.
  • Increased stress and burnout of caregivers due to the timing of sundowning symptom onset.

Symptoms

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. 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 caregivers are not uncommon.
  • Mental and physical fatigue increase with the setting of the sun. This fatigue can play a role in the individual's irritability.
  • An individual may experience an increase in 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.
  • Hallucinations (visual and/or auditory) and paranoia can cause increased anxiety and resistance to care.

Causes

While the specific causes of sundowning have not been empirically proven, some evidence suggests that circadian rhythm disruption increases sundowning behaviors. 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, 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. Resources in an institution's environment can also play a role as a symptom trigger. A reduced number of staff in the evening can be attributed to more unmet needs and a lower threshold for agitation for individuals with sundown syndrome.

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. 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 hours to days.

Disturbances in circadian rhythms

It is thought that with the development of plaques and tangles associated with Alzheimer's disease there might be a disruption within the suprachiasmatic nucleus (SCN). The SCN is located in the hypothalamus and is associated with regulating 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 analyze this disruption properly. By the time a person experiencing Alzheimer's has died, they have usually surpassed the level of brain damage (and associated dementia) 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. The pineal gland produces melatonin when signaled by the SCN to help maintain circadian rhythms. Melatonin supplementation can be administered to older adults as their natural hormonal production decreases over time.

Serotonin has also been observed to potentially have a key role in the regulation of circadian rhythm as research has shown that serotonergic agonism in the SCN results in "phase shifts" in portions of the light-dark cycle. In addition to the effects on circadian rhythm, serotonin is also known to be involved in the regulation of aggression. Due to the serotonergic signaling deficiencies of Alzheimer's disease, it has been commonly reported that deficiencies in serotonin have been associated with worsening circadian rhythm or aggression.

Risk factors

Elderly people often experience multiple comorbidities that may contribute to the phenomenon of sundowning syndrome through neurodegeneration.

Treatment

Treatment of sundown syndrome may vary based on when agitated behavior is observed throughout the day.

Non-pharmacological treatments

  • If possible, a consistent sleeping schedule and daily routine that a patient is comfortable with can reduce confusion and agitation.
  • If the person's condition permits, having increased daily activity incorporated into their schedule can help promote an earlier bedtime and need for sleep.
  • Check for over-napping. People 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 may try letting people choose their own sleeping arrangements each night, wherever they feel most comfortable sleeping, as well as allow for a dim light in the room to alleviate confusion associated with an unfamiliar place.
  • Light therapy can help regulate circadian rhythms. Older adults can struggle to receive consistent sunlight due to bedrest and institutional limitations. Mood and spatial positioning improvements have been noted in people experiencing dementia with exposure to indoor light, but the evidence is currently inconclusive.
  • Reducing the amount of overwhelming noise in the late afternoon or early evening can help the transition to sleep.
  • Music therapy, aromatherapy, acupressure, psychosocial support, caregiver education, multi-sensory stimulation, and simulated presence therapy are possible treatment pathways, but evidence is currently lacking in clinical practice.
  • Exercising at consistent times daily has been proposed to improve circadian rhythm and reduce the symptoms of sundown syndrome in people with Alzheimer's and dementia. It has also been observed that people with Alzheimer's walking in the morning or afternoon hours had improvements in sundowning symptoms.

Pharmacological treatments

  • Some evidence supports the use of melatonin to induce sleep. The length of time required for a person to transition from fully awake to asleep has been shown to be more regular in melatonin users. Better memory and more positive emotional states have also been observed in people experiencing Alzheimer's disease.
  • Drug classes such as hypnotics, benzodiazepines, acetylcholinesterase inhibitors (AChIs), N-methyl D-aspartic acid antagonists (NMDA), selective serotonin reuptake inhibitors (SSRIs), and sedative antipsychotics have been used to treat sundowning, but their side effects limit their overall effectiveness in a risk versus benefit balance. Various side effects in the risk category include increased fall risk, vivid dreams, or nocturnal agitation.

Research directions

There are several pathways in the pipeline for scientists seeking therapeutic options for sundowning syndrome.

  • NADH cytochrome C reductase is an enzyme involved in the synthesis of neuron energy. Stress, hypometabolism, and oxidative damage may decrease physiologic reserve in the elderly and can lead to a decrease in neuron energy production and an increase in neuron damage.
  • Thioredoxin reductase is an antioxidant that neutralizes oxidative free radicals that can cause cell death. The brain is vulnerable to oxidative free radicals because it receives 20% of the human body's oxygen supply. Finding a way to maintain the thioredoxin reductase pathway can decrease plaque formation and SCN degeneration.
  • Inflammatory stress in mouse models can provide a pathway for studying neurodegeneration. It is hypothesized that neurodegeneration has a relationship with inflammatory cytokines such as IL-1β. The role of cytokines in sundowning can improve our understanding of the pathology.
  • Injection of chemogenetic ligands into the eye to stimulate the SCN through the retinohypothalamic tract is another possible treatment for sundown syndrome as a similar strategy has been thought to have potential with regards to therapy for mood-related disorders.

Controversy

In addition to sundown syndrome not being officially recognized in the DSM-5, there is also the thought that sundown syndrome may be a phenomenon of caretakers' perception of patient agitation in the early afternoon to evening. Some studies have observed sundown syndrome occurring at times other than sunset which may suggest the symptoms associated with sundown syndrome are time-dependent rather than occurring specifically at sundown.

References

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