Sundowners disease
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Understanding Sundowners Disease: Key Insights and Management Strategies
Definition and Characteristics of Sundown Syndrome
Sundown Syndrome (SS), also known as sundowning, is a condition characterized by increased agitation, confusion, and restlessness in the late afternoon, evening, or night, predominantly affecting older adults with dementia1 2 3. The syndrome is often observed in long-term care settings and is associated with a disrupted circadian rhythm, which is the most widely accepted pathophysiological explanation1 7. The frequency of SS varies significantly, ranging from 2% to 82% among different populations, with no evident differences between genders or ethnicities1.
Clinical Manifestations and Risk Factors
The symptomatic manifestations of SS are heterogeneous, including psychomotor alterations and cognitive disturbances that occur cyclically around sunset1. Common symptoms include increased restlessness, sleep disorders, and exacerbation of behavioral symptoms such as agitation and confusion2 4 5. Cognitive impairment is often seen as a predisposing factor, although some studies suggest SS could be a predictor of impending cognitive decline1. Physiological factors like odor of urine, frequent awakenings, and fewer medical diagnoses, as well as psychosocial factors such as recent admission to a facility, have been linked to the occurrence of SS5.
Sundowning and Dementia
Sundowning is particularly prevalent among individuals with dementia, including Alzheimer's disease, frontal lobe dementia, and Lewy body disease2 4. The condition is associated with disturbances in circadian rhythms, such as altered core body temperature and motor activity patterns, which are more pronounced in patients with Alzheimer's disease7. These circadian disruptions contribute to the severity of sundowning symptoms, indicating a chronobiological basis for the syndrome2 7.
Management and Interventions
Effective management of SS remains challenging due to the scarcity of comprehensive clinical trials. However, both pharmacologic and nonpharmacologic approaches have been explored1 4. Nonpharmacologic interventions, such as regular physical activity, have shown promise. For instance, walking for 30 minutes a day, four times a week, has been found to significantly reduce sundowning symptoms in individuals with Alzheimer's disease, with afternoon walking showing faster effects than morning walking8. Additionally, aerobic exercise combined with cognitive training has been effective in reducing cortisol levels and behavioral symptoms associated with SS, suggesting a potential role for exercise-based treatments9.
Conclusion
Sundown Syndrome is a complex and poorly defined condition that significantly impacts individuals with dementia and their caregivers. While the exact pathophysiology remains unclear, disrupted circadian rhythms and cognitive impairment are key contributing factors. Nonpharmacologic interventions, particularly regular physical activity, offer a feasible and effective approach to managing SS symptoms. Further research is needed to develop standardized measurement tools and comprehensive clinical trials to better understand and treat this condition.
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Most relevant research papers on this topic
Sundown Syndrome in Older Persons: A Scoping Review.
Sundown syndrome is a cyclic delirium-like condition affecting older adults around sunset, with inconsistent risk factors and potential as a predictor of cognitive decline.
Systematic ReviewSundowning syndrome in demented patients without neuroleptic therapy.
Sundowning syndrome is common in demented patients without neuroleptic therapy, and is related to restlessness, sleep disorders, and a history of hypotension lipothymia.
Observational StudyAn investigation of the sundowning syndrome
Geriatric clinicians have observed that some demented individuals show increased agitation, restlessness and confusion in late afternoon, evening or night. This has popularly been named ‘sundowning’, or the ‘sundowning syndrome’. References to ‘sundowning’ in clinical writings disagree on virtually every aspect of the syndrome, and little research has been conducted to investigate this phenomenon.
Sundown syndrome and dementia
Sundown syndrome is a complex behavioral disorder in individuals with dementia, and understanding it may lead to more effective environmental, behavioral, and pharmacological interventions.
Systematic Review
Rigorous JournalSundown Syndrome in Institutionalized Elderly
Sundown syndrome is a common phenomenon in nursing homes, with one in eight residents affected, and is associated with increased restless and verbal behavior in the evening, particularly in demented residents.
Observational Study
Highly CitedSundown syndrome: a systematic review of the literature.
Sundown syndrome has a prevalence of 1% in the US population, with antecedent and precipitating factors varying, and interventions effective in reducing its impact.
Systematic ReviewSundowning and circadian rhythms in Alzheimer's disease.
Alzheimer's disease disrupts circadian rhythms and sundowning is linked to a phase delay of body temperature.
Observational StudyHighly CitedEffects of walking on sundown syndrome in community-dwelling people with Alzheimer's disease.
Regularly walking for 30 minutes a day, four times a week, is beneficial for alleviating sundown syndrome symptoms in community-dwelling people with Alzheimer's disease.
RCTEffectiveness of Exercise- and Cognitive-Based Treatments on Salivary Cortisol Levels and Sundowning Syndrome Symptoms in Patients with Alzheimer's Disease.
Aerobic exercise and cognitive training effectively reduce sundowning syndrome symptoms in Alzheimer's disease patients, suggesting a possible hypothalamic-pituitary-adrenal axis dysregulation.
RCTRigorous JournalSleep in Alzheimer's disease and the sundown syndrome
Disturbances of sleep and sundowning are common in Alzheimer's disease patients, with neurologic basis for these disturbances and potential causes and treatments for sundowning.
Highly Cited