Sundown Syndrome: Is It Reflected in the Use of PRN Medications for Nursing Home Residents?

Exum, Mary; Phelps, Brady J.; Nabers, K E; Osborne, J. Grayson

doi:10.1093/geront/33.6.756

Cited by 28 publications

(21 citation statements)

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“…According to the reviewed literature, among medical factors which may contribute to sundowning in the elderly individuals with dementia are: chronic pain syndrome due to arthritis and malignancy, organ systemic disorders (including congestive heart failure, ischemic heart disease, asthma, chronic obstructive pulmonary disease, gastroesophageal reflux, incontinence, benign prostatic hypertrophy), psychiatric conditions (including depression, anxiety, psychosis), and effects of various medications 19,63,70. In demented patients, physical discomfort and illness may also be expressed as behavioral abnormalities.…”

Section: Resultsmentioning

confidence: 99%

Sundown Syndrome in Persons with Dementia: An Update

Khachiyants

Trinkle

Son

et al. 2011

Psychiatry Investig

148

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"Sundowning" in demented individuals, as distinct clinical phenomena, is still open to debate in terms of clear definition, etiology, operationalized parameters, validity of clinical construct, and interventions. In general, sundown syndrome is characterized by the emergence or increment of neuropsychiatric symptoms such as agitation, confusion, anxiety, and aggressiveness in late afternoon, in the evening, or at night. Sundowning is highly prevalent among individuals with dementia. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition. Neurophysiologically, it appears to be mediated by degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin. A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications. To decrease the morbidity from this specific condition, improve patient's well being, lessen caregiver burden, and delay institutionalization, further attention needs to be given to development of clinically operational definition of sundown syndrome and investigations on etiology, risk factors, and effective treatment options.

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Section: Resultsmentioning

confidence: 99%

Sundown Syndrome in Persons with Dementia: An Update

Khachiyants

Trinkle

Son

et al. 2011

Psychiatry Investig

148

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“…In the clinical literature, one criticism of the notion of sundowning has been that it occurs near the end of the work day, at the same time of day that nurses or caregivers change shifts or become fatigued themselves (19). Thus, critics have argued that the perception of increased afternoon/evening behavioral disruptions may well arise from the caretakers' own fatigue and not any change on the part of patients themselves (20).…”

Section: Discussionmentioning

confidence: 99%

Altered temporal patterns of anxiety in aged and amyloid precursor protein (APP) transgenic mice

Bedrosian

Herring

Weil

et al. 2011

Proc. Natl. Acad. Sci. U.S.A.

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Both normal aging and dementia are associated with dysregulation of the biological clock, which contributes to disrupted circadian organization of physiology and behavior. Diminished circadian organization in conjunction with the loss of cholinergic input to the cortex likely contributes to impaired cognition and behavior. One especially notable and relatively common circadian disturbance among the aged is "sundowning syndrome," which is characterized by exacerbated anxiety, agitation, locomotor activity, and delirium during the hours before bedtime. Sundowning has been reported in both dementia patients and cognitively intact elderly individuals living in institutions; however, little is known about temporal patterns in anxiety and agitation, and the neurobiological basis of these rhythms remains unspecified. In the present study, we explored the diurnal pattern of anxiety-like behavior in aged and amyloid precursor protein (APP) transgenic mice. We then attempted to treat the observed behavioral disturbances in the aged mice using chronic nightly melatonin treatment. Finally, we tested the hypothesis that time-of-day differences in acetylcholinesterase and choline acetyltransferase expression and general neuronal activation (i.e., c-Fos expression) coincide with the behavioral symptoms. Our results show a temporal pattern of anxiety-like behavior that emerges in elderly mice. This behavioral pattern coincides with elevated locomotor activity relative to adult mice near the end of the dark phase, and with time-dependent changes in basal forebrain acetylcholinesterase expression. Transgenic APP mice show a similar behavioral phenomenon that is not observed among agematched wild-type mice. These results may have useful applications to the study and treatment of age-and dementia-related circadian behavioral disturbances, namely, sundowning syndrome.Alzheimer's disease | cholinesterase | nucleus basalis of Meynert | behavioral and psychological signs and symptoms of dementia B oth normal aging and dementia are associated with disturbances in the biological clock that contribute to dramatic circadian disorganization, including the sleep-wake cycle, body temperature rhythm, and daily patterns of hormone release (1). Generally, aging is associated with reduced amplitudes among these daily rhythms; the most severe changes are associated with Alzheimer's disease (AD) (2). Circadian disorders affect more than 80% of individuals over age 65 (3) because of several converging factors; loss of neurons in the suprachiasmatic nucleus, decreased melatonin and melatonin receptor sensitivity, and minimal zeitgebers because of lifestyle all contribute to circadian dysfunction (1, 4).Normal aging and dementia are also associated with impairments in cognition and behavior, in part caused by loss of cholinergic input to the cortex (5). In particular, parts of the basal forebrain, most notably the nucleus basalis of Meynert (NBM), undergo degenerative changes, such as down-regulation of choline acetyltransferase (ChAT) activity (the r...

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“…Predictable environmental factors, such as a nursing shift change, may be involved in causing agitation in some patients (Exum et al, 1993). Most data, however, continue to show that, regardless of the type of behavior, type of facility, or diagnosis of dementia being studied, the late afternoon and early evening are periods of high vulnerability for agitation.…”

Section: Resultsmentioning

confidence: 99%

Circadian Rhythms and Agitation

Bliwise

2000

Int. Psychogeriatr.

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In mammals, many aspects of physiology vary over the 24-hour day in a predictable, periodic manner. Hormones, such as thyroid-stimulating hormone and melatonin, as well as cardiovascular and autonomic measures such as heart rate, blood pressure, and body temperature all have a predictable diurnal pattern. It is important to understand that such variation is generated internally; that is, such variation represents a fundamental, endogenous circadian variation. Circadian variability is typically distinguished from the numerous exogenous factors that can influence the physiologic parameters in question by its periodic pattern (Turek & Zee, 1999). For example, sleep lowers body temperature, and physical activity, upright posture, food intake, and the state of wakefulness increase body temperature. Such exogenous masking factors can affect body temperature at any point in the 24-hour day. Thus, the behavioral act of going to sleep lowers body temperature, but the fall in body temperature during wakefulness also heralds the onset of sleep and incipient sleepiness. Nonetheless, when all such factors are strictly controlled (by having volunteers confined to supine bed rest with restricted activity, sleep deprivation, hourly isocaloric food intake, and controlled lighting conditions), body temperature continues to oscillate in a highly predictable way, affected only by age, sex, and, perhaps, mental status.

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Sundown Syndrome: Is It Reflected in the Use of PRN Medications for Nursing Home Residents?

Cited by 28 publications

References 0 publications

Sundown Syndrome in Persons with Dementia: An Update

Sundown Syndrome in Persons with Dementia: An Update

Altered temporal patterns of anxiety in aged and amyloid precursor protein (APP) transgenic mice

Circadian Rhythms and Agitation

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