Controversies in geriatric medicine
Sundown syndrome and dementia

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Abstract

The terms “sundown syndrome” or “sundowning” are used to describe a wide range of neuropsychiatric symptoms often occurring in individuals with dementia. It is a poorly defined entity. The goal of this review is to describe the phenomenon of this syndrome, its clinical characteristics and management. Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2014. Search terms used included behavioural and psychological symptoms of dementia (BPSD), circadian rhythms, dementia, sundowning, sundown syndrome. Publications found through this indexed search were reviewed for further relevant references. Sundowning is a complex behavioural disorder with tremendous costs for families, caretakers, and patients themselves. Increased understanding of the sundowning syndrome may lead to more effective environmental, behavioural, or pharmacological interventions.

Introduction

The behavioural and neuropsychiatric symptoms of dementia and Alzheimer's disease (AD) have become an increasingly important focus of clinical research. They include aggressiveness [1], repetitive behaviour [2], delusions [3], [4] (some bizarre and uncommon) [5], [6], misidentifications [7], wandering [8], apathy [9], suicidal [10] and sociopathic behaviour [11]. Both normal aging and dementia are associated with altered circadian regulation of physiology and behaviour. The clinical phenomenon of exacerbation of behavioural symptoms that occurs in the late afternoon or evening among dementia patients or elderly institutionalised patients has been reported in the clinical literature more than 70 years ago [12]. These behaviours include increased disorientation, confusion, agitation, restlessness, wandering and anxiety.

Section snippets

Nosology and clinical characteristics

The terms “sundown syndrome”, “sundowning” or “nocturnal delirium” are used to describe a wide range of neuropsychiatric symptoms occurring in individuals with dementia. It is a poorly defined entity. It is not a disease, but a set of symptoms that occur at a specific time of the day that may affect people with dementia. Sundowning shares similarities with delirium, e.g. attention deficits and activity disturbances [13]. However, contrary to delirium, sundowning seems to persist for a longer

Outcomes

Sundowning has been described as a problem of considerable magnitude in the management of demented patients [24]. The phenomenon is associated with significant caregiver distress [25] and it is a frequent or major cause for families to move the patient from home into a skilled nursing facility [26], [27]. Obviously, if a person with dementia is awake and roaming around the house at night, this behaviour impacts the caregiver's sleep as well: according to a large study in Germany, 51% of

Aetiology

The cause of sundown syndrome still remains unclear. Interpretations have ranged from behavioural theories to specifically biological ones. Studies that have attempted to explain aetiology of sundown syndrome can be divided into three major groups: physiological, psychological, and environmental. The inadequate influence of external “Zeitgebers” such as social conventions and daylight may also contribute to the syndrome [32], [33].

Other potential aetiological factors

Several drugs may induce side effects such as akathisia, tardive dyskinesia, muscle rigidity, anticholinergic toxicity (tachycardia, constipation, and confusion), orthostatic hypotension, and others and may further contribute to development of sundowning in demented patients [47]. Also, diurnal mood variation, a pattern of mood variability in which a person's worst mood and best mood vary in a predictable fashion, is a symptom of major depression and might explain some cases of sundowning [45].

Management

It is essential to adopt a multifactorial strategy to both understanding and intervening in sundown syndrome; the approaches must be based on the particular circumstances of each individual. At present, treatment options for sundowning are limited, primarily because of our limited knowledge of the aetiology and pathophysiology of this disorder. Obviously, treatment of this illness must take into account all the associated conditions that, according to the literature, may contribute to trigger

Conclusions

Despite the lack of a formal recognition, “sundowning” is broadly used to describe a set of neuropsychiatric symptoms occurring in elderly patients with or without dementia at the time of sunset, at evening, or at night. It is a complex behavioural disorder with tremendous costs for families, caretakers, and patients themselves. It represents a concrete problem, which is difficult to manage for physicians and caregivers, and it is probably linked to various biological, psychological and social

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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