Sundowning Syndrome in Dementia

This assignment delves into the complex issue of sundowning syndrome specifically in individuals with dementia. It highlights the difficulties in diagnosing and managing this condition due to factors like fluctuating agitation levels and caregiver fatigue during late evenings or nights. The need for a clear definition and understanding of sundowning within the context of dementia is emphasized, calling for future research to address these gaps.

Running head: SUN DOWNING SYNDROME AND ELDERLY DEMENTIA
Sun downing syndrome and elderly dementia
Name of the Student
Name of the University
Author note

1SUN DOWNING SYNDROME AND ELDERLY DEMENTIA
Sun Downing Syndrome (SD) is a highly prevalent condition that is associated with
individuals with dementia occurs during the middle stages of mixed dementia or Alzheimer’s
disease (Ferrazzoli, Sica and Sancesario 2013). This is called ‘late-day confusion’ creating
agitation and confusion in the late afternoon and evening being less pronounced during the day.
There is no exact reason for this behaviour although it is aggravated due to low lighting, fatigue,
increased shadows, internal clocks disruption, infections or separating reality from dreams. It is
syndrome associated with nocturnal delirium and form of Behavioural and Psychological
Symptoms of Dementia (BPSD) affecting around 10% to 25% patients in nursing care residents
and 66% dementia dwelling patients (Yevchak, Steis and Evans 2012). Structuring of
environment, meeting psychological and physical needs, scheduled activities of daily living,
enhanced social activities and preventing loneliness can reduce SD symptoms (Venturelli et al.
2016). It is hard to distinguish sundowning as it has an unclear diagnostic criteria and definition.
Therefore, the following essay involves the discussion of sundowning syndrome as a nursing
issue and critical appraisal of current evidence associated with it.
During my clinical placement, I was working at dementia ward in nursing home where I
was assigned to look after sun downing syndrome patients with dementia. I found it challenging
to look after them during my shift and planned to research syndrome. A literature review was
conducted to explore this condition, describing what it is, why it occurs and its prevalence with
proper management and treatment in reducing agitation being a major nursing issue.
Sundowning has entered the common parlance of aged care nursing and dementia
caregivers questioning whether it is common syndrome as assumed associated with demented
individuals or not (Ferrazzoli, Sica and Sancesario 2013). However, it is not a formal form of
psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-MD).

2SUN DOWNING SYNDROME AND ELDERLY DEMENTIA
Moreover, the lack of consistent definition and diagnostic criteria are the man contributing
factors to the conflicting and challenging interpretation of research findings particularly for
nurses in terms of treatment outcomes (Nelson and DeVries 2017). The treatment guidelines are
also not specific for SD in the major dementia treatment. Apart from lack of consensus, the
hypothesis that symptoms (agitation) occur during late afternoon and evening is quite burdening
for the nursing staffs and caregivers questioning the existence of SD (Ferrazzoli, Sica and
Sancesario 2013). Therefore, it is important to have an insight into the current literature evidence
related to SD and relevant to aged care nursing discussed in the subsequent section.
Khachiyants et al. (2011) conducted a systematic review on epidemiology, etiology,
differential diagnosis risk factors, prognosis and prevention of SD. The results depicted that SD
is the second most common disruptive behavior form in institutionalized patients with dementia
appearing endemic after wandering. 12.4% of elderly patients in nursing homes stated that
cognition status disruption occurs during late afternoon. This data suggests that it becomes
impossible for aged care nurses to carry out a validated comparative analysis about SD
prevalence in different populations like non-institutionalized or institutionalized (Martins and
Fernandes 2012). Moreover, the frequently observed abnormalities in behavior of demented
patients with late afternoon exacerbation at late evening or night pose a significant burden to the
nursing staffs and caregivers triggering challenges (Ferrazzoli, Sica and Sancesario 2013).
However, the paper presented limited data in the prevention of SD as the current literature lacked
effective methods description.
Canevelli et al. (2016) in their paper illustrated SD is a challenging manifestation and
relevant to dementia in large number of affect individuals posing burden to aged care nursing
and economic burden. There is lack of evidence regarding disentangling and clarifying the

3SUN DOWNING SYNDROME AND ELDERLY DEMENTIA
multifaceted and complex pathophysiological bases of SD phenomena. There is also lack of
validated tool and screening for SD in the routine clinical practice especially outpatient settings.
These factors pose future developments and research regarding SD in dementia for aged care
nurses emerging as an issue in the nursing specialty.
Cipriani et al. (2015) published a paper explaining that SD is a poorly defined entity that
lacks accurate understanding of clinical characteristics, treatment and management. The study
stated the role of suprachiasmatic nucleus (SCN) in hypothalamus for the generation and
synchronization of behavioral and physiological rhythm. SCN is biological clock that control
melatonin production suppressed by dark and light alterations. They stated that sundowning is
based on cortical activation or arousal reaction depending on cortex cholinergic differentiation
where sleep disruption is the prime contributor. They also established correlations between noise,
amount of light, staff fatigue and shortages.
According to Blais, Zolezzi and Sadowski (2014) non-pharmacological interventions like
music therapy, bright light therapy and aromatherapy may be of some benefit, however,
pharmacological therapy provide minimal benefit only associated with safety concerns. The use
of antipsychotics and melatonin showed evidence, however benzodiazepines are not
recommendable as there are adverse side effects in elderly patients. This shows there is poor
management of SD and quality of evidence supporting treatment is weak. As non-
pharmacological interventions are safe, they are first line of SD treatment and require further
development of SD management strategies.
According to Gnanasekaran (2016) the clinical phenomenon of sundowning syndrome is
known as ‘early evening disruptive behavior’. The paper suggested that there is limited medical

4SUN DOWNING SYNDROME AND ELDERLY DEMENTIA
literature regarding definition criteria and consistent diagnosis. The current understanding about
this syndrome is greatly incomplete with limited justification. The literature is scarce and there is
lack of comprehensive understanding of SD with studies failing to realize the basic existence of
this syndrome. However, this study is perceived during evening hours creating stress and fatigue
among nursing staffs in long-term care facilities.
According to Zhou, Jung and Richards (2012) the antipsychotic medications given for
dementia causes sleep disturbances or irregular circadian rhythms in the patients that may be a
reason for the sundowning syndrome associated with this condition. Night awakening due to SD
in patients is distressing for both patients with dementia and caregivers especially clinical
depression among nurses and caregivers.
From the above discussion, it is evident that there is limited literature available
suggesting that some demented patients display sundowning, although, it is a prevalent syndrome
among elderly population. Due to this reason, nurses and caregivers are unable to provide
accurate treatment and management of the condition. Moreover, the agitation that occurs during
the late evening or night is also a matter of concern. At that time-frame, there is shift change or
fatigue that occurs among nurses and caregivers also causes poor diagnosis and management of
SD among dementia patients. Therefore, future studies are required to have a clear definition,
understanding and differential diagnosis of SD in demented individuals.

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References
Blais, J., Zolezzi, M. and Sadowski, C.A., 2014. Treatment options for sundowning in patients
with dementia. Mental Health Clinician, 4(4), pp.189-195.
Canevelli, M., Valletta, M., Trebbastoni, A., Sarli, G., D’Antonio, F., Tariciotti, L., de Lena, C.
and Bruno, G., 2016. Sundowning in Dementia: Clinical Relevance, Pathophysiological
Determinants, and Therapeutic Approaches. Frontiers in medicine, 3.
Cipriani, G., Lucetti, C., Carlesi, C., Danti, S. and Nuti, A., 2015. Sundown syndrome and
dementia. European Geriatric Medicine, 6(4), pp.375-380.
Ferrazzoli, D., Sica, F. and Sancesario, G., 2013. Sundowning syndrome: A possible marker of
frailty in Alzheimer’s disease?. CNS & Neurological Disorders-Drug Targets (Formerly Current
Drug Targets-CNS & Neurological Disorders), 12(4), pp.525-528.
Gnanasekaran, G., 2016. “Sundowning” as a biological phenomenon: current understandings and
future directions: an update. Aging clinical and experimental research, 28(3), pp.383-392.
Khachiyants, N., Trinkle, D., Son, S.J. and Kim, K.Y., 2011. Sundown syndrome in persons with
dementia: an update. Psychiatry investigation, 8(4), pp.275-287.
Martins, S. and Fernandes, L., 2012. Delirium in elderly people: a review. Frontiers in
neurology, 3.
Nelson, R.J. and DeVries, A.C., 2017. Medical Hypothesis: Light at Night Is a Factor Worth
Considering in Critical Care Units. Advances in Integrative Medicine.

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Venturelli, M., Sollima, A., Cè, E., Limonta, E., Bisconti, A.V., Brasioli, A., Muti, E. and
Esposito, F., 2016. Effectiveness of exercise-and cognitive-based treatments on salivary cortisol
levels and sundowning syndrome symptoms in patients with Alzheimer’s Disease. Journal of
Alzheimer's Disease, 53(4), pp.1631-1640.
Yevchak, A.M., Steis, M.R. and Evans, L.K., 2012. Sundown syndrome: a systematic review of
the literature. Research in gerontological nursing, 5(4), pp.294-308.
Zhou, Q.P., Jung, L. and Richards, K.C., 2012. The management of sleep and circadian
disturbance in patients with dementia. Current neurology and neuroscience reports, 12(2),
pp.193-204.