Understanding Sundown Syndrome & what you can do to help

Characterised by the increase of symptoms such as agitation, confusion, anxiety, and aggressiveness commencing in the late afternoon, evening, and at night. It is highly prevalent among people with dementia, in a nursing home population, it was found that 12.4% of people with dementia presented with sundowning syndrome. However, please note that the study was carried in nursing homes in America.

Causes of Sundown Syndrome can be grouped into three main categories:
1. Physiological
2. Psychological
3. Environmental

Physiological and Psychological:
– Sensory Deprivation
– Sleep/Wake Cycle
– Change in body temperature
– Medication & Psychiatric conditions

Environmental:
– Environmental Stimulation

Assessment tools available:
Cohen-Mansfield Agitation Inventory (CMAI)
Pittsburgh Agitation Scale (PAS)
Screaming Behavioural Mapping Instrument (SBMI)

Interventions

Check for
1. Physical illness (Infection, Constipation, Medical Illness, delirium)
2. Discomfort (pain, hunger, thirst, general)
3. Psychological (violation of space, environmental stressors, unmet need, perceived threat/imprisonment/unfamiliar environment, boredom, loneliness, isolation, failed attempt to communicate, lack of activities, poor environment/sensory deprivation, reduced stress threshold)

Prevention:
Structure daily schedule that is familiar to the resident.
Physical exercise & sleep routine (https://sleepfoundation.org/ask-the-expert/sleep-hygiene).

Activities staff can undertake in a Dusk till Dawn programme or treatment:
Time: 15 minutes before sundowning symptoms occur
Environment: Minimise stimulation such as loud noises or lights from the television/radio, reduce surrounding staff movements, etc.

Environmental interventions/ behavioral modifications is recommended as the first line of treatment
Others include:
music therapy, aromatherapy, multisensory stimulation, and simulated presence therapy.

Avoid:
Restraints, this may escalate behaviours.
Showering the resident in the evening if this is not a familiar activity for the resident.

References:

Duckett S. Managing the sundowning patient. J Rehabil. 1993;1:24–28.

Evans LK. Sundown syndrome in institutionalized elderly. J Am Geriatr Soc. 1987;35:101–108.

Khachiyants, N., Trinkle, D., Son, S. J., & Kim, K. Y. (2011). Sundown Syndrome in Persons with Dementia: An Update. Psychiatry Investigation, 8(4), 275–287. http://doi.org/10.4306/pi.2011.8.4.275

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