Expert on sundowning
Dr. Brian Goldman (photo from Brian Goldman)
While most people have heard of dementia, many of us won’t have heard the term sundowning before.
According to Dr. Brian Goldman, emergency physician at Mount Sinai Hospital in Toronto, sundowning is generally part and parcel with dementia of various kinds.
“Sundowning refers to a person who is sleepy during the day and very active at night,” he explained. “Almost as soon as the sun goes down, that’s when they become active. The activity can be not just when awake and walking about in an agitated or restless state.… For sundowning to have its maximum impact on the patient and others – the caregivers and care providers – you have to have dementia [as well].
“A person who is cognitively intact, who is simply sleeping during the day and being up all night, would have the cognitive reserve to be able to handle that. They might feel they have a problem, need to see a doctor, or they might rearrange their lives because, when everyone’s sleeping, they’re up, [but] they’d be able to cognitively make sense of it.”
Goldman explained dementia as “a chronic disorder caused by a brain disease or injury. It is characterized or marked by impaired cognition or thinking, memory and personality changes.”
Goldman – who grew up in Toronto’s North York, the heart of the Jewish community – said he is seeing more elderly people with dementia. Often he is one of the first people to notice the symptoms.
“As an emergency physician,” he said, “I would say that an increasing percentage of the patients I see in the emergency department are frail seniors. When I started out in the 1980s, we would see an occasional patient over the age 90, but now it’s commonplace.
“I have professional experience, but I also have personal experience. Both my parents have passed away in the last two years and they both reached frail senior years. My mother had dementia. My father did not.”
Why some dementia patients also suffer from sundowning while others do not, Goldman said, remains a mystery. As well, the number of people who suffer from this newly defined condition of sundowning is also unknown, with estimates ranging from as low as two to three percent of people with dementia up to more than 60%.
“It has been said that sundowning tends to occur when the person is in unfamiliar surroundings, though it can also occur in the home,” said Goldman. “It’s well known that some people with dementia have damage to the pathways to their brain that recognize light coming in through their eyes and stimulating a part of the brain called the pineal gland. The pineal gland secretes the hormone melatonin.”
Melatonin is secreted somewhere around 2 or 3 a.m. every morning. It resets your body’s circadian rhythm. If that pathway is disrupted, it makes sense that your sleep-wake cycles would be seriously disrupted.
Another theory is that people who sundown are dreaming vividly. They are flipping between the awake and dreaming states quickly and frequently. And, again, because they don’t have the cognitive reserve, they do not know if they are dreaming or awake.
There is not yet a lot known about sundowning and another phenomenon known as delirium.
According to Goldman, delirium is confusion associated with the activation of the fight or flight response along with symptoms that include tremors, shaking, a fast heart rate, sweating and dilated pupils. These symptoms are sometimes also referred to as “toxic delirium.” People with toxic delirium have a rapid, traumatic change in their demeanor. Triggers of toxic delirium are often fever, urinary infection, pneumonia, flu, or even a heart attack.
“You recognize it if you see a sudden change from what the person was doing a week ago,” explained Goldman. “They look sick, sweaty … something seriously wrong … and there is an underlying cause. Treat the cause and the toxic delirium goes away.
“Sundowning is a more chronic pattern that can go on for months. There is no vast dramatic change. The only change in pattern you might notice, wherein dad or mom wander off at night once a month, then it becomes once a week, then every night. It’s a gradual pattern.”
Ways to help this condition, according Goldman, include regularizing a sundowner’s routine: having meals at set times, a set time for exercise (but not at night), set times for bathing and toileting (like washing in the morning or before bed), and the like.
“The experts say that caffeine should be avoided,” he added. “You want people to walk. Walking is good for them. Visitors are good, but probably not close to the time they’re going to bed. Also, reduce noise from TVs and radios and address the lighting in the room, ensuring you don’t have harsh lighting that could cast disturbing shadows on the wall.”
Besides these steps and before turning to sleep medication, Goldman advised exploring some other preventive approaches. Light therapy has shown some promise, he said, affecting patients in a similar way as those with seasonal affective disorder. This involves getting special light-generating therapy units, which are available without a prescription and come with instructions on use.
When it comes to lost brain pathways, Goldman sees the technique as especially helpful when approached in a “use it or lose it” fashion. “If you want to build up a reserve, this might be a way of doing that, with year-round light therapy,” he said.
“Certainly, making them busier during the day with exercise and other stimulation is the way to go. Somebody with dementia wants adventures in the same way that everyone wants adventures, something new. Keeping to the same routine everyday is helpful for structure, but the novelty factor can be helpful as well.”
Goldman said these practices can offer some relief of the effects of dementia, including Alzheimer’s, the most common cause and form of dementia.
Rebeca Kuropatwa is a Winnipeg freelance writer.