Parkinson's and Sundowning

Good Information 

Sundown syndrome is a term that describes the onset of confusion and agitation that generally affects people with dementia or cognitive impairment and usually strikes around sunset.

Episodes of delusions, hallucinations, agitation, and increased dementia that intensify in the evening. clinicians do not fully understand the timing of sundowning episodes. Theories include correlations with hormonal cycles in the body, fluctuations in brain neurotransmitter levels that result from medication peaks and troughs, a “crash” letdown+ from the activities of the day, and the somewhat surrealistic images that can occur as a combination of artificial lighting and shadows as evening begins. As are other dimensions of neurodegenerative diseases, it is likely a combination of all of these factors. Sundowning is a particularly common manifestation in Alzheimer’s disease; its appearance in a person with Parkinson’s disease suggests that dementia is present.

Sundowning is stressful for caregivers because they know it is coming and they know it is unpredictable. Agitation reaches a peak when family members are also tired and ready to relax, and the resources they need to be innovative and supportive are often wearing thin by this time of the day. Sometimes the loved one responds to efforts to keep activities and the surroundings calm and quiet. other times, it seems that nothing family members try makes any difference. Sometimes changes in the anti-parkinson’s medication regimen improve the situation. Although in the person with Alzheimer’s disease antipsychotic medications are sometimes helpful, these drugs are a more limited option for the person with Parkinson’s because the risk of motor side effects or intensified symptoms of Parkinson’s is significant. Quetiapine, clozapine, and perhaps arip-iprazole are thought to be the best antipsychotics for people with Parkinson’s.

Establishing a predictable routine seems to be the most consistently helpful approach for managing sundowning. The routine should start while there is still plenty of daylight and should take place every day regardless of the day’s activities. This schedule can be confining for family members and the person’s response will continue to vary from day to day, but the sense of structure is useful to caregivers as well. other recommendations include making sure to turn on lights in the house before darkness sets in and having someone stay with the person during the transitional time between daylight and darkness. Most people who experience sundowning become calm again as night falls.

http://what-when-how.com/parkinsons-disease/sundowning-parkinson’s-disease/

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WHAT IS SUNDOWNING, WHAT CAUSES IT AND HOW DOES IT IMPACT THE CAREGIVER?

SEPTEMBER 30, 2014 BY EDITOR PRO Staff Writer

Sundowning is basically a group of symptoms that may come with or without a disease. By itself, it is not a disease; however, it may affect people with Parkinson’s, dementia, Alzheimer’s, Lewy Body Variant and the like. Sundowning, by its very name, occurs at a specific time of day, generally starting in the late afternoon and lasting until bedtime. It is thought to be associated with impaired circadian rhythmicity, environmental and social factors, and impaired cognition.

Sundowning can be exhibited in any or all of the following examples: Agitation, anxiety, confusion, combativeness, ignoring directions, irritability, restlessness, and screaming or yelling and may even manifest in constant pacing and/or wandering. Some of these behaviors may not be specific to Sundowning and can be the manifestation of dementia, delirium, Parkinson’s disease, and sleep disturbances. Other clinical features of Sundowning include mood swings, abnormally demanding attitude, suspiciousness, and visual and auditory hallucinations in the late afternoon and evening.

Research indicates that 20–45% of Alzheimer’s patients will experience some sort of Sundowning symptoms.

The exact cause of Sundown syndrome is unknown. Several theories have been proposed to understand the clinical phenomenon of Sundowning. Studies that have attempted to explain etiology of Sundown syndrome can be divided into three major groups: physiological, psychological, and environmental. A change in the biologic clock caused by dementia is a likely reason.

A variety of treatment options have been found to be helpful to ameliorate the neuropsychiatric symptoms associated with this phenomenon to decrease the morbidity from this specific condition, improve patient’s well-being, lessen caregiver burden, and delay institutionalization: bright light therapy, melatonin, acetylcholinesterase inhibitors, N-methyl-d-aspartate receptor antagonists, antipsychotics, and behavioral modifications.

Before considering any specific treatment for Sundown syndrome, it is reasonable to gather a careful history including a journal of the patient’s daily timeline and activities as they pertain to the Sundowning, and have performed a thorough physical examination, and laboratory investigations in order to evaluate a patient for the Sundowning syndrome’s possible connection to various medical conditions.

Determining What Triggers Your Loved One’s Sundowning – As stated earlier, it is very helpful for caregivers to try to determine what may trigger Sundowning symptoms. There may be specific things that you might alter if you determine they may be triggering the behaviors. These alterations may prevent Sundowning from occurring or at least lessening its intensity.

Check medications for possible side effects.

Check with the physician to rule out pain or other developments that might be causing increased behaviors.

Have the lighting levels up which will reduce shadows and gloom.

Maintain an afternoon, evening and bedtime routine.

Play soothing music in the place of television or talk radio activities.

Stay physically active during the day; however, keep the daily activities from being overtiring or over stimulating.

Go outside into the sunshine during the day.

Keep naps short so as to keep them from being wide awake when they should be ready to go to sleep for the night.

Reduce caffeine.

Ensure the environment is calm and quiet, reduce noise, move to a quiet room.

Perhaps offer food and beverages prior to sunset.

Try to reduce their agitation by talking to them reassuringly about their concerns. 

Redirect their behavior. Give them a task to refocus them and relieve boredom.

Keep nightlights on in areas that can be dark.

Ask the doctor if melatonin would help with sleep routine.

Sundowning Impacts Caregivers –Unfortunately, most of the aggression is directed at the caregiver and the patient’s behavior changes about the time the caregiver is tired from a long day and is hoping to begin to unwind. Even worse, the behavior changes and anxieties can last until bedtime, further worsening symptoms and escalating behaviors making it harder for the person with dementia to fall to sleep. The effect Sundowning has on a caregiver is not only difficult for the caregiver to deal with, it can be super stressful causing caregiver illness and burn out.

We continually encourage caregivers to care for themselves first by scheduling an hour, an afternoon, a day or longer of time for yourself. It is imperative to focus on your own needs, care for your own health and get support and respite every chance possible, especially when dealing with a person with dementia. If possible, schedule paid caregivers, friends, family members or others to take over some responsibilities so you can take time for yourself. Paid caregivers, friends, family members or others can help with household tasks or caregiving duties. In order to continue be a good caregiver it is critical to maintain your own well-being.

A caregiver can get wonderful emotional support from others who are in the same or similar situations. Join a caregiver group. Learn from and share with others their and your experiences. Others may have tips and techniques that could help you deal with your situation, while you may have tips and techniques that can help them. Mostly you will know that you are not alone.

Learn what is coming next in your loved one’s disease process so you can be prepared. Ask for the Five Stages of Parkinson’s and/or learn The Five Stages of Dementia which describe a patient’s ability to perform in six different areas of cognition and functioning: orientation, memory, judgment, home and hobbies, personal care, and community.

The most effective way to deal with your loved one’s Sundowning is to learn from each experience they have by keeping a journal of the symptoms; what may have triggered them? How was this day different from others? What physical signs did they show? How long did the episode last? What worked to calm them this time? By using what you’ve learned from each occurrence will make it easier to deal with the next one. Perhaps you will be able to lessen each episode or reduce the frequency of the experiences, which will make your job as a caregiver easier.

http://www.parkinsonsresource.org/education/what-is-sundowning-what-causes-it-and-how-does-it-impact-the-caregiver/