Analysis Of Sun Downing Syndrome Dementia

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Analysis Of Sun Downing Syndrome Dementia

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Discuss about the Analysis Of Sun Downing Syndrome Dementia.

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During my clinical placement at a dementia ward, in a nursing home, I was assigned the responsibility of caring for an elderly dementia patient, with sundowning syndrome. I found it challenging to look after my client, especially after sunset as the patient manifested symptoms of agitation and confusion. Therefore, I intended to conduct a literature search on sundowning to understand the prevalence of the disorder, the underlying factors that contribute to its incidence and the strategies that can be effectively implemented in the hospital setting for its management. Sundowning syndrome is a common neurological phenomenon that is often associated with restlessness and confusion, among patients who suffer from dementia or have delirium (Jonghe, Munster and Rooij 2014). With sunset, most elderly patients show a drastic change in their behaviour and become extremely agitated and confused. They also begin to hallucinate, which manifests in the form of delirium (Ferrazzoli, Sica and Sancesario 2013). Therefore, sundowning can be referred to as a phenomenon that is frequently observed in geriatric psychiatry wards (Coogan et al. 2013).
The precise time frame for manifestation of these complications begins at around 4-5 p.m. and extends till midnight (Bedrosian and Nelson 2013). However, this clinical phenomenon is considered as a matter of debate because no accurate definition, aetiology, interventions or validity of clinical constructs are known. Owing to the absence of distinct demarcations between sundowning and dementia, nursesd working in geriatric wards face huge concerns (Roth 2012). This essay will encompass a discussion on the nursing issues that are faced and will provide evidences from some related literature.
Sundowing affects more than 20% geriatric residents and around 66% dementia patients living in aged care homes (Richardson et al. 2013). However, the Diagnostic and Statistical Manual of Mental Disorders (DSM-MD) fails to accurately diagnose the disease (Halek and Bartholomeyczik 2012). There are no specific treatment guidelines available for the condition. Nursing professionals often implement pharmaceutical interventions that rely on medications such as, risperidone, haloperidol, chlorpromazine, and thioridazine to pacify the individuals and to mask they are problematic behaviours (Yevchak, Steis and Evans 2012).
Canevelli et al. (2016) conducted a literature search and stated that there is no unifocal definition for sundown syndrome. Owing to the fact that there is lack of consistent data on the prevalence of this syndrome with regards to the gender age and race of patients, it becomes difficult for nurses to manage such individuals. Stressed caring exhibited by a fatigue and burdened nursing professional often leads to burn out and results in implementation of wrong management strategies. The authors identified some of the reduction in melatonin production, impaired neurotransmission of cholinergic nerves, circadian rhythm disruption and regeneration of suprachiasmstic nucleus as the contributing factors.
Similar results for demonstrated by Cipriani et al. (2015) who emphasized on the role of suprachiasmatic nucleus (SCN) in the hypothalamus for generating and synchronising physiological biochemical and behavioral rhythm. They supported the statement that SCN functions as the central biological clock of human brain. They supported findings from previous research by stating that production of melatonin is under the control of this central clock, which in turn is suppressed by alterations in light and dark. The authors further stated that sundowning is based on arousal reaction or cortical activation, which depends on cholinergic differentiation of cortex. Thus, they considered sleep disruption as an important contributor. They were also accurate in establishing correlations between the phenomenon with the amount of light, noise, understaffing and fatigue.
The role of circadian rhythm in sundowning syndrome was further explained by Zhou, Jung and Richards (2012) who stated that the suprachiasmatic nucleus located in the hypothalamus helps in governing the 24 hour cycle. They associated such behavioral disturbances with night restlessness, which in turn, triggers clinical depression in most patients. Evidences were provided for the association between melatonin secretion alterations such patients. The authors suggested that low bright light exposure on patients, staying in nursing homes was associated with frequent night-time awakenings and agitations. Thus, they stated that night awakenings due to sundowning are quite distressing for the patients as well as their caregivers.

Stadlober, Sharp and Mudford (2016) made an analytic approach to sundowning among older individuals and showed congruency with previous findings by recognizing disruption in circadian rhythm due to low levels of light exposure in aged care home as the major factor. They associated sundowning to change in availability of nursing staff attention and administration of antipsychotics. They further recommended measurements of variables like staff attention for determining the exact effects on the phenomenon.
The literature research conducted by Gnanasekaran (2016) provided evidence for effect of melatonin secretion in the pineal glands, in response to darkness. Lack of adequate light and water was thought to result in oxidative damage that generates free radicals. These become toxic and result in several deleterious effects in the individuals, thereby deregulating the circadian rhythm. The study indicated the presence of limited literatures on the diagnosis and definition of the phenomenon. Although the authors emphasized on the capacity of light energy to promote photo-biostimulation of cells by breaking the water molecule, the literature provided little information on recognizing the basic occurrence of the syndrome.
According to Blais, Zolezzi and Sadowski (2014) melatonin secretion, administration of antipsychotics on dementia patients, inadequate light and acetylcholinesterase inhibitors were identified as the major contributors The authors illustrated the importance of non-pharmacological interventions such as, moderate physical activity, bright light therapy, music therapy and aromatherapy for reversing degenerative changes in the suprachiasmatic nucleus, among people with sundowning. The administration of benzodiazepine was not recommended due to its adverse health effects. This provided evidence for supporting the fact that there is a lack of adequate management or treatment strategies.
Thus, it is quite evident from the above discussion that there is a lack of appropriate literature on the clinical phenomenon called sundowning syndrome. Although, it is prevalent among older adults, I understood that there is inadequate data that can describe the symptoms of confusion, erratic behavipur and agitation that are manifested by the individuals in care homes. This contributes to the ineffectiveness of nurses and other caregivers to provide holistic care to the elderly. Furthermore, the manifestation of confused behavior during night or late evenings create burden on the nurses. Shift changes are quite common during evenings. This often leads to stress or fatigue among nurses, which results in poor diagnosis and treatment of the patients. Thus, there is a need to increase research studies on the effectiveness of light therapy for improving sleep patterns among older adults.

References
Bedrosian, T.A. and Nelson, R.J., 2013. Sundowning syndrome in aging and dementia: research in mouse models. Experimental neurology, 243, pp.67-73.
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(73), pp.1-7.
Cipriani, G., Lucetti, C., Carlesi, C., Danti, S. and Nuti, A., 2015. Sundown syndrome and dementia. European Geriatric Medicine, 6(4), pp.375-380.
Coogan, A.N., Schutová, B., Husung, S., Furczyk, K., Baune, B.T., Kropp, P., Häßler, F. and Thome, J., 2013. The circadian system in Alzheimer’s disease: disturbances, mechanisms, and opportunities. Biological psychiatry, 74(5), pp.333-339.
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.
Halek, M. and Bartholomeyczik, S., 2012. Description of the behaviour of wandering in people with dementia living in nursing homes–a review of the literature. Scandinavian journal of caring sciences, 26(2), pp.404-413.
Jonghe, A., Munster, B.C. and Rooij, S.E., 2014. Effectiveness of melatonin for sundown syndrome and delirium. Journal of the American Geriatrics Society, 62(2), pp.412-412.
Richardson, T.J., Lee, S.J., Berg-Weger, M. and Grossberg, G.T., 2013. Caregiver health: health of caregivers of Alzheimer’s and other dementia patients. Current psychiatry reports, 15(7), p.367.
Roth, H.L., 2012. Dementia and sleep. Neurologic clinics, 30(4), pp.1213-1248.
Stadlober, L., Sharp, R.A. and Mudford, O.C., 2016. A preliminary behavior analytic approach to “Sundowning” among older adults with major neurocognitive disorder. European Journal of Behavior Analysis, 17(2), pp.200-213.
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.

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