Sundowners Syndrome

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What is Sundowners Syndrome?
Sundowners syndrome, also known as sundowning, is a type of mood or sleep disorder often associated with the early stages of dementia and Alzheimer's. Patients experience periods of extreme agitation and confusion during the late afternoon or early evening hours, often leading to irritability towards caregivers or hospital staff. While the causes of sundowners are unknown, patients and caregivers can take some useful steps to help reduce the symptoms of the condition.

Causes

The exact cause of sundowners syndrome remains a mystery. While the episodes are most commonly found in dementia patients, the symptoms can also appear in those suffering from other conditions, such as degenerating eye conditions. Some medical experts believe the condition may occur because of changes in lighting conditions or sleep disturbances; that the episodes tend to come on around sundown may suggest a link with the body's natural day and night cycles. Some research also raises the possibility of more organic causes such as drug interactions or stress associated with diminishing cognitive function.

Symptoms

The symptoms of this condition may vary from patient to patient. Some people may become extremely restless and refuse to sit or lie down. Disorientation, language problems, and even hallucinating occurs in some patients. Sundowning patients may experience increased fear or anxiety, feel jumpy or unreasonably afraid. In some cases, anger and panic causes patients to verbally or even physically abuse caregivers or visitors.
Triggers

Some episodes of sundowning are triggered by a specific event or issue. Some patients start growing agitated if they are hungry, for instance, while others may experience distress as the sun goes down, as the changing light creates shadows and makes the environment look different. In nursing homes, a staff change or disruption in the daily routine might also trigger this condition. Identifying triggers and helping patients manage them is a common form of treatment for the condition.

Treatment

Treatment for sundowners syndrome is generally limited to managing the underlying condition which triggers it, such as Alzheimer's disease. Anti-depressants may lessen the severity of the confusion, while other drugs may improve cognitive function. Melatonin, a hormone that increases sleepiness, is sometimes prescribed to reduce agitation in the evenings. Since sundowners syndrome is also closely associated with sleep disorders and fatigue, sedatives and other sleeping aids may also help. Some caregivers suggest encouraging the patient to take several naps throughout the day and limiting stimulating activities to the morning hours.

Making positive environmental and lifestyle changes is another method of reducing episodes. Limiting caffeine after the morning may prevent feelings of agitation or jitters in the late afternoon. Engaging in outdoor activities in the morning and early afternoon can sometimes help patients feel more tired and less agitated in the evenings. Ensuring a consistent daily routine often helps patients feel more safe and secure in their environment, and may reduce instances of panic or distress associated with sundowning. Providing a snack in the afternoon may also help reduce hunger-related triggers in the evening.

Light is often a big part of treatment for this syndrome. Patients in hospitals and care facilities may not be exposed to very much sunlight during the day, which could upset the body's natural day and night rhythms and lead to sundowning. In addition to making sure that patients get some sunlight during the day, providing extra light in the evening can also help. Since the symptoms can be triggered by the changing light levels at twilight, ensuring that interior lights are turned on or increased before dusk may prevent the shifting light from triggering an episode.

Related Conditions

There are other conditions which closely resemble sundowners syndrome, especially in unfamiliar hospital settings. Some elderly patients may become confused or irritable as a result of the anesthetics used during their surgeries. Others who spend time in the ICU or are connected to noisy medical equipment may experience a condition called hospital psychosis, which may also be especially noticeable during evening hours. One of the major differences between hospital psychosis and sundowning is that psychosis can affect any age group, while sundowners syndrome is generally limited to the elderly population.

Vascular Dementia

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Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain.

You can develop vascular dementia after a stroke blocks an artery in your brain, but strokes don't always cause vascular dementia. Whether a stroke affects your thinking and reasoning depends on your stroke's severity and location. Vascular dementia also can result from other conditions that damage blood vessels and reduce circulation, depriving your brain of vital oxygen and nutrients.

Factors that increase your risk of heart disease and stroke — including high blood pressure, high cholesterol and smoking — also raise your vascular dementia risk. Controlling these factors can help lower your chances of developing vascular dementia.

Vascular dementia symptoms vary, depending on the part of your brain where blood flow is impaired. Symptoms often overlap with those of other types of dementia, especially Alzheimer's disease. Vascular dementia symptoms may be most clear-cut when they occur suddenly following a stroke. When changes in your thinking and reasoning seem clearly linked to a stroke, this condition is sometimes called "post-stroke dementia."

Another characteristic pattern of vascular dementia symptoms sometimes follows a series of strokes or mini strokes. In this pattern, changes in your thought processes occur in noticeable "steps" downward from your previous level of function, unlike the gradual, steady decline that typically occurs in Alzheimer's disease.

But vascular dementia can also develop very gradually, just like Alzheimer's disease. What's more, vascular dementia and Alzheimer's often occur together. Studies show that people with dementia symptoms usually have brain changes typical of more than one type. Some doctors call this condition "mixed dementia."

Vascular dementia symptoms include:

Confusion
Trouble paying attention and concentrating
Reduced ability to organize thoughts or actions
Decline in ability to analyze a situation, develop an effective plan, and communicate plan to others
Difficulty deciding what to do next
Problems with memory
Restlessness and agitation
Unsteady gait
Sudden or frequent urge to urinate, or inability to control passing urine
Wandering at night
Depression

Vascular dementia results from conditions that damage your brain's blood vessels, reducing their ability to supply your brain with the large amounts of nutrition and oxygen it needs to perform thought processes effectively.

Common conditions that may lead to vascular dementia include:

Stroke (infarction) blocking a brain artery. Strokes that block a brain artery usually cause a range of symptoms that may include vascular dementia. But some strokes don't cause any noticeable symptoms. These "silent brain infarctions" still increase dementia risk. With both silent and apparent strokes, the risk of vascular dementia increases with the number of infarctions that occur over time. One type of vascular dementia involving many strokes is called multi-infarct dementia.

Narrowed or chronically damaged brain blood vessels. Conditions that narrow or inflict long-term damage on your brain blood vessels can also lead to vascular dementia. These conditions include the wear and tear associated with aging; high blood pressure; hardening of the arteries; diabetes; lupus erythematosus; brain hemorrhage; and temporal arteritis.

Frontotemporal Dementia

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Frontotemporal dementia (frontotemporal lobar degeneration) is an umbrella term for a diverse group of uncommon disorders that primarily affect the frontal and temporal lobes of the brain — the areas generally associated with personality, behavior and language.

In frontotemporal dementia, portions of these lobes atrophy or shrink. Signs and symptoms vary, depending upon the portion of the brain affected. Some people with frontotemporal dementia undergo dramatic changes in their personality and become socially inappropriate, impulsive or emotionally indifferent, while others lose the ability to use and understand language.

Frontotemporal dementia is often misdiagnosed as a psychiatric problem or as Alzheimer's disease. But frontotemporal dementia tends to occur at a younger age than does Alzheimer's disease, typically between the ages of 40 and 70.

Frontotemporal Dementia Symptoms

Identifying precisely which diseases fall into the category of frontotemporal dementia presents a particular challenge to scientists. The signs and symptoms may vary greatly from one individual to the next. Researchers have identified several clusters of symptoms that tend to occur together and are dominant in subgroups of people with the disorder. More than one symptom cluster may be apparent in the same person. The signs and symptoms of frontotemporal dementia progressively worsen with time, almost always over years, eventually requiring 24-hour care.

Behavioral changes
The most common signs and symptoms of frontotemporal dementia involve extreme changes in behavior and personality. These include:

Increasingly inappropriate actions
Loss of empathy and other interpersonal skills
Lack of judgment and inhibition
Apathy
Repetitive compulsive behavior
A decline in personal hygiene
Changes in eating habits, predominantly overeating
Lack of awareness of thinking or behavioral changes
Speech and language problems
Some subtypes of frontotemporal dementia are marked by the impairment or loss of speech and language difficulties. For example, primary progressive aphasia is characterized by an increasing difficulty in using and understanding written and spoken language. People with another subtype, semantic dementia, utter grammatically correct speech that has no relevance to the conversation at hand or may have difficulty recalling the words for common objects.

Movement disorders
Rarer subtypes of frontotemporal dementia are characterized by problems with movement, similar to those associated with Parkinson's disease or amyotrophic lateral sclerosis (ALS), which is also often called Lou Gehrig's disease.

Movement-related signs and symptoms may include:

Tremor
Rigidity
Muscle spasms
Poor coordination
Difficulty swallowing
Muscle weakness

Frontotemporal Dementia Causes

A variety of mutations on several different genes have been linked to specific subtypes of frontotemporal dementia. But more than half the people who develop frontotemporal dementia have no family history of dementia.

In some cases of frontotemporal dementia, the affected parts of the brain contain microscopic Pick bodies — abnormal protein-filled structures that develop within brain cells. Frontotemporal dementia was once known as Pick's disease, but now that terminology is reserved for the subtype that actually features these abnormal structures.

Lewy Body Dementia

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Lewy Body Dementia is not a rare disease. It affects an estimated 1.3 million individuals and their families in the United States. Because LBD symptoms can closely resemble other more commonly known diseases like Alzheimer’s and Parkinson’s, it is currently widely underdiagnosed. Many doctors or other medical professionals still are not familiar with LBD.

LBD is an umbrella term for two related diagnoses. LBD refers to both Parkinson’s disease dementia and dementia with Lewy bodies. The earliest symptoms of these two diseases differ, but reflect the same underlying biological changes in the brain. Over time, people with both diagnoses will develop very similar cognitive, physical, sleep, and behavioral symptoms.

While it may take more than a year or two for enough symptoms to develop for a doctor to diagnose LBD, it is critical to pursue a formal diagnosis. Early diagnosis allows for important early treatment that may extend quality of life and independence.

LBD is a multisystem disease and typically requires a comprehensive treatment approach. This approach involves a team of physicians from different specialties who collaborate to provide optimum treatment of each symptom without worsening other LBD symptoms. Many people with LBD enjoy significant improvement of their symptoms with a comprehensive approach to treatment, and some can have remarkably little change from year to year.

Some people with LBD are extremely sensitive or may react negatively to certain medications used to treat Alzheimer’s or Parkinson’s in addition to certain over-the-counter medications.

Who was Lewy?

In the early 1900s, while researching Parkinson's disease, the scientist Friederich H. Lewy discovered abnormal protein deposits that disrupt the brain's normal functioning. These Lewy body proteins are found in an area of the brain stem where they deplete the neurotransmitter dopamine, causing Parkinsonian symptoms. In Lewy body dementia, these abnormal proteins are diffuse throughout other areas of the brain, including the cerebral cortex. The brain chemical acetylcholine is depleted, causing disruption of perception, thinking and behavior. Lewy body dementia exists either in pure form, or in conjunction with other brain changes, including those typically seen in Alzheimer's disease and Parkinson's disease.

Alzheimers Education and Care

Caregiving Tips: Strategies for Success

Alzheimers Education and Care. Read books, attend workshops and consult with healthcare professionals. Subscribe to AFA’s free caregiver magazine, care ADvantage. Avoid caregiver burnout. Make time for yourself. Join caregiver support groups and discussion boards. Pursue interests beyond your caregiving role, such as exercise, hobbies, journaling and art. Visit www.carecrossroads.org to see mini-documentaries featuring family caregivers and to read caregivers’ creative contributions.

Learn caregiving techniques. Key areas are communication skills, safety concerns, and managing behavioral challenges and activities of daily living.

Understand the experience of your loved one. Adjust your expectations. Be patient and kind.

Avoid caregiver burnout. Make time for yourself. Join caregiver support groups. Pursue interests beyond your caregiving role, such as exercise, hobbies, journaling and art.

Maintain your own physical and mental health. Exercise, respite and other activities can reduce stress. Seek medical help if there are signs of depression.

Discuss the situation with family and friends. Support systems are critical.

Do cognitive stimulation activities with your loved one. Listening to music, word puzzles and memory games can easily be done at home.

Foster communication with physicians. Be involved in your loved one's medical care. Ask questions about the progression of the disease, express concerns and discuss treatment options.

Take care of financial, legal and long-term care planning issues. Try to involve your loved one in decision-making, if they are still capable of providing input, and consider their wishes related to future care and end-of-life issues.

Smile. Kindness, humor and creativity are essential parts of caregiving. Hugs, hand massage and other gentle physical contact will help your loved one feel connected and loved.

Think positive. Focus on your loved one's remaining strengths and enjoy your relationship while you are still able to.

Reach out for care. Call the Alzheimer's Foundation of America—866.AFA.8484, for counseling, information and referrals to local resources nationwide.

Alzheimers Stages

Alzheimer's stages vary. The stages below provide a general idea of how abilities change during the course of the disease.

Stage 1: No impairment
Stage 2: Very mild decline
Stage 3: Mild decline
Stage 4: Moderate decline
Stage 5: Moderately severe decline
Stage 6: Severe decline
Stage 7: Very severe decline

Not everyone will experience the same symptoms or progress at the same rate. This seven-stage framework is based on a system developed by Barry Reisberg, M.D., clinical director of the New York University School of Medicine's Silberstein Aging and Dementia Research Center.

Stage 1: No impairment (normal function)
The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia.

Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease)
The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers.

Stage 3: Mild cognitive decline (early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms)
Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Common stage 3 difficulties include:

Noticeable problems coming up with the right word or name
Trouble remembering names when introduced to new people
Having noticeably greater difficulty performing tasks in social or work settings Forgetting material that one has just read
Losing or misplacing a valuable object
Increasing trouble with planning or organizing

Stage 4: Moderate cognitive decline (Mild or early-stage Alzheimer's disease)
At this point, a careful medical interview should be able to detect clear-cut symptoms in several areas:
Forgetfulness of recent events
Impaired ability to perform challenging mental arithmetic — for example, counting backward from 100 by 7s
Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances
Forgetfulness about one's own personal history
Becoming moody or withdrawn, especially in socially or mentally challenging situations

Help is available
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Stage 5: Moderately severe cognitive decline (Moderate or mid-stage Alzheimer's disease)
Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimer's may:
Be unable to recall their own address or telephone number or the high school or college from which they graduated
Become confused about where they are or what day it is
Have trouble with less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s
Need help choosing proper clothing for the season or the occasion
Still remember significant details about themselves and their family
Still require no assistance with eating or using the toilet.

Stage 6: Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease)
Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may:
Lose awareness of recent experiences as well as of their surroundings
Remember their own name but have difficulty with their personal history

Remember:
It is difficult to place a person with Alzheimer's in a specific stage as stages may overlap.


Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver
Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet
Experience major changes in sleep patterns — sleeping during the day and becoming restless at night
Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly)
Have increasingly frequent trouble controlling their bladder or bowels
Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding
Tend to wander or become lost

Stage 7: Very severe cognitive decline (Severe or late-stage Alzheimer's disease)
In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases.
At this stage, individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing impaired.

Dementia Symptoms

Dementia Symptoms is a term that describes a collection of symptoms that include decreased intellectual functioning that interferes with normal life functions and is usually used to describe people who have two or more major life functions impaired or lost such as memory, language, perception, judgment or reasoning; they may lose emotional and behavioral control, develop personality changes and have problem solving abilities reduced or lost.

There are different classification schemes for dementias roughly based (and with overlap) on observed problems; some frequently used are cortical (memory, language, thinking, social) , subcortical (emotions, movement, memory), progressive (cognitive abilities worsen over time), primary (results from a specific disease such as Alzheimer's disease and secondary (occurs because of disease or injury).

Alzheimer's disease (AD): is the most common cause of dementia in people over age 65 with cause possibly related to amyloid plaques and neurofibrillary tangles; almost all brain functions, including memory, movement, language, judgment, behavior, and abstract thinking, are eventually affected.

Vascular dementia: is the second most common cause of dementia caused by brain damage from cerebrovascular or cardiovascular problems (strokes) or other problems that inhibit vascular function; symptoms similar to AD but personality and emotions effected only late in the disease.
Lewy body dementia: is common and progressive where cells in the brain's cortex die and other contain abnormal structures (Lewy bodies); symptoms overlap with Alzheimer's disease but also include hallucinations, shuffling gait, and flexed posture with symptoms that may vary daily.

Frontotemporal dementia: is dementia linked to degeneration of nerve cells in the frontal and temporal brain lobes and some evidence for a genetic factor (many have a family history of the disease); symptoms in patients (usually ages 40 – 65) have judgment and social behavior problems such as stealing, neglecting responsibilities, increased appetite, compulsive behavior and eventual motor skill problems and memory loss.
HIV-associated dementia: is due to infection of the brain with HIV virus; symptoms include impaired memory, apathy, social withdrawal, and concentration problems.

Huntington's disease: is a heredity disorder caused by a faulty gene and children of a person with the disorder have a 50% chance of getting the disease; symptoms begin in 30-40 year old people with personality changes such as anxiety, depression and progress to show psychotic behavior severe dementia and chorea - involuntary jerky, arrhythmic movements of the body.
Dementia pugilistica: is also termed Boxer's syndrome, is due to traumatic injury (often repeatedly) to the brain; symptoms commonly are dementia and parkinsonism (tremors, gait abnormalities) and other changes depending where brain injury has happened.

Corticobasal degeneration: is a progressive nerve cell loss in multiple areas of the brain; symptoms begin at about age 60 on one side of the body and include poor coordination and rigidity with associated visual-spatial problems that can progress to memory loss, hesitant speech and dysphagia (difficulty swallowing).

Creutzfeldt-Jakob disease: is a rare disease that seems related to a gene mutation that causes rapid (death about one year after symptoms begin to develop) degenerative and fatal brain disease in people usually over 60 years old; personality changes and reduced coordination develop, rapidly followed by impaired judgment and vision and many patients develop a coma before they die.

Other rare hereditary dementias: – Most of these diseases develop in people between 50 – 60 years old and most have variable symptoms of poor reflexes, dementia, hallucinations, paralysis and most develop coma before death; some of the names of these diseases are Gerstmann-Straussler-Scheinker disease, familial British dementia, familial Danish dementia and fatal familial insomnia.

Secondary dementias: These dementias occur in patients with other disorders of movement such as Parkinson's disease or multiple sclerosis and may because by one or more problems listed above; these dementias may share symptoms with any of the above mentioned dementias but researchers are unsure if this is due to disease overlap or other causes.
Dementias in children: While infections, trauma and poisoning can lead to dementia in both children and adults, there are some dementias that are unique to children but may result in mental problems, seizures, reduction or loss of motor skills, blindness, neurodegeneration and death; many are inherited disorders such as Niemann-Pick disease, Batten disease, Lafora disease and mitochondrial abnormalities.

Other conditions that may cause dementia: Reactions to medications, endocrine and metabolic problems, nutritional deficiencies, infections, subdural hematomas, poisoning, brain tumors, anoxia (lack of oxygen), heart and lung problems.
What conditions are not dementia: Although these conditions may resemble some aspects of dementia, they have different causes, usually are treatable and have better outcomes; examples are depression, delirium, mild cognitive impairment and age-related cognitive decline.

Dementia causes: All causes of dementia result from death and damage of nerve cells in the brain; genetics and possibly the formation of different types of inclusions in the brain cells are likely the major causes, although some researchers suggest that certain inclusions may be only side effects of an underlying disorder.
Risk factors for dementia include advancing age, genetics (family history), smoking, alcohol use, atherosclerosis, high cholesterol, diabetes, high plasma homocysteine levels, mild cognitive impairment, Down syndrome

Dementia is diagnosed by using many methods such as patient's medical and family history, physical exam, neurological evaluations, cognitive and neuropsychological testing, CT's, MRI's and other brain scans, mental status exams, electroencephalograms, blood tests, psychiatric evaluations, and even some pre-symptomatic tests are available for some patients that may have a genetic link to dementia.

Most treatments for dementia will neither reverse or stop the disease; however, there are treatments and medications that may reduce the symptoms and slow the disease progression; they are tight glucose control by persons with diabetes, intellectual stimulating activities, lowering cholesterol and homocysteine levels, regular exercise.