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From: B. Harris)
Subject: Re: "Sundowning"
Date: 14 Mar 1999 07:52:34 GMT

In <7cfnc2$s4t$> Emma Chase VanCott
<> writes:

>Polar <> wrote:
>>In an article on pharmacological treatment of agitation in dementia,
>>this term appeared as one of the behavioral disturbances.
>>What does "sundowning" mean in this context?
>In the evening, demented folks can become more agitated. With most
>dementias, early in the day is good for them, and then it goes downhill
>from there. A recommended sedative for the demented elderly is Benadryl.
>(see Kaplan & Sadock's psychiatry text for more info.)

   Any textbook that recommends a drug with anticholinergic properties
like Benedryl as a sedative for the demented elderly, should probably
be tossed in the garbage.  Sheesh.  This must be one of those psych
tests that suggests a little amitriptyline for the same purpose.  That
kind of thing just generates more business for geriatricians.

                                         Steve Harris, M.D.

From: B. Harris)
Subject: Re: "Sundowning"
Date: 14 Mar 1999 09:53:57 GMT

In <> (Polar)

>	In an article on pharmacological treatment of agitation in
>dementia, this term appeared as one of the behavioral disturbances.
>	What does "sundowning" mean in this context?

   A good question.  What it means usually is that somebody is being
lazy.  For this diagnosis must be one of exclusion if it is to be used
at all.

   "Sundowning" is a term which was all the rage ten years ago, and
continues to be highly regarded as a "diagnosis."  The idea is that
elderly persons who are mildly demented, and even some ill ones who are
not, are frequently supposed to get newly demented, or more demented,
at night when the lights are turned off, and stimulus drops.

   IHMO as a gerontologist, it's a wildly overrated term, and I wish to
God it had never been invented, even though there is a smidgeon of
truth to it as an average effect in people who are demented already.
It is true that demented people in hospitals often do not go to sleep
when they "should" at night, and when the lights go off they (being
disoriented in time and space) sometimes get more anxious (rather like
small children in strange places), and cause a lot of problems for
nighttime staff.  Night staff in hospitals have larger patient loads
because less is being done on the wards, and staffing reflects this.
But it's also true that due to staffing, the various problems of
dementia, which haven't changed, simply get noticed more at night.
This gets labeled as "extra" cognitive problems.  An expectation
therefore grows that elderly people who were thinking fine during the
day, should regularly, and suddenly (and even normally) go off their
rockers at night, for no particular reason.  It's a lot like the myth
that babies are born more at night than during the day (also not true--
for natural deliveries in humans there's no time preference at all).
But babies born at night do cause more tiredness, and they get noticed.

    The damage that a concept like "sundowning" does is this: it lets
staff blame any new delerium which occurs in an elderly patient, on the
fact that that the sun has gone down, and thus is something you don't
have to worry about much.  This piece of astrology, relating events on
Earth to celestial mechanics, is a lot easier than the tests of modern
technological medicine--- incredibly complicated things like checking
vital signs, drawing a WBC differential, and doing finger oxymetry and
a dip urinalysis.

   I can tell you lots of stories about "sun downers" who were headed
toward being "morning goners" from my experience as a geriatrician, but
probably the most personal involves my own father.  He fell afoul of
this sundowner idea a few years ago, while in the ICU on a ventilator,
recovering after multiple tramas sustained in a light airplane crash.
After three days of being completely lucid, using an alphabet board to
ask the nurses and doctors complicated and insightful questions about
his treatment, suddenly one evening he began to spell out nonsense.
His doctors began to write things in the chart like "sundowning" and
"post operative fever." (He'd had some orthopedic surgery).

   Now, my father at the time was a working college English professor,
and the plane he'd gone down in was piloted by himself-- had in fact
been *built* by him a couple of years before.  He was not then, and is
not now, demented.  Or even slightly demented.  Was, in fact, a
multi-talented man who had sufferered no great head trauma, and who had
nice clear CT and MRI scans.  His son, the gerontologist, therefore
raised holy hell, and said irreverently that sundowning was NOT the
problem and that both this and "post operative fever" were terms used
too often by people who didn't want to be bothered.  The patient's
wife, who happened to be a retired nurse, wanted to know why her
husband was having new right upper quadrant abdominal tenderness...?
The infectious disease specialist, which the patient's pain-in-the-ass
son yanked into the case in order to find the infection, with these
clues quickly began to suspect all was not right. :-?.  After a day of
the appropriate antibiotic, my father's grossly infected and nearly
necrotic gallbladder was removed.  Following which his fevers
mysteriously went away, his mental status mysteriously recovered, and
he was extubated.  He made it out of the ICU and is mentally fine to
this day, spending his retirement writing articles on his new computer,
and doing gunsmithing on the side.  Instead of pushing up daisies.

  Some patients without somebody to watch over them, however, don't get
that lucky.  One problem with HMOs is that the old fashioned "team"
approach to medicine, long decried as bill padding, is being
dismantled.  Thus, if your one doctor doesn't "get" it, for some
reason, there's nobody else to insist that something isn't quite right,
and that some consultation is needed.  And if your nursing staff is
overworked, nobody might notice that there's something REALLY wrong
until it's way too late to fix it.

                                  Steve Harris, M.D.

From: B. Harris)
Subject: Re: "Sundowning"
Date: 15 Mar 1999 05:10:10 GMT

In <7chrnn$> Frank
LeFever) writes:

>I am especially sensitized to relevance of infections (e.g. urinary
>tract) as basis for sudden unexplained "dementia" not only because of
>my experience with this phenomenon in elderly patients in the (rehab)
>hospital in which I work, but also because of my interest (over the
>past several years) in neuroimmune processes. I am expecially impressed
>by the adverse cognitive impact of IL-1 (elicited in abundance during
>infection) and the potential for dissociation of its cognitive effects
>from its pyrogenic effects.

   You bet.  Even young people get out out of their heads with the flu,
and it's not just meningitis, and it happens even when fever is
control.  Some bad neuro-active stuff is being made, and IL-1, IL-2,
TNF, IL-10, and (who knows?) nitric oxide from bNOS and bradykinins in
the brain may all mediate some of it.  In immune inflammatory cascade,
things go off everywhere, many bad humours are made, and the blood
brain barrier is not, apparently, everywhere impermiable.

   And there's something special about sympathetic drive in the
demented elderly.  I'd seen a guy in significant delerium from
tachycardia due a drug reaction.  No fever, no infection, no hypoxia.
Good blood pressure.  Resolved with Clariten.  I sometimes wonder if
fever (mediated by IL-1 and other macrophage gunk) doesn't trigger some
sypathetic systems which themselves have direct effects.  In this case,
the treatment may well be a brain active beta blocker, or methyldopa.
But these drugs are often avoided in the elderly because of reported
mentation problems, and because it seems too much like treating
symptoms.  But we do sort of the same thing with the dopaminergic
system when we give the agitated elderly neuroleptics.  Perhaps we're
on to something.  Balance between parasympathetic and sympathetic tone
in the brain in dementia certainly seems to be disrupted, and perhaps
there are other ways of restoring it in delerium that we haven't
thought of besides withholding anticholinergics and treating the
underlying causes of sympathetic activiation (which is what we do now).

   And yes, in geriatrics, the dip urinalysis (particularly in elderly
women) is the fifth vital sign.  Next comes pulse oxymetry.

                                         Steve Harris, M.D.

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