'Sundowning': deteriorating behavior tied to cognitive decline
Transcript
[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Some people with dementia become confused or anxious in the late afternoon and into the evening as the sun goes down. The term that describes what they experience is sundowning. I'm talking about that with Dr. Antonio Culebras. He's a professor of neurology at Upstate and the dean of sleep medicine in Central New York, as he started the first sleep center in Syracuse in the 1970s. Welcome back to "The Informed Patient," Dr. Culebras.
[00:00:40] Antonio Culebras, MD: Thank you.
[00:00:42] Host Amber Smith: I've heard the term sundowning, but I didn't realize it's a sleep disorder. What are the typical symptoms?
[00:00:49] Antonio Culebras, MD: It is a behavioral deterioration in the evening hours. So it is not typically a sleep disorder, but a deterioration of behavior that typically occurs in persons who are demented, persons who have been institutionalized. Or it can also occur at home in the early times when the patient starts to have cognitive problems. It generally occurs in the early evening, and it's very disrupting because the person gets out of bed and starts wandering around the house, opening and closing doors and closets and refrigerators and so on. And it's very disrupting for the caregivers.
[00:01:35] Host Amber Smith: Is it just because of the change in the light versus dark? Is that what sort of prompts this?
[00:01:41] Antonio Culebras, MD: We don't know exactly what the problem is in this type of behavioral deterioration, but we do know that the circadian regulation has something to do with it. The circadian rhythm which is controlled by the biological clock in our brains, has to do with the times that we go to bed and the times that we get up and the times that we fall asleep and so on. So when this circadian regulation is impaired, the chances of developing sundowning increase. And that's when individuals who should be asleep, get up and start wandering around the house.
Perhaps some of them are more confused than others. Perhaps some will even show agitation. But that's mostly in institutions, where these people are living. But, the reason why the person who is demented has more of a tendency to develop this problem in institutions is because their rhythm, the sleep wake rhythm, and the rhythm of meals and the rhythm of noises and the rhythm of persons that they see changes drastically from what they have at home. And that seems to increase the chances of developing sundowning.
[00:03:02] Host Amber Smith: So this nocturnal wandering, is it the same as we, we've heard of sleepwalking. Are they the same?
[00:03:10] Antonio Culebras, MD: No, they are not. Sleepwalking is what we call a parasomnia. The person is asleep, but the brain centers that control walking are not asleep. They're still active. So the person can move about, but the person is asleep. It's very common in children, and it usually disappears, by the age of 15 or 20. It can occur in adults. But sleepwalking does not appear in persons who are demented. It can appear just by itself, sometimes associated with other sleep problems. Sometimes it is induced by medications. But these are two different situations, because the person who is sundowning is not asleep. The person who is sundowning is confused.
[00:04:05] Host Amber Smith: Does the person who is sundowning, do they know or do they sense that something is wrong, or off?
[00:04:12] Antonio Culebras, MD: Most likely not because of their confusion. And it's a change in the lifestyle that induces this sundowning. They are not totally aware of the fact that they are disrupting as a result of getting out of bed and moving about, looking for something that they never find, or not even knowing what they're looking for.
[00:04:42] Host Amber Smith: Is sundowning uniquely seen in people with dementia or Alzheimer's, or do you ever see it in people who don't have those diagnoses?
[00:04:51] Antonio Culebras, MD: It's mostly seen in people who have Alzheimer's. It can also be seen in other neurodegenerative disorders that affect sleep, or for instance, in Parkinson's disease, and in persons who have that condition that we call the Lewy Body Disease. These are also individuals who are on the verge of developing cognitive problems. So it is mostly associated with a cognitive decline.
[00:05:21] Host Amber Smith: Does it get progressively worse?
[00:05:25] Antonio Culebras, MD: It could get progressively worse if the patient, in addition to sundowning, develops a delirium agitation and becomes extremely aggressive or disruptive in the course of these events.
[00:05:41] Host Amber Smith: Do you think that primary care doctors treat this adequately, or is this a condition where a sleep specialist should really be consulted?
[00:05:50] Antonio Culebras, MD: A sleep specialist should be consulted if a true sleep problem is suspected. But, generally, improving the quality and the continuity of sleep, and improving the regularity of the sleep-wake schedule, for instance, preventing naps during the day that could steal sleep from the night and cause the person to wake up in the middle of the night, by adding meals on a regular basis at the same time every day. And by exposing the patient to sunlight or daylight during daytime hours and perhaps leaving a little light in the room during the night, just in case they get up and see what they are doing.
These are management events that can be implemented by anyone. The primary care physician who understands the condition could instruct the patients and the caregivers to be more regular with their sleep-wake schedule.
[00:07:03] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with neurologist Dr. Antonio Culebras. He specializes in sleep medicine, and he's one of the co-founders of World Sleep Day. So how did you get involved in studying sundowning?
[00:07:21] Antonio Culebras, MD: It was mostly in the (hospital) stroke unit where we saw patients who were sundowning, not necessarily in the sleep center.
In the stroke unit, as you can imagine, we were getting patients with the initial stages of dementia, and it was not unusual to see sundowning in some of patients with early vascular dementia. The nurses obviously were quite aware of the problem, and they were able to manage the situation.
The sundowning of course was accelerated by the fact that the patients who were probably at home were suddenly finding themselves in a unit with all kinds of paraphernalia and people coming and going and shades down and no daylight. So all these are activators of the sundowning event. We used to see them regularly in the stroke unit. Of course, it was also seen in the general neurology unit, when persons with cognitive problems were admitted.
[00:08:35] Host Amber Smith: Well, you talked about some things that people might try at home to kind of make this less of an agitating time. I wonder, do you ever recommend anti-anxiety medications, or do they help with this?
[00:08:48] Antonio Culebras, MD: Medications have been tried and have not been very successful. For instance, physicians have tried melatonin. It really doesn't work. And they have tried melatonin agonists, and that doesn't work either. More recently, there have been medications introduced that are called orexin antagonists, and they induce sleep during the night. They create a mini narcoleptic state during the night, and people sleep with more continuity. And that is the key, to induce continuity of sleep.
The traditional hypnotics, like barbiturates and so forth, are not recommended because if a patient gets up in the middle of the night, and in addition to the sundowning event they have difficulty walking as a result of taking the hypnotic, they could fall. And this is a risk that we don't want to take. Trazodone has also been used in some patients because it improves the continuity of sleep. But I should not be talking about medications because each person is different, and that should be the judgment of the primary care physician or of the physician who knows the patient best.
[00:10:17] Host Amber Smith: Now you were a co-founder of World Sleep Day, 16 years ago, on March 15th. Why did you think it was important to have a day dedicated to raising awareness of sleep?
[00:10:28] Antonio Culebras, MD: Because awareness of sleep was not there, and it's still very poor. We spenh, one third of our lives asleep. If this were not important, it would be the most egregious mistake caused by nature. And nature never fails. So it has to be very important to sleep. And we are increasingly more aware of all the phenomena that occur in our brains and in our body during sleep, to make sure that we are fully alert and functional the following day. So this type of awareness was very poor.
For instance, they teach us in school how to exercise and what a good diet and healthy diet is. They never teach us how to sleep. There is no class in school, in the school system, telling us how to sleep. And yet we need to know how to sleep. We need to be regular in our sleep - wake schedules, and we need to be exposed to daylight, when the daylight is there. And we need to abstain from prolonged siestas.
In fact, the World Sleep Society have created the 10 Commandments of Sleep Hygiene. And there are for adults, and there are for children. And awareness of these commandments is what we generally emphasize during World Sleep Day.
We ask our affiliated sleep centers around the world to celebrate sleep health. And they do it by presenting conferences, TV shows, publishing articles in the newspapers, and on and on and on. And the objective is to increase the awareness of sleep health.
So these 10 Commandments are available in the World Sleep Society and the World Sleep Day website.
[00:12:40] Host Amber Smith: I'd like, if you don't mind, if you could tell us what the 10 Commandments of Good Sleep are.
[00:12:45] Antonio Culebras, MD: So No. 1, fix a bedtime and an awakening time. In other words, be regular with your sleep wake schedule, including weekends. I know that teenagers are not going to like this, but be as close as you can to the regular sleep wake schedule every day of the week.
2. If you are in the habit of taking naps, do not exceed 30 minutes because if you do, you are stealing sleep from the night that's coming up. And the closer you take the nap to your bedtime, the more sleep you are going to steal from the night, which means that you're going to disrupt the continuity of sleep.
No. 3, avoid excessive alcohol ingestion at least four hours before bedtime. And do not smoke. Well, do not smoke ever.
No. 4, avoid caffeine at least six hours before bedtime. Caffeine, coffee with caffeine, tea with, and so on, chocolate, even with caffeine. Caffeine is a very potent stimulant of the brain, and it lasts from six to 10 hours in the system, in our body. So whatever caffeine you are ingesting at 12 noon, it's going to be there, of course in declining amounts, by 10 or 11 p.m. So do not drink any coffee. If you are sensitive to coffee and caffeine, do not drink any coffee past 12 noon.
No. 5, avoid heavy, spicy, sugary foods at least four hours before bedtime. A light snack is acceptable.
No. 6, exercise regularly, but not right before bed because exercise stimulates our alertness. And if you exercise one hour or two hours before going to bed, you are still activated in your brain as a result of the exercise. But I do recommend that people exercise regularly, perhaps in the morning, perhaps in the early afternoon.
No. 7, use comfortable bedding. If your bed is uncomfortable, you are not going to sleep well, of course. Everyone knows that, but not everyone takes action to improve the comfort of their bed.
No. 8, find a comfortable temperature setting for sleeping, and keep the room well ventilated. Everyone has the experience that during the summertime, in the absence of air conditioning, when it's very hot, we don't sleep well. If the environmental temperature goes above 25 degrees centigrade, (77 degrees Fahrenheit) we are not going to sleep well. So this is something that needs to be taken into consideration.
No. 9, very important -- block all distracting noises, and eliminate as much light as possible. And eliminate tablets and TV sets and telephones when you are in bed. These devices disrupt the onset of sleep. And, unfortunately, virtually everyone does it. Well, they should not do it.
And, No. 10, reserve the bed for sleep. Do not prepare your taxes when you are in bed. And there are people who will go to bed with files here and files there and start preparing their taxes. And, well, don't do that because that's going to activate your brain, and you are not going to be able to sleep well.
So those are the 10 Commandments, with some modifications for children. But, if the commandments are followed, if the sleep-wake schedule becomes regular, if you are exposed to daylight when daylight is there -- obviously, a blue sky is better than a cloudy sky, but daylight is good enough -- then you are going to be able to sleep better. And if the sleep quality during the night is good, your alertness during the day is going to be optimal.
[00:17:16] Host Amber Smith: Well, thank you for those. And before we wrap up, I do want to let listeners know that you recently were honored by the World Sleep Society for your groundbreaking work promoting the importance of sleep to good health. And the honor is that there will be an annual Antonio Culebras Award that will recognize the work of an organizer who celebrates healthy sleep from somewhere in the world. So, that's quite an honor.
[00:17:40] Antonio Culebras, MD: Yes, indeed. I was very pleased when that honor was announced.
[00:17:45] Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Culebras.
[00:17:49] Antonio Culebras, MD: My pleasure.
[00:17:51] Host Amber Smith: My guest has been Dr. Antonio Culebras. He's a neurologist at Upstate who specializes in sleep medicine. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.