Reviews for Primary Care - Fall 2007 - (Page 43) Insomnia and Neurological Disorders restricted to the nighttime hours and diurnal naps should be limited if possible to a short, 60-minute, afternoon nap. Caffeine intake should be discouraged, and meals should be served in the dining room as opposed to in bed. Bright light therapy is being looked at as a possible treatment of circadian rhythm disturbances, as noted previously, and for the treatment of agitation in the nursing home setting.19 Sundowning Syndrome Sundowning refers to agitation in dementia patients that has specific temporal exacerbation during the early evening or nocturnal hours.20,21 Sundowning syndrome describes a combination of nocturnal confusion, hyperactivity, delirium, disorganized thinking, wandering, restlessness, impaired attention, agitation, insomnia, hypersomnia, hallucinations, anger, delusions, anxiety, and illusions.18,21 Sundowning implies a predilection for the abnormal behavior to evolve or occur during the evening or night; although caregivers and nursing home staff describe the escalation of symptoms toward the late afternoon or evening, there are actually few data to support that this indeed occurs.22,23 Sundowning may very likely have several different underlying pathophysiologic mechanisms. It is suggested that rather than using “sundowning,” healthcare providers should use more descriptive terms when communicating among themselves and when approaching family members. Examples may include terms such as the patient showed “agitation and physically aggressive behavior” or “wandering and pacing.” Patients with AD have increased susceptibility to sundowning, which is a frequent cause of institutionalization. It is critical to make an early diagnosis and prescribe appropriate management.7,24 Unfortunately, sundowning is often used loosely, ambiguously describing nocturnal agitation without specifically connoting a precise pathophysiologic mechanism or diagnosis. Specific therapy for sundowning is targeted at uncovering the underlying causes. Often, the clinical history and diagnostic testing do not provide a clear answer, and therapy may take the approach of treating by trial and error. When specific pharmacologic therapy is contemplated, it is suggested to “start low and go slow.” The integration of psychosocial support including education and respite care can be very helpful. Several modalities have been suggested to ameliorate various features of the sundowning syndrome. Data evaluating the use of antipsychotic agents and benzodiazepines have demonstrated improvements in sleep or nocturnal behavior but lacked real-time behavioral observations as relevant outcomes.20 Agents such as the antipsychotics often have adverse effects, such as sedation, confusion, orthostatic hypotension, and parkinsonism, which are often clinically significant in elderly patients with dementia.20 The high-potency antipsychotics are associated with an increased risk of producing extrapyramidal side effects, whereas the low-potency agents have more sedating, anticholinergic, and orthostatic hypotensive properties.20 Clozapine is a unique antipsychotic agent in that it is specific to the dopamine D4 receptor and thus may improve the psychiatric manifestations of sundowning without causing significant extrapyramidal side effects. Melatonin, if used in physiologic doses and at appropriate times, can be helpful for those suffering from insomnia or circadian rhythm disorders.25 One study described a role for oral melatonin (2 mg) for sleep initiation and maintenance in melatonin-deficient nondemented elderly insomniacs.26 Behaviorally, the sleeppromoting effects of melatonin are also distinctly different from those of the traditional hypnotics and are not associated with alterations in sleep architecture.27 However, at high doses (over 3 mg), melatonin may cause side effects and disrupt the delicate mechanism of the circadian system, dissociating mutually dependent circadian body rhythms.25 A misleading labeling of the hormone melatonin as a food supplement and the notorious lack of quality control over melatonin preparations on the market unfortunately continue to be a serious concern, and healthcare providers should use caution when prescribing it to elderly patients with dementia.25 Parkinson’s Disease Sleep disorders are encountered in the majority of patients with idiopathic Parkinson’s disease (PD), adversely affecting their quality of life.28 Pathological daytime sleepiness and fatigue are common in patients with PD and are the most disabling features of this disease.29 As with patients with AD, sleep problems in PD patients also correlate with increased severity of disease. The frequency of sleep complaints in patients with PD is estimated to be between 60% and 90%. Approximately one third of patients with PD rate their overall nighttime problem as moderate to severe.30 Patients with PD may experience a number of sleep disorders, including insomnia, parasomnia, and daytime somnolence (including excessive daytime sleepiness and sleep attacks).1 Excessive nocturia can disturb sleep, particularly in the severe disease group, and may be related to the natural evolution of dysautonomia in PD.31 Typical sleep abnormalities include fragmented sleep with increased number of arousals and awakenings, and PD-specific motor phenomena such as nocturnal immobility, rest VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 43
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