Managing Sundown Syndrome and Dementia in Stroke Patients

Restlessness

The grandmother is 77 years old and had a stroke affecting her right side three years ago.
After recovery, she did not experience mobility issues or other complications, although her right side functions a bit slower.
She has diabetes (insulin-dependent) and hypertension, and she started dialysis in October 2014.
This year, her condition has worsened; she cannot remember events that occur from 6 PM to the next morning, and she does not have a complete recollection of the morning events either.
Another issue is that from 7:30 PM to 10 PM, she cannot stay in one place for more than five minutes and keeps moving around, even though she appears weak.
In May of this year, she visited the hospital for a consultation, where she underwent a dementia assessment that indicated a mild degree of dementia.
A full-body MRI showed increased signs of brain degeneration, particularly in areas that control neurological functions.
Since June, her condition has deteriorated further, starting around 4:30 PM.

Could this be a case of sundown syndrome combined with dementia due to the stroke? Previously, she was prescribed psychiatric medications (Fluoxetine, Olanzapine, and Risperidone 0.25 mg) for seven days, but they seemed ineffective.
Currently, she takes one Risperidone pill after dialysis to help her stay calm for her afternoon nap, but she wakes up about an hour later.
She goes to bed at 10 PM, taking one Melatonin and one Risperidone, but she almost always wakes up between 3:00 AM and 3:30 AM, claiming she hasn’t eaten.
She also gets up 2-3 times between 4:00 AM and 6:00 PM.
The family of three is at their limit.
What methods can assist in managing her situation?

Ann, 40~49 year old female. Ask Date: 2016/08/05

Dr. Su Zongwei reply Psychiatry

This is indeed dementia.
It cannot be treated solely with sleep medications; please seek treatment from a psychiatrist to improve the symptoms.

Reply Date: 2016/08/05

More Info

Managing Sundown Syndrome and dementia in stroke patients, particularly in the context of your mother-in-law's situation, requires a multifaceted approach that addresses both the cognitive and behavioral symptoms associated with dementia, as well as the specific challenges posed by her medical history, including her stroke, diabetes, hypertension, and renal issues.

Understanding Sundown Syndrome
Sundown Syndrome, or the "sundown phenomenon," is characterized by increased confusion, agitation, and restlessness that typically occurs in the late afternoon or evening. This phenomenon is particularly common in individuals with dementia and can be exacerbated by environmental factors, fatigue, and changes in routine. In your mother-in-law's case, her history of stroke and subsequent cognitive decline may contribute to the severity of her symptoms.

Potential Causes and Contributing Factors
1. Neurological Damage: The stroke she experienced may have caused damage to areas of the brain responsible for memory and behavior regulation. This could lead to difficulties in processing information and increased confusion, particularly during the evening hours when fatigue sets in.

2. Environmental Changes: Changes in lighting, noise levels, and the presence of unfamiliar faces can contribute to feelings of anxiety and confusion. As evening approaches, the decrease in natural light can also affect mood and behavior.

3. Physical Health: Her underlying conditions, such as diabetes and renal issues, can affect her overall health and cognitive function. Medications for these conditions may also have side effects that impact her mental state.

Management Strategies
1. Structured Routine: Establishing a consistent daily routine can help reduce anxiety and confusion. Regular meal times, activities, and a set bedtime can provide a sense of stability. Try to keep her engaged in activities during the day to reduce restlessness in the evening.

2. Environmental Modifications: Create a calming environment in the evening. Use soft lighting, reduce noise, and ensure that she is in a familiar and comfortable setting. Familiar objects and photographs can also provide comfort and reduce anxiety.

3. Behavioral Interventions: Redirecting her attention when she becomes restless can be effective. Engage her in simple activities such as folding laundry, looking through photo albums, or listening to music she enjoys. These activities can help keep her mind occupied and reduce agitation.

4. Medication Review: Consult with her healthcare provider regarding her current medications. It may be beneficial to review her medications for potential side effects that could exacerbate her symptoms. Adjustments to her psychiatric medications or the introduction of new medications specifically for managing agitation may be necessary.

5. Sleep Hygiene: Encourage good sleep practices. This includes maintaining a regular sleep schedule, creating a restful environment, and limiting caffeine and sugar intake in the afternoon and evening. If she is waking frequently at night, consider discussing with her doctor the possibility of adjusting her nighttime medications.

6. Support for Caregivers: Caring for someone with dementia can be overwhelming. Ensure that you and other family members have access to support, whether through respite care, support groups, or counseling. Taking care of your own mental health is crucial in providing the best care for her.

7. Professional Help: If her symptoms continue to worsen, it may be necessary to involve a geriatrician or a neurologist who specializes in dementia care. They can provide a comprehensive assessment and recommend tailored interventions.

Conclusion
Your mother-in-law's situation is complex, and managing her symptoms will require patience and a combination of strategies. By creating a structured environment, modifying her surroundings, and ensuring that her medical needs are met, you can help improve her quality of life and reduce the impact of Sundown Syndrome. Always keep communication open with her healthcare team to ensure that her care plan is effective and responsive to her changing needs.

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