Objective: The objectives of this study were to determine the amount and frequency of agitated behaviour of demented persons at specific times of the day to find out if there is any evidence for "Sundowning"- a term used to describe increased agitation during afternoon and evening.
Design: Prospective controlled open study
Materials and Methods: The study sample comprised 54 demented persons-according to the ICD-10-classification- and 33 residents of a nursing home without dementia. Dementia staging was done by means of the Mini-Mental State Examination (MMSE). Nursing staff was interviewed daily to rate the frequency and severity of agitated behavior during three periods of the day: morning (7 a.m.- 2 p.m.), afternoon/evening (2 p.m.- 9 p.m.), and night (9 p.m.- 7 a.m.) using the Cohen-Mansfield Agitation Inventory (CMAI). We then compared the CMAI-scores of patients with mild, moderate and severe dementia and those of all demented persons at the three different periods of the day. Afterwards we subtracted morning CMAI-scores from afternoon CMAI-scores to divide the demented persons into three subgroups : Those with a difference >1,00= "Sundowners," those with a difference < -1,00 = "Sunrisers," and those without remarkably different CMAI-scores (difference between -0,99 and 0,99) = "Constants".
Results: Demented persons showed higher CMAI-scores than persons without dementia. The scores increased in relation to the severity of dementia. Looking at all CMAI-scores of demented persons we found a reduced score in the night period but there were no significant differences between morning and afternoon/evening. On the other hand, it was possible to subgroup the demented persons by the difference of the CMAI-score in the morning vs. afternoon : "Sundowners" : n = 17 (31%); M 4,18; SD 3,10; Min 1,00; Max 12,29. "Sunrisers" : n = 23 (43%); M -4,98; SD 3,85; Min -16,86; Max -1,43. "Constants" : n = 14 (26%); M -0,05; SD 0,55; Min -0,86; Max 0,86.
Conclusion: Using the CMAI there was some evidence for an increased level of agitation during afternoon/evening only for a subgroup of demented persons. We therefore conclude that "Sundowning" is no general phenomenon of demented persons. "Sunrising" has not yet been described as a non-cognitive dementia symptom. Its relatively high percentage in our sample is surprising and needs further investigation. Our hypothesis is, that "Sunrising" is an expression of the "Morgentief" (circadian maximum of depressive symptoms in the morning) in agitated "depression in dementia". This hypothesis takes into account the frequent comorbidity of dementia and depression with agitation in old age.
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