cognitive decline

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‘Sundowning’: Why Hospital Staffs Dread Nightfall, And How To Help Seniors Avoid It

By Dr. David Scales

The elderly woman had been normal all day, my colleague told me, tolerating it well when a tube was placed in her bladder to measure her urine. But that evening, she was found wandering the hospital halls yelling in Italian, carrying her urine bag under her arm thinking it was her purse, traumatized that hospital staff were trying to take it away.

Another night in the hospital, a female Sri Lankan colleague saw an elderly man who was convinced she was a Nazi soldier. Reassurances and even a plea from the doctor — “How could I be a Nazi? I have brown skin!” — could not persuade him otherwise. The next day the patient was back to normal, incredulous when told about what transpired the night before.

An 80-year-old man — I’ll call him Bill — came to our emergency room after a fall. He seemed fine and his tests were negative, but his family wanted him admitted over night for observation. That evening, he began shouting out, repeatedly wanting to get up and walk to the bathroom (forgetting he had just gone). Our calming efforts only riled him up more.

This erratic nighttime behavior is called “sundowning.” Staff in hospitals and nursing homes always worry what will happen as twilight approaches. As the sun sets, many elderly patients can change drastically: They can become extremely confused, agitated, not know where they are, and even hallucinate. In other words, they exhibit signs of delirium, a confused state that can lead them to do things they otherwise wouldn’t.

Ulrich Joho/Flickr

Ulrich Joho/Flickr

Thankfully, not every elderly patient sundowns, but when one does, it can be emotionally traumatizing for everyone. To be confused or hallucinate, or to see a relative acting out in irrational ways, is frightening and destabilizing. Yet, sundowning seems to be extremely common. So, what is it? Why do people sundown? And what can you do to minimize the risk of sundowning in yourself or a close friend or relative?

Experts agree that confusion and agitation are more common in the evening and at night. But there is surprisingly little scientific consensus on what sundowning actually is.

The debate is in how much sundowning and delirium are related. Some experts think they’re the same thing, others separate but related entities.

It’s hard to study sundowning without a clear definition and diagnostic criteria. Experts can’t even be sure how often it happens. A recent review found a rate of anywhere from 2.4 percent to 66 percent. Continue reading

Delirious: Study Finds Simple, Humane Fixes For Aged, Disoriented Patients

(Xavi Talleda/Flickr)

(Xavi Talleda/Flickr)

By Alison Bruzek
Guest Contributor

The patient was an older man, living at a nursing facility. He’d originally been admitted to the hospital for surgery to treat a urinary tract infection. But now, lying in his bed at the hospital after the operation, he was convinced that two people were standing outside his room and planning to blow it up.

“We could tell this person was delirious,” says Dr. Eyal Kimchi, a neurologist at Massachusetts General Hospital

Delirium is a complicated syndrome, most common among the hospitalized elderly where it’s estimated 29 to 64 percent of patients have it. However, it’s underreported and researchers estimate as many as two-thirds of cases go undiagnosed.

While usually temporary, it leaves people feeling severely confused. Their brains switch rapidly between mental states, increasing their risk of falling and later brain problems like dementia.

Though the patient’s mind was muddled, the idea of an explosion hadn’t appeared to him out of the blue — he was at the hospital around the time of the Boston Marathon bombing. What had likely happened, says Kimchi, is the patient had begun misattributing the news reports he saw playing on the television to actual life.

And even though that patient fully recovered, some of those delirious thoughts remained. “Ultimately this person said, ‘I know I’m better, I know I was confused, but I also know they were trying to blow up the place,’ ” says Kimchi.

People with delirium can often run the gamut of states, from hyperactive and aggressive to withdrawn and nearly comatose. The causes are not well understood but it’s a combination of a person’s predisposition to delirium as well as an event that sets it off, says Kimchi. These could be “surgery, infections, other sorts of brain injuries like trauma,” he says. “It’s still very hard to predict on an individual basis.”

While there’s not a lot of research on the predictors of delirium, there are ways to prevent it, according to a study released this week in the Journal of the American Medical Association Internal Medicine.

Prevention may be as simple as reminders and attentive care, says, Dr. Tammy Hshieh, a researcher of aging and geriatrics at Brigham and Women’s Hospital and author of the JAMA study. She suggests preventative measures like reorienting patients to where they are, keeping them hydrated and healthy, and ensuring they have hearing aids or glasses or other physical assistance is an effective method to stop delirium. Continue reading

Facing The Inevitable: From Lost Keys To Dementia

I recently turned 50 and, on cue, my AARP card came in the mail and my doctor told me to schedule my first colonoscopy.

Also on cue, I’ve noticed what seems to be my own increased mental scattered-ness — misplaced keys, sluggish name recall. As a catastrophizer, I immediately link this apparent (but my doctor assures me normal) ever-so-slight decrease in cognitive sharpness to full blown Alzheimer’s and the start of a bleak, diminished future.

I am slightly comforted by two factors. First, I’m hardly alone. As Michael Kinsley eloquently reports in his recent New Yorker piece, “Have You Lost Your Mind?” we baby boomers are the first generation to have witnessed our parents cognitive decline and know in terrifying detail what’s in store for us; but at least we’re all on this sinking ship together. Second, there’s a lot of genetics behind Alzheimer’s and cognitive decline, and in that department, I’m not in bad shape. My parents kvetch, but they’re both nearly 80 and my mother, in particular, lives an incredibly active life on her own in Brooklyn: she recently learned chess, ushers off-Broadway with friends most weekends and walks and does yoga everyday.

joeduty/flickr

joeduty/flickr

Also, researchers are busily trying to tackle this problem on numerous fronts. On Sunday, for example, Harvard scientists reported what felt like a breakthrough: a new protein that in mice seems to have a rejuvenating effect on brains and muscles.

And a fairly technical study just out in Biological Psychiatry also hints at the possibility of future fixes: using something called “imaging genetics” researchers at the Lieber Institute for Brain Development and the National Institute of Mental Health are trying to identify “key molecular switches that control age-related memory impairment” and are specifically looking at a protein known to play a role in human memory, called “KIBRA and the gene responsible for its production.” Continue reading