Demans Hastalarında Gözardı Edilen Bir Konu: Gün Batımı Sendromu ve Hemşirelik Yaklaşımları

Akşamın erken saatleri veya öğleden sonra, özellikle demanslı bireylerde nöropsikiyatrik semptomlar şiddetlenmekte ve bu durum “Gün Batımı Sendromu” olarak tanımlanmaktadır. Busendrom literatürde uzun zaman önce tanımlamasına rağmen gözardı edilen bir alan olmuştur. Bununla birlikte konuyla ilgili kanıta dayalı çalışmaların eksikliği, klinik özelliklerini ve önleme stratejilerini belirlemede yetersiz kalmaktadır. Bu durum hem hastayı hem de bakım vericisini etkilemekte ve özellikle bakım veren yüküne olumsuz yönde katkı sağlamaktadır. Oryantasyon bozukluğu, konfüzyon, ajitasyon, huzursuzluk, anlamsız gezinme gibi davranışların ortaya çıktığı gün batımı sendromu daha çok deliryumla karıştırılmaktadır. Ancak deliryumun aksine, gün batımının daha uzun bir süre devam ettiği ve özellikle akşamın erken saatlerinde aynı davranışların ortaya çıktığı görülmektedir. Gün batımı sendromu belirtilerini erkenden tespit etmek, hem demanslı bireyin hem de bakım vericisinin yükünü azaltmaya yardımcı olacaktır. Bu nedenle multidisipliner bir ekip anlayışı benimsenmesi gereklidir. Bu ekipte yer alan hemşirelere önemli görevler düşmektedir. Hemşireler demanslı hasta ile karşılaştığında, klasik hemşirelik değerlendirmesine gün batımı sendromuna yönelik ipucu veren gözlemleri de eklemelidir. Böylece gün batımı sendromu da dahil birçok nöropsikiyatrik semptomun erken tanınmasına yardımcı olacaktır. Bu derlemede literatürdeki eksiklik göz önünde bulundurularak, gün batımı sendromunun klinik özellikleri, patofizyolojisi, tedavi yönetimi ve hemşirelik yaklaşımlarını sunmak, konu ile ilgili hemşirelere ve diğer sağlık profesyonellerine rehber olmak amaçlanmıştır.

Anahtar Kelimeler:

Gün batımı sendromu, demans, hemşirelik

An Ignored Subject in Dementia Patients: Sundowning Syndrome and Nursing Approaches

Neuropsychiatric symptoms are exacerbated in the early hours of the evening or in the afternoon, especially in people with dementia, which is defined as “Sundowning Syndrome”. Although this syndrome has been described in the literature a long time ago, it has been ignored. However, the lack of evidence-based studies on the subject is insufficient to determine the clinical features and prevention strategies. This affects both the patient and the caregiver and in particular contributes negatively to the caregiver burden. Sundowning syndrome, in which behavior such as disorientation, confusion, agitation, restlessness and wandering occurs, is mostly confused with delirium. Unlike delirium, however, it is seen that the sundowning continues for a longer period of time and the same behavior occurs especially in the early hours of the evening.Early detection of Sundowning syndrome symptoms will help reduce the burden of both the demented individual and the caregiver. Therefore, it is necessary to adopt a multidisciplinary team approach. Nurses in this team have important duties. When nurses meet a patient with dementia, they should include observations that give a clue to Sundowning syndrome to the classic nursing assessment. This will help in the early recognition of many neuropsychiatric symptoms, including Sundowning.In this review, it is aimed to present clinical features, pathophysiology, treatment management and nursing approaches of Sundowning syndrome and to guide nurses and other health professionals related to the subject considering the deficiency in the literature.

PDF

___

Asayama,K., Yamadera, H., Ito, T., Suzuki, H., Kudo, Y., Endo, S. (2003). Double blind study of melatonin effects on the sleep-wake rhythm, cognitive and non-cognitive functions in Alzheimer type dementia. J Nippon Med Sch, 70(4), 334‐341. doi: 10.1272/jnms.70.334
Bachman, D., Rabins, P. (2006). “Sundowning” and other temporally associated agitation states in dementia patients. Annu Rev Med, 57, 499-511. doi: 10.1146/annurev.med.57.071604.141451
Bedrosian, T.A., Nelson, R.J. (2013). Sundowning syndrome in aging and dementia: research in mouse models. Exp Neurol, 243, 67-73. doi: 10.1016/j.expneurol.2012.05.005
Blais, J., Zolezzi, M., Sadowski, C.A. (2014). Treatment options for sundowning in patients with dementia. Mental Health Clinician, 4(4), 189-195. doi: 10.9740/mhc.n204525
Burns, A., Byrn, J., Ballard, C., Holmes, C. (2002). Sensory stimulation in dementia. British Medical Journal, 325, 1312-1313. doi: 10.1136/bmj.325.7376.1312
Campbell, N., Ayub, A., Boustani, M.A., Fox, C., Farlow, M., Maidment, I., Howards, R. (2008). Impact of cholinesterase inhibitors on behavioral and psychological symptoms of Alzheimer's disease: a meta-analysis. Clinical Interventions in Aging, 3(4), 719-728. doi: 10.2147/cia.s4250
Canevelli, M., Adali, N., Voisin, T., Soto, M.E., Bruno, G., Cesari, M., Vellas, B. (2013). Behavioral and psychological subsyndromes in Alzheimer's disease using the Neuropsychiatric Inventory. International Journal of Geriatric Psychiatry, 28(8), 795-803. doi: 10.1002/gps.3904
Canevelli, M., Valletta, M., Trebbastoni, A., Sarli, G., D'Antonio, F., Tariciotti, L., de Lena, C., Bruno, G. (2016). Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches. Frontiers in Medicine, 3, 73. doi: 10.3389/fmed.2016.00073
Cardinali, D.P., Brusco, L.I., Liberczuk, C., Furio, A.M. (2002). The use of melatonin in Alzheimer's disease. Neuro Endocrinology Letters, 23 Suppl 1, 20-23. Erişim adresi: https://pubmed.ncbi.nlm.nih.gov/12019347/
Cipriani, G., Lucetti, C., Carlesi, C., Danti, S., Nuti, A. (2015). Sundown syndrome and dementia. European Geriatric Medicine, 6(4), 375-380. doi: 10.1016/j.eurger.2015.03.006
Cohen-Mansfield, J., Garfinkel, D., Lipson, S. (2000). Melatonin for treatment of sundowning in elderly persons with dementia – a preliminary study. Arch Gerontol Geriatr, 31(1), 65-76. doi: 10.1016/s0167-4943(00)00068-6
de Vugt, M.E., Stevens, F., Aalten, P., Lousberg, R., Jaspers, N., Winkens, I., Jolles, J., Verhey, F.R. (2004). Do caregiver management strategies influence patient behaviour in dementia?. International Journal of Geriatric Psychiatry, 19(1), 85-92. doi: 10.1002/gps.1044
Dewing J. (2003). Sundowning in older people with dementia: evidence base, nursing assessment and interventions. Nursing Older People, 15(8), 24-32. doi: 10.7748/nop2003.11.15.8.24.c2281
Dodel, R., Belger, M., Reed, C., Wimo, A., Jones, R.W., Happich, M., … Haro, J.M. (2015). Determinants of societal costs in Alzheimer's disease: GERAS study baseline results. Alzheimers Dement, 11(8), 933-945. doi: 10.1016/j.jalz.2015.02.005
Forbes, D., Blake, C.M., Thiessen, E.J., Peacock, S., Hawranik, P. (2014). Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia. The Cochrane Database of Systematic Reviews, (2), CD003946. doi: 10.1002/14651858.CD003946.pub4
Gehrman, P.R., Connor, D.J., Martin, J.L., Shochat, T., Corey-Bloom, J., Ancoli-Israel, S. (2009). Melatonin fails to improve sleep or agitation in double-blind randomized placebo-controlled trial of institutionalized patients with Alzheimer disease. The American Journal of Geriatric Psychiatry, 17(2), 166-169. doi: 10.1097/JGP.0b013e318187de18
Gitlin, L.N., Kales, H.C., Lyketsos, C.G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. JAMA, 308(19), 2020-2029. doi: 10.1001/jama.2012.36918
Gnanasekaran, G. (2016). “Sundowning” as a biological phenomenon: current understandings and future directions: an update. Aging Clin Exp Res, 8(3), 383-392. doi: 10.1007/s40520-015-0431-3
Haffmans, P.M., Sival, R.C., Lucius, S.A., Cats, Q., van Gelder, L. (2001). Bright light therapy and melatonin in motor restless behaviour in dementia: a placebo-controlled study. International Journal of Geriatric Psychiatry, 16(1), 106-110. doi: 10.1002/1099-1166(200101)16:1<106::aid-gps288>3.0.co;2-9
Hall, G.R., Buckwalter, K.C. (1987). Progressively lowered stress threshold; a conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing, 1(6), 399-406. Erişim adresi: https://pubmed.ncbi.nlm.nih.gov/3426250/
Harper, D.G., Volicer, L., Stopa, E.G., McKee, A.C., Nitta, M., Satlin, A. (2005). Disturbance of endogenous circadian rhythm in aging and Alzheimer disease. The American Journal of Geriatric Psychiatry, 13(5), 359-368. doi: 10.1176/appi.ajgp.13.5.359
Hendry, K., Quinn, T.J., Evans, J., Scortichini, V., Miller, H., Burns, J., Cunnington, A., Stott, D.J. (2016). Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study. Age and Ageing, 45(6), 832-837. doi: 10.1093/ageing/afw130
Herrmann, N., Lanctôt, K.L., Sambrook, R., Lesnikova, N., Hébert, R., McCracken, P., Robillard, A., Nguyen, E. (2006). The contribution of neuropsychiatric symptoms to the cost of dementia care. International Journal of Geriatric Psychiatry, 21(10), 972-976. doi: 10.1002/gps.1594
Kales, H.C., Gitlin, L.N., Lyketsos, C.G., Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62(4), 762-769. doi: 10.1111/jgs.12730
Khachiyants, N., Trinkle, D., Son, S.J., Kim, K.Y. (2011). Sundown syndrome in persons with dementia: an update. Psychiatry Investigation, 8(4), 275-287.doi: 10.4306/pi.2011.8.4.275
Little, J.T., Satlin, A., Sunderland, T., Volicer, L. (1995). Sundown syndrome in severely demented patients with probable Alzheimer’s disease. J Geriatr Psychiatry Neurol, 8(2), 103-106. doi: 10.1177/089198879500800205
Mahlberg, R., Kunz, D., Sutej, I., Kühl, K.P., Hellweg, R. (2004). Melatonin treatment of day-night rhythm disturbances and sundowning in Alzheimer disease: an open-label pilot study using actigraphy. Journal of Clinical Psychopharmacology, 24(4), 456-459. doi: 10.1097/01.jcp.0000132443.12607.fd
Matsumoto, N., Ikeda, M., Fukuhara, R., Shinagawa, S., Ishikawa, T., Mori, T., … Tanabe, H. (2007). Caregiver burden associated with behavioral and psychological symptoms of dementia in elderly people in the local community. Dementia and Geriatric Cognitive Disorders, 23(4), 219-224. doi:10.1159/000099472
Pollak, C.P., Perlick ,D. (1991). Sleep problems and institutionalization of the elderly. J Geriatr Psychiatry Neurol, 4(4), 204-210. doi: 10.1177/089198879100400405
Rogers, S.L., Doody, R.S, Mohs, R.C., Friedhoff, L.T. (1998). Donepezil improves cognition and global function in Alzheimer disease: a 15-week, double-blind, placebo-controlled study. Donepezil Study Group. Arch Intern Med, 158(9), 1021-1031. doi: 10.1001/archinte.158.9.1021
Satlin, A., Volicer, L., Ross, V., Herz, L., Campbell, S. (1992). Bright light treatment of behavioral and sleep disturbances in patients with Alzheimer’s disease. Am J Psychiatry, 149(8), 1028-1032. doi: 10.1176/ajp.149.8.1028
Scarmeas, N., Brandt, J., Blacker, D., Albert, M., Hadjigeorgiou, G., Dubois, B., … Stern, Y. (2007). Disruptive behavior as a predictor in Alzheimer disease. Archives of Neurology, 64(12), 1755-1761. doi: 10.1001/archneur.64.12.1755
Schofield, I., Dewing, J. (2001). The care of older people with a delirium in acute care settings. Journal of Nursing Older People, 13(1), 21-25. doi: 10.7748/nop2001.03.13.1.21.c2167
Singer, C., Tractenberg, R.E., Kaye, J., Schafer, K., Gamst, A., Grundman, M., Thomas, R., Thal, L.J., Alzheimer's Disease Cooperative Study (2003). A multicenter, placebo-controlled trial of melatonin for sleep disturbance in Alzheimer's disease. Sleep, 26(7), 893-901. doi: 10.1093/sleep/26.7.893
Skjerve, A., Nygaard, H.A. (2000). Improvement in sundowning in dementia with Lewy bodies after treatment with donepezil. Int J Geriatr Psychiatry, 15(12): 1147-1151. doi: 10.1002/1099-1166(200012)15:12<1147::aid-gps262>3.0.co;2-l
Srinivasan, V., Pandi-Perumal, S.R., Cardinali, D.P., Poeggeler, B., Hardeland, R. (2006). Melatonin in Alzheimer's disease and other neurodegenerative disorders. Behavioral and Brain Functions, 2, 15. doi: 10.1186/1744-9081-2-15
Terzaghi, M., Sartori, I., Rustioni, V., Manni, R. (2014). Sleep disorders and acute nocturnal delirium in the elderly: a comorbidity not to be overlooked. Eur J Intern Med, 25(4), 350-355. doi: 10.1016/j.ejim.2014.02.008
Venturelli, M., Scarsini, R., Muti, E., Salvagno, G.L., Schena, F. (2013). Sundowning syndrome and hypothalamic-pituitary-adrenal axis dysregulation in individuals with Alzheimer’s disease: is there an association?. J Am Geriatr Soc, 61(11), 2055-2056. doi: 10.1111/jgs.12491
Volicer, L., Harper, D.G., Manning, B.C., Goldstein, R., Satlin, A. (2001). Sundowning and circadian rhythms in Alzheimer’s disease. Am J Psychiatry, 158(5), 704-711. doi: 10.1176/appi.ajp.158.5.704