Sundowner Syndrome and Bipolar Disorder : Unraveling the Complex Relationship

1. What is Sundowner Syndrome? 

   Sundowner syndrome also known as sundowning, is a term used to describe a cluster of symptoms that worsen in the late afternoon and evening.⁽¹⁾ It is known to be associated with various conditions, particularly in older adults, which include Alzheimer’s disease and other forms of dementia.

   People experiencing sundowner syndrome may present with increased agitation, confusion, anxiety, restlessness and mood swings. The late-day confusion of sundowner syndrome may involve:

   • Hallucinations
   • Restlessness or pacing
   • Wandering
   • Anxiety and irritability
   • Difficulty sleeping
   • Disorientation or loss of focus
   • Losing interest in listening to suggestions or cooperating with loved ones and other care providers

   What exactly causes sundowner syndrome is not fully understood but it is believed to be related to a combination of factors including changes in the brain, fatigue, sensory overload, and disruption in circadian rhythm.

   Sundowner syndrome can be managed by creating a structured and calming environment, addressing any underlying medical or psychiatric issues, and providing support and reassurance to the affected individuals. 

2. What is Bipolar Disorder? 

   Bipolar disorder also known as manic depressive illness, is a mental condition that is characterized by extreme mood swings or episodes of mania and depression.

   Individuals with bipolar disorder may experience intense emotional highs, known as manic or hypomanic episodes, and lows known as depressive episodes. The intensity and duration of mood swings may vary. Also, the episodes may be separated by periods of normal mood.

   The key features of bipolar disorder include: 

   • Elevated or irritable mood
   • Impulsive behavior
   • Poor judgment
   • Increased irritability and activity
   • Hypomanic episodes which however are less severe than manic episodes
   • Changes in appetite and weight
   • Fatigue or loss of energy
   • Thoughts of suicide and death

   The exact cause of bipolar disorder is not fully understood but it involves a combination of genetic, biological, and environmental factors. It can be treated by mood-stabilizing medications, psychotherapy, and lifestyle adjustments. This can help manage the symptoms and improve the overall well-being.

The relationship between sundowner syndrome and bipolar disorder involves the shared characteristics, potential connection, and how the two conditions may interact.

• With symptoms worsening in the late afternoon and evening individuals with sundowner syndrome may experience increased agitation, confusion, and mood disturbances during these hours.
• Individuals with bipolar disorder may experience mood swings that may vary throughout the day.

• The cause of sundowner syndrome may not be known but neurological factors are believed to play a role.
• Bipolar disorder is associated with neurological abnormalities including neurotransmitters such as serotonin and dopamine.

• Aging: Sundowner syndrome is observed to occur in older adults. Also, bipolar disorder is observed to occur in some individuals later in life.
• Cognitive impairment: Both conditions may involve cognitive impairment, but the manifestation may be different. In sundowner syndrome cognitive function may decline in the evening while bipolar disorder can have cognitive effects during manic or depressive episodes.

• Sundowner management may involve creating a structured environment, addressing environmental triggers, and providing support during evening hours.
• Bipolar disorder treatment includes mood-stabilizing medications, psychotherapy, and lifestyle adjustments to manage mood swings and enhance overall stability.

The impact of bipolar disorder on sundowner syndrome involves the characteristics and fluctuations associated with bipolar disorder that may influence the occurrence and severity of sundowner syndrome. 

• Individuals with bipolar disorder may be more susceptible to sundowner symptoms during the evening hours. The inherent mood swings and circadian rhythm disruption associated with bipolar disorder could contribute to the exacerbation of symptoms during this time.^(2,3)
• The cyclical nature of bipolar disorder, characterized by alternating periods of mania, hypomania, and depression may coincide with sundowner symptoms.⁽⁴⁾ The heightened agitation, impulsivity, and restlessness during manic episodes, may potentially intensify sundowning behavior.
• The medications used for the management of bipolar disorder may impact sundower syndrome. Certain medications may contribute to sedation or cognitive effects, influencing the severity of sundowner syndrome.^{(5, 6)}
• In bipolar disorder, there may be a disruption of sleep patterns, which may lead to insomnia during manic episodes or excessive sleep during depressive episodes. Due to these irregular sleep patterns, there may be fatigue and increased vulnerability to sundowner syndrome in the evening.
• Co-occurrence of bipolar disorder and sundowner syndrome can affect daily functioning. Individuals may struggle with mood fluctuations, cognitive difficulties, and increased vulnerability to environmental triggers during the evening. This may impact the overall quality of life of a person.

Understanding how bipolar disorder influences sundowner syndrome is crucial for developing comprehensive care strategies.

Management of sundowner syndrome with bipolar disorder requires a comprehensive and individual approach. The aim is to address the symptoms of sundowner syndrome and underlying mood swings associated with bipolar disorder. 

• Evaluating the impact of bipolar medication on sundowner syndrome and making adjustments to minimize the side effects.
• Introducing medications with sedative properties might help in the management of agitation and restlessness during evening hours.
• Implementing a structured daily routine including calming activities in the evening. Creating a calming environment during the evening to minimize triggers associated with sundowner syndrome.
• Cognitive behavior strategies can be helpful in the management of anxiety and restlessness thereby addressing both sundowner syndrome and bipolar disorder.
• Strategies can be implemented to improve sleep hygiene. This may include consistent bedtimes, minimizing stimuli before bedtime, and creating a comfortable sleep environment. Education should be provided to caregivers about both conditions.
• It is important to foster communication between mental health professionals managing bipolar disorder and those addressing geriatric sundowning-related concerns. Education should be provided to caregivers about both conditions.
• Regular physical activity should be encouraged. This may contribute to mood regulation and overall well-being.⁽⁷⁾ Nutritional factors should be assessed to ensure individuals are maintaining a balanced diet.
• The symptoms should be monitored regularly allowing for prompt adjustment to the care plan.
• Supportive therapies including therapeutic activities such as music therapy or art therapy which can engage individuals during evening hours can promote a sense of calm. Facilitating participation in support groups for individuals with bipolar disorder and their caregivers to share experiences and coping strategies can also be helpful.

Creating a clear plan for managing crises or severe episodes involves mental health professionals, emergency services, and caregivers. Individual responses to interventions may vary.

All cases of bipolar disorder may need professional treatment. Steps can be taken to reduce episodes of mood symptoms and ease symptoms on their own. Support can be taken from a trained mental health professional as it is usually a key to lasting improvement.

For anyone who feels they could have bipolar disorder, contacting a therapist as soon as possible is important. A therapist can help by offering more guidance on navigating sleep problems and other nighttime distress.

Also, if anyone notices evening time wakefulness along with difficulty in concentrating, restlessness, irritability, or a mix of emotions and depression, consulting a therapist is important. Mixed mood episodes are serious it is best to get professional help.

Sundowner syndrome is characterized by exacerbated symptoms in the late afternoon and evening and can significantly impact the lives of those with bipolar disorder.

There is no strong evidence that shows a connection between bipolar disorder and sundowner syndrome. A person may experience sleep disturbance or worsening bipolar symptoms in the evening which may resemble the symptoms of sundowner syndrome. Also, bipolar disorder might increase the risk of development of dementia.

Steps can be taken to manage sleep issues and other bipolar symptoms in the evening and this may involve changes in routine, setting usual bedtime and waketime, performing regular exercises, and creating time for relaxation.

As research continues on the understanding of the neurological mechanism and shared risk factors between these conditions, the potential for more targeted treatments and improved support systems becomes apparent. A compassionate and holistic approach considering the unique needs of each individual, is essential to enhance the well-being of those navigating the complex interplay of sundowner syndrome and bipolar disorder.