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Sundowning: severe dementia and bringing on the night

John H. johnh at faraway.xxx
Sat Mar 29 02:22:42 EST 2003

"KP-PC" <k.p.collins at worldnet.att.net%remove%> wrote in message
news:Qq2ha.3791$cO3.136567 at bgtnsc04-news.ops.worldnet.att.net...
> If what you say were 'all there is', then the only 'therapy'
> necessary would be to assure that  patients' nutritional intakes were
> rigorously-balanced - vitamin pills would 'cure' all 'dementia'.

No, I'm not giving the full story here, of course vitamin therapy won't cure
the problem. There are many causes at work here, at present all I'm trying
to do is make a start at understanding this. Thus Larry's comment re sensory
confusion and subsequent anxiety is important and offers another angle by
which to approach this problem. As does Tony's comments re medication
timing. Furthermore, no amount of vit D supplementation will overcome the
deterioration and subsequent release of proinflammatory cytokines into the
CNS, I suspect in dementia cases the _chronic_ lack of sunlight is one
factor precipitating an increased inflammatory response from an already
seriously compromised base that sets the stage for dysfunctional responses
to anxiety and stress(a reasonable assumption given recent demonstrated
efficacy of bright light therapy in dementia). Interestingly, old studies on
the epidemology of MS indicated a very strong association between sunlight
and MS, this was later delineated to reveal that it was not sunlight per se
but lack of vitamin D (identified by fact that high fish eating cultures had
low MS prevalence and fish contain lots Vit D.) Additionally, other studies
have suggested a link between sunlight during pregnancy and incidence of
schizophrenia. Schizophrenia is now accepted a neurodevelopmental disorder
with significant tissue loss in various regions of the CNS.

What I need to do is deepen my understanding of this condition, have a much
closer look at the types of dementia where sundowning is more pronounced,
and relate this to the known aspects of the types of damage caused by
various types of dementia. Thus, I would expect that frontal lobe dementia
_should_ be more vulnerable to sundowning problems. But as I have long ago
learned, there are no simple answers in this bloody game. To be honest,
contrary to you, I empathise with researchers, therapists and carers. It's
easy to be on the outside and proffer solutions, but as anyone who deals
with the mentally ill knows all too well, what's in the books and theories
often aint in the world. We take small steps, we continue to try, you may
wish to barrage the general research and therapeutic community with
criticisms, I'd prefer to focus my attention on ways to help. Accordingly, I
intend to approach some residential care units to seek their observations
and ideas concerning this phenomenon. I'm only starting, your approach seems
to be that you already have all the answers. Reminds me of H L Mencken, "For
every human problem there is a simple solutions - simple, stupid, and
wrong." Unlike yourself I prefer empiricism to theory, I assume my ignorance
and do the hard yards, the reading and thinking, rather than extrapolating
from what I believe to be true. I started this topic to seek input from
people who have some experience in dealing with this condition and already
some (Tony & Larry) have helped. You will note that rather than relying on
ethereal notions about brain function they have provided concrete

> Of course there can be inbred metabolic deficits, and at least some
> of these could be 'show-stoppers' [until retroactive gene therapy
> might address such].
> But the biggest 'problem' remains the absence of understanding with
> respect to the way nervous systems actually work, on the parts of the
> 'helpers'.
> As a result of the 'ignorance' they carry into the 'therapeutic'
> setting, the 'helpers' fail with respect to, "First, do no harm."
> They 'intervene' in ways that only impose more dis-order within
> nervous systems whose main 'problem' is that they have descended into
> the dis-order that is what relatively-high TD E/I is.

Your criticisms of carers are unjustified because:

No-one knows what causes sundowning. No-one enjoys locking people away,
therapists would be delighted to find a remedy to many problems associated
with dementia. Your explanations offer no significant insight into the
condition. As a psychiatrist once told me, 'we treat conditions, we don't
cure them'. Not yet anyway, but only through perseverance will further
progress ensue. Bees to honey, I'd rather help than berate. I suggest you
adopt the same attitude and desist from lamenting humanity. That lament has
been echoed through the ages and does nothing to solve the problems, it is
often little more than masked arrogance because it is predicated on the
belief of the accusers that they somehow are above the problem and those who
cause it. I prefer the attitude exemplified by the philosopher Karl Popper,
"We may differ in what we know but in our infinite ignorance we are all

> What's necessary is to develop treatement strategies that focus upon
> re-establishing internal order - that, in effect, temporarily
> externalize TD E/I-miniization.

In severely damaged brains the probability of restoring 'order' is
effectively nil, one can only hope to ameliorate the condition, not cure it.

> It's why I'm not actually 'sorry' that during the course of my
> working to bring NDT's stuff forward, 'ignorant' folks reacted to my
> efforts by throwing me into a 'psychiatric' institution, and twice
> imprisoning me. As a result, I was able to study the dynamics that
> occur within such places first hand.
> In all three instances, all there was was 'ignorance' posing as
> 'authority', doing more harm than good.
> If anyone wants to actually address the 'problem', =this= is where
> they must actually begin.
> It's 'humanity' as a whole that's certifiably 'insane', but which,
> through 'blindly'-automated TD E/I-minimization that derives in
> noting more than repetition of merely-'familiar' consensual 'rules',
> declares itself to be 'sane', and woe to anyone who tells it plain,
> that the "emperor has no clothes".
> And it's 'hilarious' - NDT has been out-there for decades already,
> and all folks've done with respect to it, in ways that're inversely
> correlated to individuals' adherence to 'coersed-consensus' stuff, in
> 'move away from'.

> It's all 'inside-out, upside-down, and backward' with respect to
> Truth, but who cares? "We've got all of our so-and-so's saying
> such-and-such, and we're safe in our understanding, as long as we
> look to such."
> And 'the beast', "Abstract Ignorance" [ the absence of understanding
> of how nervous systems process information via 'blindly'-automated TD
> E/I-minimization within nervous systems that, nevertheless, do
> process information via 'blindly-automated TD E/I-minimization] is
> 'rolling on the floor laughing.
> It's got so many 'helpers' - so many folks who work with-it to
> sustain the dis-order that is Ignorance, why shouldn't it 'laugh'?
> I 'cry', though. I 'cry'. There exists no greater Tragedy - that
> Humans Love ['move toward'] Ignorance, and Hate ['move away from']
> Understanding - even imposing such upon the Children, in ways that,
> literally, constitute sacrificing them to 'the beast'.
> I 'cry'.
> "Still it moves."
> K. P. Collins
> "John H." <johnh at faraway.xxx> wrote in message
> news:mwWga.236$Sa5.8255 at nnrp1.ozemail.com.au...
> | Just now a friend of mine advised that in nursing homes vitamin D
> deficiency
> | is a real problem(think this was on the Aus sci program Catalyst
> just last
> | week). Vitamin D maintains tranforming growth factor beta which
> helps
> | modulates the immune system. In dementia patients interleukin 1 is
> usually
> | if not always elevated in the brain, tgf b can play an important
> role in
> | modulating the release of il 1. il1 plays a key component in the
> stress
> | response vis a vis my previous comments re nore. Some concordance
> with your
> | remarks re sensory input and subsequent perceptual disorientation.
> |
> | Your comments re a totally dark room are interesting, supporting
> your idea
> | that low light and subsequent sensory loss may initiate a confusion
> state,
> | leading to anxiety ... . Interesting point. Thanks.
> |
> | Light therapy probably relates to tgf b more than circadian jazz,
> still
> | can't see how it could help in relation to this particular issue.
> |
> | My friend in the nursing home advised that yes in the night these
> patients
> | really do go on a bender. Strange thing.
> |
> | John H.
> |
> |
> | "Larry Brash" <lbrash at ozemail.com.au> wrote in message
> | news:3E841E89.AF3E7298 at ozemail.com.au...
> | > "John H." wrote:
> | > >
> | > > Recently a friend of mine starting working in a dementia ward
> for
> | severely
> | > > demented individuals. She was advised by other staff that to be
> careful
> | > > after sundown because many of the patients become violent and
> extremely
> | > > difficult to control. I'm mystified by this, just wondering if
> anyone
> | else
> | > > has noticed this in severe dementia and\or if they have any
> ideas re the
> | > > same. I did note a few months ago a report stating that bright
> light
> | therapy
> | > > proved beneficial for some dementia patients but this doesn't
> account
> | for
> | > > the above observations.
> | >
> | > This phenomenon occurs in delirium, e.g. post-op delirium, DTs
> etc.
> | > There is always a clear worsening in the evening. Delirious
> people seem
> | > almost lucid in the daytime and off the planet at night. 15-20%
> of
> | > general hospital patients are delirious at any point in time.
> | >
> | > It seem to be due to the reduced sensory (mainly visual) input
> that
> | > occurs at sunset. The degree of reduction in light between full
> day
> | > light and a well light room at night is actually massive (at
> least
> | > hundred fold difference). A dimly light room is the worse. A
> totally
> | > dark room is actually better.
> | >
> | > Of course, the intact brain copes with this easily, but the
> impaired
> | > brain (i.e. delirium) does not cope and starts to experience
> sensory
> | > distortions (illusions) and hallucinations (mainly visual).
> Disturbed
> | > behaviour may then result in response to this.
> | >
> | > Dementia patients, who are in care, are usually well advanced and
> | > experience delirium very easily. Urinary tract infection,
> constipation
> | > being some of the more common mundane triggers for this.
> | >
> | > Delirium literally means "out of (de) the furrow (lirium)"
> [Latin].
> | > Dementia means "out of one's mind" and originally referred more
> to
> | > psychosis than organic impairment.
> | >
> | > I don't know if Light Therapy would work but it is an interesting
> thought.
> | >
> | > --
> | > Larry Brash
> |
> |

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