Sundowning in Parkinson’s Disease: Causes, Symptoms, and Alleviation

Parkinson’s disease (PD) is a neurodegenerative disorder that affects millions of people worldwide. It is a chronic and progressive disease that causes tremors, stiffness, and difficulties with balance and coordination. In addition to these motor symptoms, PD can also affect cognitive and emotional functions. One of the most distressing cognitive symptoms of PD is sundowning, which affects up to 50% of patients with PD. Sundowning is characterized by the onset or worsening of non-motor symptoms, such as anxiety, confusion, paranoia, hallucinations, and insomnia, that occur during the late afternoon or evening hours. This article will explore the causes and symptoms of sundowning in PD and provide practical strategies to alleviate or minimize the sundowning effect.

Causes of sundowning in Parkinson’s disease

The exact causes of sundowning in PD are not fully understood. However, several factors may contribute to the onset or worsening of non-motor symptoms in the evening, including:

• Circadian Rhythm: The circadian rhythm is a 24-hour cycle that regulates our sleep-wake cycle, body temperature, and other physiological processes. In PD, the circadian rhythm is disrupted, leading to changes in the timing and quality of sleep, which can exacerbate non-motor symptoms in the evening.
• Medications: The medications used to treat PD, such as levodopa, dopamine agonists, and anticholinergics, can have side effects that worsen non-motor symptoms in the evening. For example, levodopa can cause dyskinesia, a side effect characterized by involuntary movements, which can be more pronounced in the evening.
• Fatigue: PD patients often experience fatigue, which can worsen in the evening, leading to increased irritability, anxiety, and other non-motor symptoms.
• Environmental Factors: Environmental factors, such as changes in lighting, noise levels, and social interactions, can also contribute to sundowning in PD.

Symptoms of sundowning in Parkinson’s disease

Sundowning in PD can manifest in a variety of non-motor symptoms, including:

• Insomnia: Insomnia is a common symptom of sundowning in PD. PD patients may have difficulty falling asleep or staying asleep, leading to fatigue, irritability, and other non-motor symptoms.
• Anxiety: Anxiety is another common symptom of sundowning in PD. PD patients may experience feelings of restlessness, worry, or fear in the evening, which can be difficult to manage.
• Pacing: Pacing is a behavior that is often associated with sundowning in PD. PD patients may feel the need to move or walk around in the evening, which can be disruptive to their sleep and increase fatigue.
• Hallucinations: Hallucinations are a common non-motor symptom of PD, and they can be more pronounced in the evening. PD patients may see or hear things that are not there, leading to confusion and fear.
• Paranoia: Paranoia is a non-motor symptom of PD that can be exacerbated in the evening. PD patients may become suspicious or distrustful of others, leading to social isolation and anxiety.
• Confusion: Confusion is a non-motor symptom of PD that can worsen in the evening. PD patients may have difficulty understanding their surroundings or communicating effectively, leading to frustration and anxiety.
• Irritability and Screaming: Irritability and screaming are common non-motor symptoms of PD. PD patients may become easily agitated or angered in the evening, leading to emotional outbursts.

Ways to alleviate or minimize sundowning

There are several strategies that can be used to alleviate or minimize the sundowning effect in PD. These strategies can be divided into non-pharmacological and pharmacological interventions.

Non-pharmacological interventions

• Light Therapy: Light therapy involves exposure to bright light in the morning or afternoon to help regulate the circadian rhythm. A study published in the Journal of Clinical Sleep Medicine found that bright light therapy improved sleep quality and reduced anxiety in PD patients.
• Exercise: Regular exercise has been shown to improve sleep quality and reduce non-motor symptoms in PD. Exercise can also help to reduce fatigue, which can exacerbate sundowning in PD.
• Relaxation Techniques: Relaxation techniques, such as deep breathing, meditation, and yoga, can help to reduce anxiety and promote relaxation, which can improve sleep quality and reduce non-motor symptoms in PD.
• Establishing a Regular Routine: Establishing a regular routine can help to regulate the circadian rhythm and reduce anxiety in PD patients. A study published in the Journal of Parkinson’s Disease found that establishing a regular routine improved sleep quality and reduced non-motor symptoms in PD patients.
• Social Support: Social support from family, friends, and support groups can help to reduce anxiety and improve mood in PD patients. Social isolation can exacerbate sundowning in PD, so it is important to stay connected with others.
• Environment Modification: Modifying the environment to reduce noise levels, minimize bright lights, and create a relaxing atmosphere can help to reduce anxiety and promote relaxation, which can improve sleep quality and reduce non-motor symptoms in PD.

Pharmacological interventions

• Melatonin: Melatonin is a hormone that is naturally produced by the body to regulate the sleep-wake cycle. A study published in the Journal of Neurology found that melatonin improved sleep quality and reduced non-motor symptoms in PD patients.
• Antidepressants: Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), can help to reduce anxiety and improve mood in PD patients. A study published in the Journal of Clinical Psychopharmacology found that SSRIs improved sleep quality and reduced non-motor symptoms in PD patients.
• Antipsychotics: Antipsychotics, such as quetiapine and clozapine, can be used to reduce hallucinations and delusions in PD patients. However, these medications can have side effects, such as sedation and cognitive impairment, which can worsen non-motor symptoms in PD.
• Anxiolytics: Anxiolytics, such as benzodiazepines, can help to reduce anxiety and promote relaxation in PD patients. However, these medications can have side effects, such as sedation and cognitive impairment, which can worsen non-motor symptoms in PD.
• Sleep Aids: Sleep aids, such as zolpidem and eszopiclone, can be used to improve sleep quality in PD patients. However, these medications can have side effects, such as daytime drowsiness and cognitive impairment, which can worsen non-motor symptoms in PD.
• Adjusting Medications: Adjusting the timing or dosage of medications used to treat PD can help to reduce non-motor symptoms in the evening. For example, adjusting the timing of levodopa or dopamine agonists may help to reduce dyskinesia in the evening.

Final thoughts

Sundowning is a distressing symptom of Parkinson’s disease that can significantly impact the quality of life of patients and their caregivers. The causes of sundowning in PD are complex and multifactorial, and effective management requires a multidisciplinary approach. Non-pharmacological interventions, such as light therapy, exercise, relaxation techniques, establishing a regular routine, social support, and environment modification can be effective in reducing sundowning symptoms. Pharmacological interventions, such as melatonin, antidepressants, antipsychotics, anxiolytics, sleep aids, and adjusting medications, can also be helpful in managing sundowning in PD. However, it is important to weigh the potential benefits and risks of pharmacological interventions, as these medications can have significant side effects that can worsen non-motor symptoms in PD.