Psychiatry Research, 48:211-292 Elsevier

277

Sleep and “Sundowning” in Nursing Home Patients With Dementia

Donald L. Bliwise, Jennifer S. Carroll, Kathryn A. Lee, Jamie C. Nekich, and William C. Dement

Received June 17, 1992; revised version received December 28, 1992; accepted January 16, 1993.

Abstract. “Sundowning,” a term that is sometimes equated with sleep disturbance or nocturnal delirium in dementia, is a poorly understood psychiatric phenomenon. In this study, we performed systematic, temporally specific, behavioral observations of nine profoundly demented nursing home patients 4 times an hour over a 12-hour period (1300 to OlOOh) to determine whether their agitation was more likely to occur at a particular time of day. Results indicated only equivocal evidence that agitation was any worse nocturnally or during the time near sunset, thus raising the possibility that at least some components of sundowning may reflect disruptive behaviors occurring with identical frequency throughout the day but with differential impact upon nursing staff. Additional data indicated that awakening from sleep during darkness was also associated with agitation. A final result was a trend indicating the apparent worsening of agitation seasonally (greater agitation during winter), which may suggest involvement of the circadian timing system.

Key Words. Agitation, sleep disturbance, aging, geriatric psychiatry, seasonal variation.

“Sundowning” is a poorly understood phenomenon in geriatric psychiatry. Some have used the term interchangeably with sleep disturbance in dementia (Rabins, 1981; Winograd and Jarvik, 1986), yet polysomnographically defined alterations in sleep architecture have been clearly defined in mild, moderate, and severe Alzheimer’s disease in the absence of gross nocturnal behavioral disturbance (Prinz et al., 1982a, 1982b; Vitiello et al., 1990). Others appear to have subsumed the construct of sundowning under the rubric of delirium (Lipowski, 1980, 1987), referring to the nocturnal exacerbation of confusion and disorientation that occurs not only in dementia but in a large number of toxic, metabolic, infectious, and pharmacologically induced states in individuals of varying ages. Even the behaviors

At the time this study was conducted, Donald L. Bliwise, Ph.D., was Senior Clinical Research Scientist, Stanford Medical School, Stanford, CA; Jennifer S. Carroll, M.A., was a Research Assistant and Graduate Student in the Department of Anthropology, Stanford University, Stanford, CA; Kathryn A. Lee, R.N., Ph.D., was Assistant Professor, Department of Family Health Care Nursing, University of California, San Francisco, CA; Jamie C. Nekich, Ph.D., was Postdoctoral Fellow, University of California, Berkeley, CA; and William C. Dement, M.D., Ph.D., was Professor of Psychiatry, Stanford Medical School, Stanford, CA. (Reprint requests to Dr. D.L. Bliwise, Sleep Disorders Center, Emory University School of Medicine, Woodruff Memorial Building, Suite 6000, Atlanta, GA 30322, USA.)

0165-l 781/93/$06.00 @ 1993 Elsevier Scientific Publishers Ireland Ltd.

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included under the label of “sundowning” are vague. For example, various investigators have noted anecdotally that wandering (Snyder et al., 1978), confusion (Foreman, 1986), hyperactivity (Finestone et al., 1982), restlessness (Norris, 1975), aggressive behavior (Ryden, 1988), or disorientation (Wolanin, 1984) may be worse at night, but whether these behaviors, either singly or in combination, represent sundowning is unsettled. Finally, whether sundowning refers in general to behaviors occurring throughout the night or to behaviors occurring specifically at the onset of darkness (i.e., literally, the time of sunset) is unclear (Rabins, 1981). One early anecdotal report claimed that sundowning could be induced by bringing demented patients into a dark room during the daytime (Cameron, 1941).

It is essential to realize that all of the foregoing clinical and anecdotal evidence about sundowning is not grounded on systematically collected, temporally specific behavioral observations of patients’ behavior. Who actually “sundowns” and when the behaviors occur in real time are as vague as what behaviors constitute the phenomenon itself. Few studies provide any data on the phenomenon. Evans (1987) reported, on the basis of four observations made on 90 nursing home residents at 2 times of the day (10 a.m. to noon, 4-6 p.m.) for 2 days, that patients who sundowned were more likely to be demented, incontinent, awakened on night shift, and more recently admitted to the facility. In a more intensive study in agitated nursing home residents, based on 3 minutes of observations per hour made over a 2-month period, Cohen-Mansfield et al. (1989) noted a distinctly nocturnal pattern of behavioral disruption in two of eight residents. In a later study of screaming behavior in five nursing home patients, Cohen-Mansfield et al. (1990~) reported such behavior as most likely to occur in the early evening hours. In a study using motion- activated videotapes of wandering behavior of nursing home patients, the time period from 7 to 10 p.m. appeared particularly vulnerable in more mildly demented patients (Martino-Saltzman et al., 1991). Finally, in study of well-defined Alzheimer’s patients that was carried out in a sleep laboratory, Hoch et al. (1989) noted that most disturbed nocturnal behaviors requiring staff intervention were unrelated to breathing disruptions in sleep. Pollak and Perlick (1987; Pollak et al., 1990) confirmed an early report (Sanford, 1975) that nocturnal behaviors of demented patients placing demands on caregivers (nocturnal pain, wandering, micturition, and demands for attention) often lead to institutionalization. Other than these scattered studies, little is known about patient-related factors relevant to sundowning.

An alternative way of studying sundowning may be the better-researched and more widely accepted construct of agitation. In recent years, largely through the work of Cohen-Mansfield and colleagues (Cohen-Mansfield, 1986; Cohen-Mansfield and Billig, 1986) agitation in nursing home patients has been clearly described and has been demonstrated to be reducible to several major factors. Moreover, the rich description of relationships between agitation and patient-related variables has greatly added to our knowledge of the topic. For example, agitated, aggressive behaviors were found to be more closely related to physical pain and relatively recent surgery whereas nonaggressive agitated behaviors were related to cognitive impair- ment and impairment in activities of daily living (Cohen-Mansfield and Marx, 1989, 1990a). Prior psychiatric history was unrelated to agitation, but stressful events in past years (e.g., financial problems, holocaust experiences, death of spouse) were

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related to nonaggressive physical behaviors (.Cohen,~ansfield and Marx, 1989). In addition, nursing home residents with higher levels of cognitive functioning were more verbally agitated (Cohen-Mansfield et al., 1990b) and displayed greater levels of depressed affect (Cohen-Mansfield and Marx, 1988). These results validate the assessment of agitation as the key construct in describing disruptive behavior in dementia and suggest the utility of agitation in the study of the temporal dimension of behavioral disruption. In fact, preliminary data on agitation as a function of time of day suggested that some demented patients show distinctive patterns of nocturnal agitation whereas others have an apparent exacerbation in the morning (Cohen- Mansfield et al., 1989).

In this study, we present systematically collected observational data on agitated behavior in dementia as a function of time of day. The method represents an extension of our previous work examining the occurrence of behaviorally defined sleep/ wakefulness in nursing home patients (Carroll et al., 1989; Bliwise et al., 1990a, 1990b) and incorporates key elements of the assessment of agitated behavior as described by Cohen-Mansfield et al. (1986; Cohen-Mansfield and Billig, 1986). Our primary hypothesis was that agitated behavior would be related to low levels of illumination. This hypothesis derived, in part, from the speculation that sun- downing, by its assumed temporal distribution, could reflect dysfunction within the circadian timing system (Loewenstein et al., 1982; Bliwise, 1989).

Methods

Assessment of Agitated Behavior. We considered high interobserver reliability of patients’ behavioral states to be a necessity to attempt to draw conclusions about the temporal pattern of agitation. Although there are many rating scales for the assessment of behavioral disturbance in demented patients (Kane and Kane, 1981; Spiegel et al., 1991), they lack the temporal specificity required to assess behavior in real time. A possible exception to this are the assessments of agitation of Cohen-Mansfield and colleagues (Cohen-Mansfield, 1986; Cohen-Mansfield et al., 1988), who use 7-point ratings of behavior frequency (e.g., a few times an hour, once or twice aday) to examine the occurrence of 29 specific behaviors. These ratings are typically made on the basis of an 8-hour nursing shift with a 2-week time frame (Cohen- Mansfield et al., 1988). The 29 specific behaviors constituting agitation are reducible to three general factors consisting of aggressive behavior, physically nonaggressive behavior, and verbally agitated behavior. On the basis of these results, we developed a similar scale that could then be adapted to our method of brief (lo-20 seconds) intermittent (every 15 minutes) observations of sleep/wakefulness (Carroll et al., 1989; Bliwise et al., 1990a, 19906). Pilot data suggested that the three categories of agitated behavior determined by Cohen-Mansfield (1986) could be further delineated into two categories of physical versus verbal agitation; a simultaneous rating of intensity for each of the two categories appeared to capture the key notion of aggression as emphasized by Cohen-Mansfield and colleagues. The resulting rating scale incorporated both vocalized and physical agitation (the latter further broken down into carphologic, restraint removal, searching, and tapping) behavior and included a 4-point scale of intensity of agitation (0 = none, 1 = mild, 2 = moderate, 3 = severe). The rating scale and examples of behaviors to operationalize the category of behavior at each level are shown in the Appendix. To document reliability of this rating scale across observers, we performed a formal reliability check. Three individuals (D.L.B., J.S.C., K.A.L.) experienced in research but representing different fields for which behavioral observations represent a meaningful data source (psychology, anthropology, and nursing) simultaneously observed 11 nursing home patients over 5 nonconsecutive days. Observations were made 4 times an hour and

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lasted 10 to 20 seconds. A total of 2,745 observations were made (915 per observer). Our observation procedure was similar to that used in our behavioral observation study of sleep/wakefulness (Carroll et al., 1989) except that we did not stagger the sequence of observers. We did this because agitated behaviors are often short-lived and transient. The ratings, which were recorded by each observer on a clipboard, were not discussed during the rating procedure. We calculated both percentage agreements and the K coefficients for each pair of observers. Presence/ absence of physical agitation and vocal agitation was determined by collapsing all intensity levels (l-3) into a single category. The three rater pairs had percentage agreements of 92.3%, 90.2%, and 85.8% for presence/ absence of physical agitation and 96.5%, 96.870, and 95.0% for presence/absence of vocal agitation. The K coefficients varied between 0.71 and 0.93 (mean = 0.85) (all p < 0.001).

Subjects and Site. Subjects were nine grossly demented nursing home patients of the skilled nursing facility (SNF) of the Masonic Home for Adults in Union City, California. Table I

Table 1. Demographics and medical history of patients under observation

Patient # Age Gender MMSE ADL Diagnoses Medications

1 82

2 87

3 88

4 89

5 92

6 89

7 92

8 92

9 85

7 513

6 512

10

5

11

13

17

0

11

514

412

513

413

512

513

212

Osteoarthritis in knees, hip;

possible TlAs

Generalized osteoarthritis;

Parkinson’s; COPD;

ASCVD; CVA

None

Osteoarthritis in knees and

foot; basal cell carcinoma;

ASCVD; hip fracture

Peptic ulcer; ASCVD;

severe osteoporosis; chronic

cholecystitis

Anemia;

cataracts

Digoxin, synthroid,

Sinemet,

temazepam

Haloperidol,

synthroid,

temazepam

Flurazepam

ASCVD;

generalized osteoarthritis

Naprosyn,

temazepam

Triazolam,

thioridazine

Parkinson’s; COPD; Prednisone,

myasthenia gravis; procardia,

basal cell carcinoma; pyridostigmine,

glaucoma demerol, temazepam

ASCVD; Premarin

deafness; temazepam,

visual impairment lorazepam, haloperidol

Osteoporosis; Persantine,

TIAs; deafness oxazepam, thioridazine

Note. MMSE = Mini-Mental State Examination (Folstein et al., 1975) score (maximum = 30). ADL = Activities of Daily Living (Katz et al., 1963); first figure is number of at least partially dependent functions (out of six); second figure is number of completely dependent functions (out of six); six functions include: bathing, dressing, toileting, transfer, continence, and feeding. Diagnoses: COPD = chronic obstructive pulmonary disease. TIA = transient ischemic attack. CVA = cerebrovascular accident. ASCVD = arteriosclerottc cardiovascular disease. Medications: includes both regular and PRN medications (excluding stool softeners, vitamins, minerals, aspirin).

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presents information about demographics and medical histories. Mean time in SNF was 20 months. Median survivorship following winter observations (see below) was 26 months. All had lived in the facility for at least 9 consecutive months before the autumn observations. Subjects were not selected randomly for inclusion in these observations. We intentionally spoke to nursing home staff to determine which patients were agitated, and subjects were selected on this basis. At the time the study was conducted, the SNF was located on the top floor of a four-story structure. Most patients had double rooms. There were no patios and patients remained indoors. The facility was rectangular in shape, running Southwest to Northeast (Fig. 1).

Fig. 1. Typical illumination in this skilled nursing facility

c d A c

s D

A B C D E

E i=

1630 2257 270 76 119 313

1730 702 106 65 97 1 216

1830 194 ) 54 1 65 1 76 1 106

Top: Floor plan of skilled nursing facility with compass points at far right. Bottom: Light readings (in lux) on a mid-March day without cloud cover. Letters A-E refer to specific locations: (A) elevator/sitting area; (B) typical patient room, northwest exposure (measurement taken at window): (C) middle of hallway; (D) typical patient room, southeast exposure (measurement taken at window); (E) dining area (measurement taken in middle of room).

Data Collection and Scheduling of Observations. A single observer (J.S.C.) with established reliability performed all observations on the nine patients. As in our previous studies of sleep/wakefulness (Carroll et al., 1989; Bliwise et al., 1990a, 19906) observations were made 4 times an hour. Although more frequent observations may have been desirable given the transient nature of agitated behavior, the 4 times per hour frequency allowed sufficient time for successive “rounds” of 8 to 10 patients to be completed successfully. To observe not only daytime and nighttime behavior but also fully examine the hours near sunset, we used a 12-hour observation “day” ranging from 1300 to OlOOh.

Two periods of observation were included: one in late-August/September and the other in December/ January. For convenience, we labeled these autumn and winter, respectively. Autumn observations occurred 3 days a week (Wednesday, Thursday, and Saturday or Sunday) over 3 weeks for a total of 9 days for 432 observations per subject. Winter observations were made twice a week (Tuesday and Wednesday or Wednesday and Thursday) over 3 weeks for a total of 6 days for 288 observations per subject. Winter observations were not made the week before Christmas. Weekend observations were deleted in the winter

282

because analyses of weekend/weekday differences in the autumn data showed no significant differences in agitation by day of week. Light readings were taken every other observation (i.e., every 30 minutes) with a standard light meter (Photometer 1, Quantum Instruments, Garden City, NY) placed near the subject’s line of gaze. Readings were recorded in foot- candles and then converted to lux (foot-candles X 10.8). Fig. 1 shows examples of light readings from various locations on the floor on a bright March day without cloud cover.

Data Analysis. Because of our particular interest in behavior during the time near sunset, we divided the 12-hour, 4%unit observation period into three separate time blocks: before sunset, sunset, and after sunset. The sunset period was always defined as the local time at sunset (35’ N latitude) (Nautical Almanac Office, 1987) f 2 hours, i.e., the sunset period encompassed a maximum of 16 observations. The before-sunset period consisted of the observations between 1300h local time and the beginning of the sunset period. The after-sunset period consisted of the observations between the end of the sunset period and OlOOh local time. Based on these periods, measures of sleep and agitation were then computed as the proportion of the before-

sunset, sunset, and after-sunset observations with sleep or agitation. Over the autumn observation period, sunset averaged 1813h (SD = 19 minutes); during the winter observation period. sunset averaged 164631 (SD = 10 minutes). Because sleep and agitation were not scored concurrently for a single observation, we computed measures of agitation in two different ways for the temporal analysis, as the proportion of total observations within a given (before- sunset, sunset, after-sunset) period, and then as a function of awake observations within that period. All forms of physical and vocal agitation were collapsed in these analyses. Temporal effects were examined with a repeated measures multivariate analysis of variance (MANOVA) using a single main effect of time. Seasonal effects were also examined with MANOVAs and were performed separately for the before-sunset, sunset, and after-sunset periods.

Results

Over the 15 days in autumn and winter, a total of 1,082 observations of agitation were noted. Of these, 327 occurred during the before-sunset period, 522 during the sunset period, and 233 during the after-sunset period. Within individuals, the number of units of agitation varied from 3 1 to 299 (mean = 120.2, SD = 7 1.9). Table 2 presents results from the time-of-day analyses. Predictably, more sleep was observed after sunset in both autumn and winter, though during the latter observations, decreases in observed sleep relative to both the periods before and after sunset were seen during the sunset period. During autumn, no significant effects for time of day were detectable for any measure of agitation. During the winter, however, the sunset period appeared particularly vulnerable for agitation, when defined as a function of total, but not waking, observations during this period. Fig. 2 shows an example of agitation near the sunset period. Because observed sleep was also reduced during the sunset period in winter, it appeared that agitation might be associated with sleep, by being either a cause of or an effect of reduced sleep.

There were no seasonal differences in the proportion of observations spent asleep or agitated in either the period before or the period after sunset. During the sunset period, patients were observed to sleep less during the winter (F= 27.53; dJ= I, 8; p < 0.001) and tended to be more agitated, when considered both as a function of total observations (F= 5.12; df= I, 8; p < 0.06) and waking observations (F = 3.94; df = 1, 8; p < 0.09). Change in medication status was not related to the apparent seasonal variation in agitation. Psychoactive medication use for the nine patients

283

Table 2. Mean (SD) proportion of observations with sleep and agitated behavior bv time of dav

Variable

Time of day

(4 (Cl Before @I After F sunset Sunset sunset (+2,7) p Contrasts

First observation-Autumn % Observations asleep

% Observations with

agitation

% Observations with severe

agitation (rating 2 or 3)

% Waking observations

with agitation

% Waking observations with

severe agitation (rating 2 or 3)

Second observation-Winter % Observations asleep

% Observations with

agitation

% Observations with

severe agitation (rating 2 or 3)

% Waking observations

with agitation

% Waking observations with

severe agitation (rating 2 or 3)

13.9 18.8 69.9

(11.4) (9.2) (8.8) 21.3 21.5 8.5

(22.8) (14.9) (7.4) (::;, 9.2 6.6

(7.3) (6.2) 24.2 24.7 21.2

(23.6) (17.8) (19.4)

8.6 10.5 15.9

(9.81 (8.3) (14.7)

16.9 7.2 66.0

(13.8) (6.3) (15.7)

20.0 28.6 8.1

(19.2) (19.2) (6.7) 6.7 11 .o 6.5

(8.2) (8.1) (6.0) 22.6 30.3 20.7

(20.2) (19.3) (14.6)

7.8 11.9 16.5

(9.8) (8.8) (13.9)

104.53

NS

NS

NS

NS

71.06

5.44

4.38

NS

NS

<O.OOl A.B<C

-

-

-

-

< 0.001 A,B<C

B<A

< 0.02 B>C

< 0.05 A,C<B

Fig. 2. Occurrence of observed agitation (cross-hatched boxes) as a function of time of day over 6 days-of winte; observations .

Sunset is indicated by the heavy dark line. Note clustering of agitation near sunset in this patient (patient 3 in Table 1).

284

(calculated as the proportion of days with psychoactive or pain medication) did not significantly differentiate the patients in autumn and winter.

Light meter illumination levels indicated that in neither autumn nor winter did patients experience anything close to the equivalent of outdoor sunlight while in the SNF. The mean illumination level in lux for the five observations made between 1300 and 1500h was 257 (SD = 113) in autumn and 157 (SD = 76) in winter, this difference approaching statistical significance (z = 1.95, p < 0.06). By 1900h, no light reading.in excess of 100 lux was obtained on any occasion in autumn or winter for five of nine subjects. For the other four subjects, illumination levels in excess of 100 lux were detected at 1900h for 1, 3, 7, and 4 days, respectively, out of the entire 15 days of observation. By 2100h, most patients were in beds in darkened rooms; on only 12 occasions (out of 135 possible light readings at that time) were light levels in excess of 50 lux detected. The highest recorded illumination exposure for subjects in autumn averaged 647 lux (SD = 372; range = 225-1258), whereas in winter the highest recorded illumination exposure averaged 277 lux (SD = 164; range = 113- 554). This difference was significant (z = 3.77, p < 0.01).

To explore whether there were more specific relationships between observed episodes of agitation and observed sleep, we examined all cases where agitation occurred for one or more successive observations by a function of whether, during the observation immediately preceding the agitation, the patient was awake or asleep. A total of 391 such observation episodes were observed with the vast majority (n = 321) following wakefulness. Of these 391 episodes, 139 contained at least one observation of intense agitation (rating 2 or 3). The majority of these agitation episodes (n = 105) also occurred following wakefulness. However, the proportion of such episodes occurring before sunset and at sunset (8.7%) was significantly different from the proportion of such episodes occurring after sunset (55.3%) (z = 6.05, p < 0.0001). This implies that intense agitation may be more likely to occur after sleep. Because sleep was also more likely to occur after sunset, however, this associa- tion is equivocal.

To clarify the association between agitation and sleep, we also examined how often an observation of sleep was followed by an episode of agitation. Unlike the above analyses examining whether agitation was immediately preceded by sleep vs. wakefulness (which was biased by the amount of sleep likely to occur during any given period), these analyses focused exclusively on what happened when a patient awakened from sleep, at least as defined behaviorally. Of 398 episodes of sleep, the majority (n = 344) ended with episodes of wakefulness without agitation. However, the proportion of sleep episodes followed by severe agitation episodes was significant- ly higher after sunset (12.9%) than during the before-sunset and sunset periods (6.5%) (z = 2.12, p < 0.05), suggesting that patients’ nocturnal agitation was partially related to awakenings from sleep.

Because nursing home staff typically made rounds on the floor after patients were placed in bed, we examined the effects of staff interaction on the patient’s behavioral state subsequent to entry in room by staff. Of 203 such observations, patients remained asleep the majority (62.6%) of the time. In 71 of the cases (33.6%), patients awakened without agitation and in 8 cases (3.8%) agitation was observed after staff contact.

285

Discussion

The current results present only equivocal data that agitation is any more likely to occur at sunset relative to other times during the day. During the second set of observations, agitation appeared to occur more frequently during sunset only when defined as a function of total observations, but not when defined as a function of time awake. This result is consistent with the explanation that demented patients who are awake (and thereby not asleep) have a greater opportunity to be agitated. To some extent, these results are consistent with the report of Cohen-Mansfield et al. (1988) that although agitation appeared to be more common during the day shift (as assessed by nurses’retrospective ratings from different shifts), it was unclear whether agitation was really more common at that time simply because patients were more likely to be asleep during the night. Foreman (1986) has raised similar points about the data reported by Chisholm et al. (1982) on confusion by time of day.

It remains unclear why, in our data, agitation was not appreciably worse at sunset or, at the very least, after sunset given the anecdotal and clinical literature suggesting that all forms of behavioral disruption including confusion, wandering, hyper- activity, aggression, vocalizations, and delirium are exacerbated by darkness (Norris, 1975; Snyder et al., 1978; Lipowski, 1980; Finestone et al., 1982; Wolanin, 1984; Foreman, 1986; Ryan et al., 1988; Ryden, 1988). Although a few of the more carefully performed observational studies have noted such time-of-day effects on some behaviors, the findings are neither overwhelming nor unambiguous (Evans, 1987; Cohen-Mansfield et al., 1989, 1990~; Martino-Saltzman et al., 1991). Cohen- Mansfield et al. (1989), for example, noted that a characteristic pattern of daytime agitation was more common than nocturnal agitation in their small group of nursing home patients. Evans (1987) found some evidence for sundowning-like behavior only in about 12% of her nursing home patients. These data were based on about 40 minutes of observations, which never extended beyond 6 p.m. Martino-Saltzman et al. (199 1) noted that early evening exacerbation of wandering was most pronounced in more mildly demented patients, a finding that is somewhat inconsistent with other data suggesting that nocturnal behavior disruption occurs only in the most profoundly demented individuals who have lost nearly all other self-care abilities (Ferm, 1974; Volicer et al., 1987).

These studies, together with our negative findings, at least raise the possibility that some disturbed behavior, assumed to occur nocturnally, could be partially explained by caregiver- rather than patient-related factors. That is, agitated behaviors occurring with identical frequency may affect caregivers and staff differently depending on when they occur, even though the actual frequency of behavior does not differ. Ample evidence of the familial upheaval caused by nocturnally disturbed behavior of demented patients is available (Sanford, 1975), even to the point where such disruptive behaviors may lead to the decision to institutionalize (Pollak and Perlick, 1987; Pollak et al., 1990). Nonetheless, although our data cannot demonstrate marked time-of-day effects on agitation, a number of limitations must be placed upon our results. Our sample size was exceedingly small, and our observation period was limited to 12 hours on only 15 nonconsecutive “days.” A larger number of cases would allow for multivariate prediction of medical and

286

health-related patient factors associated with agitation as well as casting a wider net over a more diverse set of patients. Studies conducted continuously over the 24-hour day for longer intervals of time (e.g., months) might also be expected to yield a more complete description of agitation by time of day. Use of a continuous video- monitoring system, for example, would obviate the need for observers and would probably be somewhat less obtrusive than our use of intermittent behavioral sampling. Such an intensive method has been implemented successfully in the study of wandering behaviors in nursing home patients (Martino-Saltzman et al., 1991), and could probably be adapted in conjunction with the system for rating agitation used in this study.

Although we found no marked time-of-day effects in accounting for sundowning, our data do yield some clues about the nature of agitation during the night. For example, the observation that patients are more likely to awaken with agitation after sunset suggests that some of the nocturnal confusion seen in demented patients may have to do simply with the process of awakening from sleep. This observation was originally made 25 years ago by Feinberg et al. (1967), who noted in the sleep laboratory that demented patients often awakened from rapid eye movement sleep seemingly unable to distinguish dreaming events from reality. To the extent that darkness leads to the misperception of distinguishing dreaming from reality, this may indeed be a cause of some sundowning-like behavior. Of interest in our data is that this pattern of agitation upon awakening from sleep was not seen during periods of greater illumination (before sunset and sunset), which offers support for the adage that low-level nighttime illumination in patients’ rooms may reduce episodes of nocturnal confusion and agitation (Massey and Riley, 1982; Levkoff et al., 1986). Relationships between awakening from sleep and confusion have been noted elsewhere as well (Evans, 1987; Cohen-Mansfield and Marx, 1990; Cariaga et al., 199 I) and may even be the basis for Cameron’s early finding in which patients became delirious after being brought into a dark room during the daytime. It is unclear in this early study whether those patients may have fallen asleep in the darkened room and awakened from sleep in a confused state (Cameron, 1941).

An unanticipated finding in our study was that agitation showed trends for seasonal variation in frequency concurrent with a seasonal decrease in illumination within this SNF. Patients slept less during the sunset period in the winter and tended to be more agitated when assessed as a function of both total observations and waking observations. Change in medication intake or terminal decline in the patient’s health did not appear to account for these alterations. There are few relevant studies in the geriatric literature documenting such seasonal variation in behavioral disturbance. Chisholm et al. (1982) noted no apparent difference in confusion in a group of nursing home patients studied in the autumn and then in winter, and Cumming et al. (1982) also found few consistent differences in agitation over a 2-month period between December and February. However, neither of these studies used the frequency of observations that we used here. There are only scattered pieces of evidence that might remotely suggest any physiological under- pinnings of such a seasonal phenomenon. For example, the acrophase of both the body-temperature cycle and melatonin may show far greater phase advances in

287

demented patients during winter relative to similar measurements made at other times of the year on those patients and similar measurements made at the same time of year on elderly controls (Touitou et al., 1984, 1986). Similarly, the amplitude of the body temperature cycle in dementia appeared higher in October and January relative to measurements made at the same time of the year in elderly control subjects. Because the temperature cycle partially drives sleep/ wakefulness and rest/ activity, it could be that such large variances in the temperature cycle may lead to excessive activity at those times in such patients during the winter months. Still, masking effects on temperature (i.e., excessive activity causing rises in body temperature rather than vice versa), as well as conflicting data on the body-temperature rhythm in dementia (Prinz et al., 1984; Touitou et al., 1986; Okawa et al., 1991) make it likely that the observed seasonal variation in agitation, if it can be replicated at all, may involve other mechanisms. considerably more complex than those speculated upon here. Moreover, before an assumption is made that such effects involve retino- hypothalamic mechanisms, it will be necessary first to document retinal integrity and adequate optic transduction in these patients (Hinton et al., 1986). For example, seasonal effects might reflect changes in ambient temperature.

Regardless of whatever the ultimate mechanism may be in accounting for the trends for seasonal variation in agitation at sunset, the low levels of illumination experienced by the patients in this nursing home are striking. We do not believe this facility is at all atypical of the many SNFs that we have encountered, although certainly newer SNFs (including one at the Masonic Home) emphasize lighting and often offer greater exposure to outdoor light and higher indoor illumination. To the extent that the sleep/ wake cycle is entrained by customary light exposure, and to the extent that these nursing home patients may spend the final years of their lives with illumination exposures seldom exceeding 500 lux, it is hardly surprising that sleep fragmentation is ubiquitous within the nursing home environment (Ancoli-Israel et al., 1989; Jacobs et al., 1989; Gall et al., 1990). Levels of illumination > 2000 lux are generally required for physiological reactivity and melatonin suppression, and several ongoing studies support the use of bright light as an effective treatment for promoting sleep in demented nursing home patients and nondemented elderly out- patients (Campbell and Dawson, 1991; Campbell et al., 1991). Whether such beneficial effects work within or external to the circadian timing system remains to be seen. Nonetheless, it should be noted that the nursing literature also contains anecdotal evidence that restlessness could be induced by bright light (Kolanoswki, 1990). Such effects could be peripheral (noxious effects of glare due to senile macular degeneration; Leibowitz et al., 1980) or central. For example, both squirrel monkeys (Edgar, 1986) and rats (Mistleberger and Rusak, 1988) with lesions of the supra- chiasmatic nucleus show tendencies for exaggerated activity levels following lights- off stimulation. If it is the transition between light and dark that is the most relevant aspect of illumination insofar as agitation is concerned, avoidance of darkness at night, rather than enhancement of illumination during the daytime, might be most beneficial. Whether agitated patients exposed to such constant conditions around the 24-hour day would show reductions in the frequency of their agitated behavior remains to be tested.

288

Acknowledgment. The research reported here was supported by grants from the National Institute on Aging (AG-06066, AC-04458, and AC-10643).

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Appendix. Agitated Behavior Rating Scale ---’

The following is a list of situations representative of the various agitated behaviors and intensities to be

coded. All observations are to be completed within a range of 10 to 20 seconds. The appropriate

behavior will be rated 0 (not present), 1 (low), 2 [mild), or 3 [high) according to the intensity of the

behavior. Behaviors I-IV are all categorized as physical agitation. Rate only one type of physical

agitation for any given observation.

I. Carphologic behavior

Intensity 1. A woman sitting in a wheelchair picks at her lap blanket as if to remove lint from it.

A woman sitting in a wheelchair clutches at the collar of her robe.

A woman sitting in a wheelchair puts her hand behind her neck and rubs at her hairline,

then keeps her hand at her hairline indicating that her movement was not in response

to an itch.

Intensity 2.

Intensity 3.

A man sitting in the hallway struggles to pull a sock over his shoe.

A man sitting in the hallway is folding and refolding a dinner bib for no apparent reason.

A woman sitting in her wheelchair rubs her lips with her fingers, clutches the collar of

her dress, arranges her lap blanket around her knees, then returns her fingers to her

lips, all in quick succession and for no apparent purpose.

A man stands in the dining hall and begins rearranging the furniture for no apparent

reason.

A man picks up an object and throws it in a temper outburst.

II. Restraint-removal behavior

Intensity 1. A woman sitting in a wheelchair fingers her gray restraint belt, but never exerts much

force on it.

Intensity 2.

Intensity 3.

A woman sitting in a wheelchair forcefully pulls at her restraint belt.

A man sitting in a gerry-chair intermittently pushes out on the locked tray table.

A man sitting in a gerry-chair pushes out and pulls in on his locked tray table in rapid

succession.

A woman in bed attempts to climb over the siderails, or between the bed and the

siderail.

A man violently rattles the siderails of his bed.

A woman pulls at her gray restraint belt on her wheelchair and attempts to slip out from

underneath it.

Ill. Searching behavior

Intensity 1, A man bent over from his chair briefly runs his hands along the floor as if looking for

something, although nothing is on the floor.

A woman sits at a table and reaches out as if to grasp something, but no objects are on

the table. She reaches just once and then sits back quietly in her chair.

Intensity 2. A man wanders (in wheelchair or walking) down the hallway for no apparent purpose.

He pauses at several room doors and peers in.

Intensity 3. A man wanders (in wheelchair or walking) down the hallway for no apparent reason.

He enters a room that is not his own. He then begins rummaging through the closet or

drawers.

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IV. Tapping/banging behavior

Intensity 1. A man sitting in a wheelchair clacks his dentures together.

A man sitting in a chair taps his fingertips of one hand against the fingertips of his other

hand.

Intensity 2.

Intensity 3.

A woman sitting in a wheelchair taps her hands across her tray table in a continuous

motion. The tapping is visible from 15 feet away.

A man sitting in a wheelchair bangs his fists down on a tray table violently. The banging

can be heard down the hallway.

V. Vocalization behavior

Intensity 1. A woman sitting in a wheelchair mumbles to herself. She speaks in low tones, but a few

words are audible.

Intensity 2.

Intensity 3.

A woman sits in her room, calling out for help. “Please come help me. Will you help me,

young lady? Can I go with you?” Her requests occur repeatedly throughout the

observation period, even if the staff gives her assistance.

A woman sits in her room and speaks to herself in a sing-song manner. Her voice is at

a normal speaking volume.

A woman rises from her chair in her room and asks of someone in the hall, “Where can

I sit? Where is my chair?”

A woman in her room is crying out in a cat-like whine. Her vocalizations can be heard

down the hall.