Substance Abuse and Abuse Q 53
An elderly man is admitted to the hospital. He was alert and oriented during the admission interview. However, his family states that he becomes disruptive and disoriented around dinnertime. One night he was shouting furiously and didn’t know where he was. He was sedated and the next morning he was fine. At dinnertime, the disruptive behavior returned. The client is diagnosed as having sundown syndrome. The client’s son asks the nurse what causes sundown syndrome. The nurse’s best response is that it is attributed to
A. An underlying depression
B. Inadequate cerebral flow
C. Changes in the sensory environment
D. Fluctuating levels of oxygen exchange
Correct Answer: C. Changes in the sensory environment
Because the confusion occurs at sundown, the cause probably changes in the sensory environment. Sundown syndrome is related to environmental and sensory abnormalities that lead to acute confusion. The evaluation and management of altered mental status are broad and require careful history and physical examination to eliminate life-threatening situations. Changes in consciousness can be categorized into changes of arousal, the content of consciousness, or a combination of both. Arousal includes wakefulness and/or alertness and can be described as hypoactivity or hyperactivity, while changes in the content of consciousness can lead to changes in self-awareness, expression, language, and emotions
Option A: An underlying depression does not cause sundown syndrome. Depression is characterized by personal withdrawal, slowed speech, or poor results of a cognitive test. Patients rarely have a rapid fluctuation of symptoms and are usually oriented and able to follow commands. When eliciting a history from a patient who presents for altered mental status, it is important to obtain information both from the patient and from collateral sources (e.g., parents, children, friends, emergency management services, bystanders, the patient’s primary physician). This information can provide more insight regarding the chronicity of the change, precipitating factors, exacerbating or relieving factors, and recent as well as chronic medical history.
Option B: There is not sufficient evidence to suggest he has inadequate cerebral blood flow. Delirium is typically an acute confusional state, defined by impairment of attention or cognition that usually develops over hours to days. Some patients may experience rapid fluctuations between hypoactive and hyperactive states, that may be interjected with periods of intermittent lucidity. A nearly pathognomonic characteristic of delirium is sleep-wake cycle disruption, which leads to “sundowning,” a phenomenon in which delirium becomes worse or more persistent at night
Option D: Fluctuating levels of oxygen exchange do not cause sundown syndrome. The ascending reticular activating system is the anatomic structure that mediates arousal. Neurons of the ascending reticular activating system are located in the midbrain, pons, and medulla, and control arousal from sleep. Metabolic conditions, likely hypoglycemia or hypoxia, can decrease acetylcholine synthesis in the central nervous system, which correlates with the severity of delirium.