What is Sundowing?

Have you ever heard of sundowning? Has your PSW told you that your mom experiences sundowning? Has someone at the long-term care home asked if your mom has sundowning before she moves into the home?

Sundowning is when a person living with dementia gradually becomes more agitated or confused and shows personality changes when the day turns into the evening. Most often, this happens around 4pm.

Some common symptoms of sundowning include: sudden behaviour changes, difficulty speaking and thinking clearly, hallucinations, verbal and/or physical aggression, pacing/wandering, paranoia, and increased confusion. As we go through some of the causes of sundowning, you’ll see that sundowning is often just a normal reaction to situations we’ve all experienced.

Sundowing

One of the most common causes of sundowning is simple exhaustion. For someone living with dementia, simple tasks throughout the day are more tiring than for someone without dementia. This is because they have fewer cognitive and physical resources to engage in those tasks and activities like going for a walk, preparing a meal, and having conversations. Just like when you are sick you get tired more easily when doing everyday tasks, people living with dementia experience this feeling daily. And just like when you are tired, you usually get more irritable, have less patience, and react quicker to things that annoy you. The same thing happens with people with dementia. But we call it “sundowning.”

So if exhaustion causes sundowning, then how can you prevent it?

Easy! Take a nap! Who doesn’t like naps after all?! Recharge, try a nap, try sitting quietly out in the sun or in a quiet room. Watching TV or listening to the radio may help but it may be too stimulating to the senses to allow the person recharge.

Another common cause of sundowning is medications wearing off later in the day. Ask your doctor for extended release or timed release medications so that the effects of the medications are more consistent throughout the day. Or perhaps there is a better schedule for taking the medications that results in a steady reaction rather than ups and downs.

Another very possible cause of sundowning is the reality your loved one is living in. If for example, they are back in their 40’s and their husband always comes home at 5pm, and it’s a little before 5pm now, it’s a natural reaction to get excited or anxious about waiting for their husband to walk in the door. Then what if it passes 5pm and their husband isn’t home yet? Then they could start to get worried and start pacing the home; getting irritable and cleaning vigorously.

Anytime you are working with someone living with dementia, you have to try to get into their head and understand their reality. If you figure out that your loved one is worried that their husband isn’t home yet, try telling them that they called earlier and said that they were going to be late because they had a business meeting, and not to worry. The best way to deal with these situations is to validate your loved one in their feelings and then give a plausible reason as to why their husband isn’t home yet, This reason should be something that would make your mother relax and not worry.

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Can Ketones Prevent Alzheimer’s Disease?

Often in Alzheimer’s disease, there is a reduction in the brain’s use of glucose (sugar) for energy. This means that the brain isn’t able to properly function because it’s not getting enough energy to carry out all of its jobs. In fact, when parts of your brain don’t get enough energy, the brain cells start to degenerate and die.

But, this inability to absorb glucose is not consistent across all parts of the brain. In people with Alzheimer’s disease, some parts of the brain are able to absorb adequate amounts of glucose while other parts can’t absorb enough. So, if the front part of the brain doesn’t absorb enough glucose, then it starts to get damaged and you’ll likely see problems with decision making and judgement.

There is hope though! A study in 2016 was done that showed the brain – even when glucose absorption is impaired – can still absorb ketones! Ketones are another energy molecule that your brain can use. We are also seeing that when a person living with Alzheimer’s disease is put on a treatment that increases ketones, their symptoms of dementia are improved!

Let’s take a closer look at ketones.

Ketones are an alternative source of energy for the brain. They are made in our bodies when we break down fat. The only time fat is broken down for energy is when the body has used all of the carbohydrates (glucose) available. Some common reasons for people to start breaking down fat include: fasting, starvation, eating a low-carb diet, eating a ketogenic diet, after a long bout of exercise, or uncontrolled Type 1 Diabetes. Watch this video for a great campfire analogy on ketones.

There are 3 types of ketones:

  1. Acetoacetate
  2. Beta-hydroxybutyric acid
  3. Acetone

Ketones

Acetoacetate is the first ketone to be made from the breakdown of fat. Then Beta-hydroxynutyrate is made from acetoacetate; and Acetone is simply a byproduct of acetoacetate which doesn’t actually get used by the brain.

 


Now it becomes quite difficult to get someone with pre-Alzheimer’s disease/Mild Cognitive Impairment or someone already with Alzheimer’s disease to start eating a Ketogenic diet. However, there are products that you can buy to help your body use ketones faster for brain energy. The aim, is to supply ketones to the parts of the brain that aren’t able to absorb glucose for energy. This way, those parts of the brain are still getting enough energy to perform their vital functions and helps to maintain healthy brain cells. In theory, you are preventing or delaying the onset of dementia. Studies are also looking at the ability of the ketogenic diet to treat and possibly reverse dementia. Now dementia by definition is irreversible and progressive, but there are ups and downs during the course of the condition. The ketogenic diet could lift the person back up to a higher functioning status and researchers predict that this could occur among people in the earliest stages of Alzheimer’s disease. Right now however, the best evidence in the use of ketones as brain fuel is for people who have Mild Cognitive Impairment before dementia or Alzheimer’s disease.

Worried that you’re getting Alzheimer’s Disease?

A lot of people start paying more and more attention to their memory blips as they get older and may chalk it up to the onset of Alzheimer’s disease or other dementia. Most people don’t remember when they were 20 years old and continually forgetting what they went upstairs for or where they dropped their purse off when they got in the house. All of a sudden, in your 60s, 70s, 80s, or 90s, the fear of getting dementia sits in the back of your mind hanging over any episode of forgetting a word, forgetting to call your sister, or forgetting what you just read in the paper. It is important not to freak out just yet! Just as when you were younger, there are a lot of reasons that our memory slips from situation to situation.

Scared brain

Interest is a factor that affects our ability to remember things. Just think about when you were younger and sitting in school listening to a lecture you just couldn’t care less about. Comparatively to a subject you were interested in, which lecture was easier to remember? The subject you were interested in. Another factor that affects memory is focus. When you are distracted by something else whether it’s something that is going on in the same room or something that happened at home, if you’re thinking about something else, it’s much harder to remember the things that are happening right in front of you. And then there is stress. Big. Bad. Stress. If you are stressing over your memory, you’re likely to forget more than if you just relaxed. Stress does a lot of bad things to our bodies, and its effects on memory are just one of them.

Now don’t get me wrong, your general memory and ability to remember different things does naturally decline as you age. This is completely normal. But the only time for concern is when these memory blips start to affect your ability to function in everyday life. Now it is time to visit your doctor.

There are a couple of changes that may indicate you are experiencing abnormal cognitive and memory changes. When you start to notice these, it is time to go see your doctor. These are the 7 Changes of Cognition:

  1. Changes in memory that affect day-to-day activities like losing your wallet and putting your purse in the microwave
  2. Changes in language abilities, often forgetting words and using words that don’t work in a sentence
  3. Changes in the ability to make sound judgement like wearing the proper clothes for the weather
  4.  Changes in mood, behaviour, and personality like going from easy-going to very uptight and hot tempered or from engaging in activities to becoming more recluse
  5. Changes in the ability to perform familiar tasks like preparing your signature dish
  6. Changes in orientation like not knowing where you are or what time, month or year it is
  7. Changes in abstract thinking like understanding complex concepts and using and understanding metaphors

If you do start to experience the 7 Changes of Cognition, you should go see your doctor.

 

 

 

What is Cognition?

By Eleanor Pineau

 

Often when I speak about my research, people ask me what cognition is. So what is it? What does it mean to have cognitive decline and how does it relate to dementia?

 

Question 1: What is cognition?

Answer: Cognition is an umbrella term used to describe all your mental processes. Cognition is made up of many factors including memory, attention, language, visuospatial abilities. Each of these factors is composed of many smaller factors. For example, memory is made up of long-term memory, short-term memory, episodic memory, semantic memory, and working memory.

Types of Memory graphic.png

What’s important for you to know is that cognition, and the processes that make it up, allow you to:

  • Experience a sensation, a perception, a notion, or have an intuition.
  • Make the decision to go to work in the morning, or pick out the clothes you are going to wear.
  • Speak and understand speech.
  • Remember where you left your keys, your mother’s name, and what your son looks like.
  • Pay attention to the road when you’re driving, or when you are having a conversation with someone.
  • Understand that a tree is a tree, and a pen is a pen.

Cognition allows you to understand and operate in the environment around you.

 

Question 2: What does it mean to have cognitive decline?

Answer: Cognitive decline means that a person has difficulties with ANY one or combination of the factors that make up cognition (i.e., memory, attention, language, visuospatial abilities).

What you need to know is that cognitive decline is a NORMAL part of aging. In fact, we cognitive decline starts in our 30s and 40s! Isn’t that crazy! But it’s ok because the declines are so minor that they don’t affect our daily lives.

 

Question 3: But isn’t cognitive decline = dementia?

Answer: Dementia is NOT forgetting where you put your keys…EVERYONE does that! It is completely normal. What dementia IS, is cognitive decline that is severe enough to impact one’s ability to complete essential daily activities such as eating, dressing, going to the bathroom, bathing, and moving around the environment.

So then what does dementia look like?

Dementia looks different in every single person that has it. Some people’s first symptoms are memory impairment. Others experience behaviour or personality changes first, while others experience problems in judgement or decisions.

Memory impairment in someone with dementia looks like this: it’s someone who forgets where they are, what they are doing, or the names and faces of their family members.

Someone else with dementia might have a personality change; so once they usually kept to themselves, and now they are more bold and interactive.

Another person with dementia might have problems with judgement and this might be expressed in giving too much money to a charity – like all their savings… eek!

As dementia progresses and affects more parts of the brain, more symptoms will appear and symptoms usually worsen. All these symptoms of dementia are due to a decline in cognition; damage to the brain.

 

Summary

Cognition is your brain – it’s all the processes that work to allow you to experience and interact with the world around you. Cognitive decline is a normal part of aging and is any decline in the ability to interact with the world. Cognitive decline may progress to Dementia. Dementia looks different in every person and all symptoms are due to a decline in cognition, damage to the brain.