I have opinions. Wanna hear them? The Going Down of the Sun

Recently, I learned of a phenomenon known as Sundown syndrome. Sundowner syndrome refers to a specific state of confusion and agitation that shows up sometime between late afternoon and dusk and persists into the evening. For the most part, experts associate Sundown syndrome, or Sundowning, with dementia.

Symptoms can include:

• hallucinations

• verbally and physically aggressive behaviour

• anxiety or irritability

• suspiciousness or paranoia

• restlessness or pacing

• wandering

• difficulty sleeping

• fatigue that leads to deep sleep from late afternoon to around eight o’clock at night

• lack of interest in listening to suggestions or cooperating with loved ones and other care providers

• disorientation or loss of focus

• A lack of desire to listen to suggestions or collaborate with family members

These symptoms that can be brought on by stimuli/events like:

• Spending a day in a place that's not familiar.

• Low lighting.

• Increased shadows.

• Trouble separating reality from dreams.

• Internal voices

• Suicidal ideation

• Being hungry or thirsty.

• Depression.

• Disruption of the body's ‘internal clock’ - their circadian rhythm.

Let’s focus on the lack of sleep issue. Circadian rhythms in particular.

The circadian rhythm, in basic terms, is the internal cycle that helps regulate various brain and body processes. This cycle, which aligns with Earth’s 24-hour day, is very responsive to changes in light. That’s why you feel tired at night, when it begins to get dark, and more alert in the morning, when the sun comes up.

It is widely accepted that chemical changes in the brain caused partly be lack of sleep can impact on circadian rhythms when someone is affected by Alzheimer’s disease, Lewy body dementia, and other types of dementia. Brain changes caused by dementia can result in psychosis, hallucinations, and delusions. Hallucinations and delusions may also occur in Alzheimer’s disease. It’s a vicious cycle (pun intended). Lack of sleep causes lots of those symptoms but those symptoms cause lack of sleep. And spin your partner round and round.

Which leads me to Bipolar Disorder. Of course it does. This is my essay-thingy about Bipolar and I like to talk about myself.

When the sun is on its way to dropping over the horizon, many of the above Sundowner symptoms and their associated stimulus seem mightily familiar to those who suffer from bipolar disorder, especially the confusion and fatigue.

So much fatigue. So much confusion. And anxiety. And psychosis.

Now, psychosis—particularly the hallucinations—is uncommon in bipolar disorder  on its own but many of us bipolar-y type people have schizoaffective disorder as carry-on luggage, so lots of delusions and auditory hallucinations, folks.

If a bipolar person, with or without extra luggage, doesn’t get enough sleep, their  circadian rhythms are blown to smithereens which leads to sundowning. Just like dementia. Clever psychiatrists and therapists have said so in smart papers which have been peer-reviewed.

This disruption to the biological clock alters normal sleep-wake cycles and triggers late afternoon/ early evening confusion, distress, and fatigue.

Most people with bipolar disorder experience altered sleep-wake cycles. Some consider circadian rhythm dysfunction a key component of the condition, not to mention a major cause of sleep problems.

Those same smart people mentioned above have found evidence suggesting that bipolar disorder may relate to a type of dementia called behavioural variant front temporal dementia, because the conditions share similar underlying causes and symptoms.

Let’s repeat that. Bipolar symptoms are the very close cousin to dementia. That concept scares the crap out of me.

Without a doubt, an irregular biological clock can affect the amount of sleep you get, not to mention its quality. But can it also cause evening confusion, disorientation, and other symptoms similar to sundown syndrome? Yes. I have anecdotal evidence. Me. If I don’t get good sleep—proper sleep of the Circadian type—I will be non-functional by four o’clock in the afternoon. Confusion. Distress. Fatigue.

Recently I participated in a Zoom meeting/chat with a lovely author friend. It was at four o’clock in the afternoon. I participated, I pushed through, and apparently I sounded quite coherent even though my confusion was on show. I couldn’t remember the questions, and I could hear the manic tone infusing my voice. I was sliding into Sundown. It was strange to watch it happening in real time in the little Zoom rectangle. Like I was having an out-of-body experience.

Sleep disturbances, plucked from this month’s issue of Awful Bipolar, have been cited as the most common signs for the onset of mania.

Mania means psychosis. A lot of up and down to the side to the left to the side to the left now spin your partner round and round and here we go again. From all anecdotal accounts, both studied and self-reported, people with Bipolar, me included, experience hallucinations involving visions, sounds, smells, textures, whispers of lies. During psychosis. Which is shown to be brought on fundamentally by sleep disturbances. It’s another Sundowner symptom. Recently, I saw ants and flies all over the walls. I checked the time. Yep, it was 3.30pm and I was exhausted and psychotic. As if I had dementia.

Okay. So we know that sleep disturbances are highly prevalent among Bipolar and dementia patients and exert a detrimental impact on the course of their chronic illnesses. It is the root that feeds the outward presentations of illnesses that many believe to be a ‘Bit of an up and down time’ and ‘Feeling just a touch too happy or sad’ and ‘Gosh, you get so much done when do you sleep?’ and ‘That aged disease’ and ‘Isn’t it a shame?’

With rapid cycling bipolar disorder, my mood can shift over the course of the day. When symptoms of depression or psychosis, including irritability, paranoia, or disorientation, come on in the evening hours, they can closely resemble sundowning symptoms. I am so tired all the time, but in the late afternoon, I am particularly exhausted to the point of falling asleep while I’m standing up. It distresses me. I am agitated. I am confused.

At that very moment, I am sundowning.