A Sensory Lens to Explain Sundowning

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Sundowning is a term broadly used to describe a set of behaviours occurring in people with or without dementia, which commonly presents later in the afternoon, evening and late at night. Behaviours include confusion, disorientation, anxiety, agitation, yelling and calling out, aggressive outbursts (verbal and/or physical), pacing and wandering. 

While not a formal psychiatric diagnosis, the prevalence of sundowning is well recognised and well documented. Some literature suggests rates of sundowning for elderly persons with cognitive impairment such as dementia are as high as 66%. Sundowning can be very challenging to manage and have a significant impact on the person and their loved ones/carers who are supporting them.

A number of theories exist regarding the possible reason/s for sundowning, though none have demonstrated a high level of scientific evidence to date. Commonly held beliefs about the prevalence of sundowning in people with dementia include:

·         Problems with circadian rhythm (the internal body clock) and difficulty differentiating between dream state during sleep and reality

·         Misinterpretation of input (light and shadows) which increases confusion, fear & agitation

·         Less stimulation after dark to act as a distraction

·         A consequence of mood symptoms or medications wearing off in the afternoons

·         Unmet physiological needs – hunger, thirst, pain, over tiredness

Sensory Modulation Brisbane has considered sundowning with a sensory lens and whether these behaviours are in fact a consequence of sensory overload. This could apply to people with dementia, Autism Spectrum Disorder and other conditions.

Sensory overload occurs when a person experiences too much sensory input for their system (too loud, too busy, too bright, too fast or too intense) resulting in increased feelings of distress and overwhelm. Think about a baby who has been too stimulated through the day, they will often become overloaded, upset and are much more difficult to settle in the evening. For a person with dementia, sensory overload will have a similar effect and thus could be a significant factor in the occurrence of sundowning behaviours. Some literature has suggested that agitation could be a behavioural response to sensory overstimulation and wandering may be an attempt at self- regulation.

People with cognitive impairment like dementia often experience sensory overload due to difficulties with:

·         understanding their unique sensory needs and preferences

·         being able to regulate sensory input throughout the day, for example turning down the volume, changing the temperature, opening or closing the door or window covers or even their choice of meal flavours and textures.

·         being able to communicate their sensory needs to others, for example telling others when they feel uncomfortable or in pain or timely requests to change sensory input in their environments

To help manage behaviours related to dementia, non-pharmacological measures including environmental assessment and modifications are recommended. Sensory modulation is therefore an effective means of reducing the prevalence and challenging consequences of sundowning behaviours, by actively managing and addressing the experience of sensory overload. Examples of sensory modulation strategies include:

1.       Dialling down sensory input into the afternoon and evening, such as –

·         Slowly turning down light levels

·         Reducing visual movement and business in the environment, including turning off the TV.

·         Reducing sound levels/volume, or use of gentle white noise in background to filter out unwanted sound

·         Eliminate unwanted scent with products such as nil odour, or using a familiar scent known to be comforting to the person (be mindful not to diffuse scents in public/common spaces as other people may not prefer/like this smell)

2.       Use of individually preferred sensory input at the times sundowning can occur, such as –

·         Gentle movement like rocking, stretching or swaying

·         Deep pressure like weighted items

·         Comforting touch like a warm bath or heat pack, snuggly throw rug, familiar tactile items to explore in hands.

3.       Engagement in familiar, calming routines and activities in the afternoon and evenings to increase feelings of comfort and stability and reduce experience of unfamiliar and novel sensory input.

4.       Access to a book or digital frame with familiar and soothing pictures of family, friends, pets, places.

References

(2011). Khachiyants, N; Trinkle, D; Son, SY & Kim, KY.  Sundown Syndrome in Persons with Dementia: An Update. Psychiatry Investigation, 8:275-287

(2022). Rhodus, E; Hunter, E; Rowles, G. Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study. Gerontology and Geriatric Medicine. 8, 1-11  https://doi.org/10.1177/23337214211068290

 Link to Online Training – How to Use Sensory Modulation with Aged Care Residents

Sensory Modulation Resource Manual (2017) J O’ Sullivan and C Fitzgibbon.

Acute Care Team Legend Rachel Woolcock using cooling down sensory modulation options.

Recently I met with one of the most experienced and skilled Mental Health Clinical Nurses in Queensland – Rachel Woolcock. Rachel has over 20 years experience with Mental Health including acute care and homeless health. Rachel has undertaken Sensory Modulation Brisbane training and applies Sensory Modulation strategies regularly when working with very distressed or agitated clients. Rachel identifies that one of the most beneficial techniques for this client group has been cooling down with the dive reflex response. In her experience, Rachel has found that it is important to acknowledge that the technique sounds 'unusual' or 'a bit funny' but continues to encourage people to try it, with positive outcomes!

Cooling down options include:

·         Zip lock bags with cold water,

·         Cold slushies

·         Cold water in sinks,

·         Cold stress balls

·         Chill towels

·         Cold face washer/face cloth/flannel

·         Using ice sprays

·         Disposable ice packs

·         Cold Shower

·         Jumping into a cold pool or ocean

·         Cold drink

·         Ice bucket challenge

Cold temperature can be useful for several reasons:

·         It can cool the body when it is hot (eg when anger flushes the face and hands).

·         As a calming strategy when anxious or panicking

·         As a calming strategy when angry or feeling destructive or aggression.

·         Cool water in conjunction with breath holding can invoke the mammalian dive reflex and reduce the heart rate. (this makes it unsuitable for people with heart conditons or anorexia nervosa without prior medical clearance. If you have a medical condion – ask your Doctor if this is ok for you)

·         As an intense sensation, it can be an alternative to self harm.

·         The sensory input can feel grounding and reduce dissociation.

·         To cease hallucinations (we have had a couple of clients try this and found it is the most useful technique that they have found)

How to use cold water to chill:

·         The cold items can be held in the hands, or applied to the face or the whole body. Each person can think about what will work for them and also how much cold that they are comfortable with using.

·         Using the icy water on the face can be an intense sensation but can provide a very quick calm down strategy.

·         Icy water can be either applied from a bowl or applied to the area under the eyes in a zip lock bag filled with water. The breath is then held. The combination of holding our breath and applying icy water activated the mammalian dive reflex. This reflex has the biological function of decreasing our heart rate to preserve the body and brain if a person falls into the icy water. By decreasing the heart rate and increasing carbon dioxide levels in the blood *by holding our breath) our feelings of calm and grounding increase. This technique is used within Sensory Modulation and also within Dialectical Behaviour Therapy as a distress tolerance skill (TIP skill) .

Further suggestions on Sensory Modulation items are in the Sensory Modulation Resource Manual or in the online course:

Using Sensory Modulation Course

Pre-recorded Videos, slides and downloadable infographics and handouts. IT is 5 hours CPD:

Sensory Modulation Resource Manual

DBT skill training handouts and worksheets  Linehan (2014)

Intense Sensations Handout

Dive Reflex Blog

Image description: young woman with dark hair holding a purple gel mask over her face. She would be doing this to calm herself when distressed.

Weighted Blankets: Need for more evidence but definitely not no evidence

Weighted blankets are a popular Christmas present this year and have also been described by Time Magazine as one of the best inventions of 2018 (Source: Choice Magazine.)   Gravity weighted blankets have sold over $18 US million dollars worth of weighted blankets yet many experts say that there is no evidence that they work.

I must admit I am getting a little tired of ‘experts’ being interviewed who state that there is no evidence for weighted blankets. I wonder if they do a recent google search or if they are going on something that they read years ago when the research trials were just beginning.

 It would be more accurate to describe that there is strong evidence in some areas and limited evidence in other areas.  In research groups, strong and limited evidence is described according to levels of evidence. This table describes the categories of levels of evidence.

Level of evidence description (Winona State University Evidence Based Practice Tool kit)

Level     I

Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.

 Level II

Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).

 Level III               

Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental

 Level IV               

Evidence from well-designed case-control or cohort studies

 Level V

Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).

 Level VI               

Evidence from a single descriptive or qualitative study

 Level VII             

Evidence from the opinion of authorities and/or reports of expert committees.

As each research paper is published, the evidence is accumulating that weighted blankets work. In 2020 alone, a quick google scholar search will bring 15 articles up on weighted blankets. This includes a systemic review and randomised control trials. As soon as one systemic review is published it is out of date. For example the 2020 article on systemic review found that there were no randomised control studies for insomnia, but since their search was in 2018, there have been multiple randomised control studies published in this area. It is pretty hard to keep up.

In this blog, I will only refer to Level 1 and Level 2 evidence as this is considered the highest levels of evidence. There are hundreds of research papers for Level 3, 4, 5, 6, 7 levels of evidence.

Level 1: Evidence that a weighted blanket decreases anxiety

A systematic review was conducted on weighted blankets and concluded that ‘ the literature supports the use of weighted blankets for anxiety reduction’

(This article also looked at insomnia however there were less articles available at the time of the review and the ones that I have included here are more recent)

“Credible research suggests that weighted blankets may be an appropriate therapeutic tool. The intervention was reviewed for use in relieving anxiety and it was found to demonstrate some success in reducing anxiety. “

Level 2 Evidence in Insomnia, Adult patients receiving chemotherapy, Adult patients with eating disorders in inpatient setting.

Another systematic review on insomnia is warranted given the recent studies in the last 2 years. This includes:

A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders

Conclusion:  

Weighted chain blankets are an effective and safe intervention for insomnia in patients with major depressive disorder, bipolar disorder, generalized anxiety disorder, or attention deficit hyperactivity disorder, also improving daytime symptoms and levels of activity.

Worth The Weight: Weighted Blanket Improves Sleep And Increases Relaxation. (randomised control trial)

Results:

Objective sleep data from the 28 participants who completed all study requirements showed 7% improvement of Wake After Sleep Onset, 2% decrease in Light Sleep, and slight improvement in Sleep Efficiency (1.5%) and Sleep Maintenance (1.4%) during intervention (all ps < 0.05). Additionally, participants felt they fell asleep faster (13% faster), experienced better sleep quality (14% better), felt more rested in the morning (17% more rested), and felt they slept better through the night without waking up (36% improvement). They also reported feeling 13% less stressed at bedtime and 17% more relaxed while trying to fall asleep.

Conclusion

Using a weighted blanket reduces self-reported feelings of stress, enhances feelings of relaxation, and can improve sleep and reduce time awake at night in people with sleep onset and sleep maintenance issues.

Weighted Blankets: Anxiety Reduction in Adult Patients receiving chemotherapy.

Conclusion: “

This randomised control trial concluded that a standard-weight, medical-grade therapeutic weighted blanket can be safely used to reduce anxiety in patients of various weights, and a visual analog scale can be a reliable indicator of patients' state anxiety.

Assessing the Impact of Weighted Blankets on Anxiety for Patients With Eating Disorders in an Inpatient Setting: A Randomized Control Trial Pilot

An RCT that assesses the efficacy of weighted blankets on anxiety for patients with severe anorexia nervosa (AN) and avoidant restrictive food intake disorder (ARFID) in an inpatient medical setting. The results demonstrate clinical significance, advancing the field of OT as it supports the use of a sensory intervention to positively impact psychological and emotional states of a patient population with limited evidence to support best practices.

Low levels but not no evidence that weighted blankets improve sleep in Autistic children.

There has been some research on using weighted blankets with autistic children that have not found strong levels of evidence of the benefits. However, the weighted blanket was favored by children and parents, and blankets were well tolerated over this period in this study. There has also been some research with small number that have shown positive benefits, but these need to be larger scale and randomised to add to the evidence base .

 In my opinion, this is a tricky area to research due to the sensory over and under responsivity of Autistic People. For example, one child may really dislike deep pressure (and therefore weighted blankets) whilst another child may find it very calming. Ideally, the sensory preferences of autistic children would be identified as part of the protocol for future research.

The practice guideline: treatment for insomnia and disrupted sleep behaviour in children and adolescents with autism spectrum disorder stated that: Clinicians should counsel that there is currently no evidence to support the routine use of weighted blankets or specialized mattress technology for improving disrupted sleep. If asked about weighted blankets, clinicians should counsel that the trial reported no serious adverse events with blanket use and that blankets could be a reasonable nonpharmacological approach for some individuals.

 Special Mention:

One researcher stands out as having published multiple papers on Weighted Blankets and championing the benefits – Tina Champagne. We can thank Tina for all of her groundbreaking work that has contributed to weighted blankets being recognised as evidence based and  in such popular use that it is now considered a great Christmas present. This is one of Tina Champagnes articles:  

Mullen and Champagne et al (2008) explored the effectiveness of a thirty pound weighted blanket on thirty-two adults. Vital sign metrics showed that using the weighted blanket in a lying down position was safe. Thirty-three percent of participants experienced a lowering of electro-thermal activity, sixty-three percent reported lower anxiety and seventy eight percent preferred the weighted blanket as a calming modality.

Safety

For people with disabilities and medical conditions it is recommended to discuss the option of a weighted blanket with an Occupational Therapist and your treating Doctor. This blog is a general description of the benefits and is not advice specific to the individual.

Further Information

Weighted Blankets are a Sensory Modulation intervention using deep pressure stimulation.

Further information on Sensory Modulation is available from:

O Sullivan, J & Fitzgibbon, C (2018) Sensory Modulation Resource Manual

Champagne, T. (2011) Sensory Modulation & Environment: Essential elements of occupation

Using Sensory Modulation Online Course 5 hours CPD.

References

Rachel Ohene, MOT, OTR/L; Christina Logan, MS, OTR/L; Ashlie Watters, PhD; Figaro Loresto, PhD, RN; Kathryn Eron; Philip Mehler, MD, FACP, FAED (2020) Assessing the Impact of Weighted Blankets on Anxiety for Patients With Eating Disorders in an Inpatient Setting: A Randomized Control Trial Pilot

A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders

Ekholm B, Spulber S, Adler M. (2020) A randomized controlled study of weighted chain blankets for insomnia in psychiatric disorders. J Clin Sleep Med. 2020;16(9):1567–

Danoff-Burg, Sharon & Rus, Holly M & Martir, L & Raymann, Roy. (2020). 1203 Worth The Weight: Weighted Blanket Improves Sleep And Increases Relaxation. Sleep. 43. A460-A460. 10.1093/sleep/zsaa056.1197

Eron, K, Kohnert, L, Watters, A, Logan, C, WEisner-Rose, M, Mehler, P. (2020) Weighted Blanket Use: A systematic Review American Journal of Occupational Therapy, August 2020, Vol. 74, 7411515404. https://doi.org/10.5014/ajot.2020.74S1-PO5511

P Gringras, D Green, BWright, C Rush, M Sparrowhawk, K Pratt, V Allgar, Naomi Hooke, D Moore, Z Zaiwalla and L Wiggs (2014) Weighted Blankets and Sleep in Autistic Children—A Randomized Controlled Pediatrics August 2014, 134 (2) 298-306; DOI: https://doi.org/10.1542/peds.2013-4285

Choice article: https://www.choice.com.au/health-and-body/conditions/trouble-sleeping/articles/do-weighted-blankets-work

Mullen, B., Champagne, T. Krishnamurty, S. Dickson, D & Gao, R. (2008) Exploring the safety and therapeutic effects of deep pressure stimulation using a weighted blanket. Occupational Therapy in Mental Health, 24, 65 -89

Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

Ashura Williams Buckley, Deborah Hirtz, Maryam Oskoui, Melissa J. Armstrong, Anshu Batra, Carolyn Bridgemohan, Daniel Coury, Geraldine Dawson, Diane Donley, Robert L. Findling, Thomas Gaughan, David Gloss, Gary Gronseth, Riley Kessler, Shannon Merillat, David Michelson, Judith Owens, Tamara Pringsheim, Linmarie Sikich, Aubyn Stahmer, Audrey Thurm, Roberto Tuchman, Zachary Warren, Amy Wetherby, Max Wiznitzer, Stephen Ashwal First published February 12, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009033

 Winona State University Evidence Based Practice Tool kit: https://libguides.winona.edu/c.php?g=11614&p=61584

: This level of effectiveness rating scheme is based on the following: Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier.

 https://pediatrics.aappublications.org/content/134/2/298.short

How do you do Sensory Modulation on an Impatient Mental Health Unit without a Sensory Room?

A Sensory Room is a dedicated room with an array of sensory items and strategies for people to trial and use to support their development of self-management skills and to change their moods through Sensory Modulation*. Sensory rooms have been found to be useful in many mental health units by those who use them. (Champagne, 2011).  

Often people express that they would like to use Sensory Modulation, but that their organisation is unable to fund a Sensory Room or find the space to put one. The good news is that is possible to use Sensory Modulation on an inpatient ward or emergency department without a Sensory Room through the use of low cost or existing sensory items or considering the environment.

Low Cost Sensory Items

Low cost items can be purchased at Discount Department Stores (eg K-Mart) . This can include:

·         hand strengtheners

·         cushions

·         weights

·         books

·         mints

·         herbal teas

·         instant ice packs

·         stress balls

·         earplugs

·         scents

·         hand creams

The Sensory Modulation Resource Manual has a list of budget sensory items.

Existing Sensory Items

Many inpatient mental health units have items that they could use for Sensory Modulation. This may include:

·         Blankets, cushions

·         Art or craft equipment

·         Music

·         Ear plugs

·         Lighting – low light, lamps or dimming switches.

·         Ice Packs

·         Games

A Personal Safety Plan can be useful to introduce to an impatient unit, to identify possible sensory triggers or sensory modulation strategies.

Considering the Environment

Within every environment, whether indoors or outdoors, opportunities exist for sensory modulation or possibly sensory overload. One design solution is to develop a distinct sensory space or zone within the mental health unit. Even within the one room, there can be smaller zones. Spaces can be designed so that people are able to move to the area that suits their unique sensory preferences and needs at the time. Zones may include the following:

·         Exercise zone

·         Calm garden zone

·         Low stimulation zone

·         Socialising zone

·         Soothing or comfort zone.

Other sensory zone ideas are available in the The Sensory Modulation Resource Manual

In a 2017 study, Yakov et al found that the lowering of lights and sounds on a mental health unit in the late afternoon reduced the rate of seclusion and restraint. Assault rates fell 83 per cent and the need for seclusions fell by 72 per cent.

On August 6th  2019, Sensory Modulation Brisbane is offering a workshop to use Sensory Modulation in Inpatient Mental Health Units. Other workshops are being held on the use of Sensory Modulation for community settings, for people working in the Non Government Agencies, and for Teacher Self Care.

*Sensory Modulation can be defined as ‘changing how you feel through using your senses’. (O’ Sullivan & Fitzgibbon, 2018).

Citations and Resources:

Adams-Leask,K., Varonal, Lisa, Dua., Charu (2018). The benefits of sensory modulation on levels of distress for consumers in a mental health emergency setting.  Volume: 26 issue: 5, page(s): 514-519 https://journals.sagepub.com/doi/abs/10.1177/1039856217751988

 Champagne, T., (2011) Sensory Modulation & Environment: Essential Elements of  Occupation – 3rd edition

 https://medicalxpress.com/news/2017-12-noise-psychiatric-icu-calmer-safer.html

S. Forsyth, Angus & Trevarrow, Rebecca. (2018). Sensory strategies in adult mental health: A qualitative exploration of staff perspectives following the introduction of a sensory room on a male adult acute ward. International Journal of Mental Health Nursing. 27. 10.1111/inm.12466.

Hedlund Lindberg, Mathilde & Samuelsson, Mats & Perseius, Kent-Inge & Björkdahl, Anna. (2019). The experiences of patients in using sensory rooms in psychiatric inpatient care. International Journal of Mental Health Nursing. 10.1111/inm.12593.

O’ Sullivan, J., & Fitzgibbon, C (2018) Sensory Modulation Resource Manual.

Svetlana Yakov et al. Sensory Reduction on the General Milieu of a High-Acuity Inpatient Psychiatric Unit to Prevent Use of Physical Restraints: A Successful Open Quality Improvement Trial, Journal of the American Psychiatric Nurses Association (2017). DOI: 10.1177/1078390317736136

Te Pou Mental Health Initiatives: Sensory Modulation: https://www.tepou.co.nz/initiatives/sensory-modulation/103