Circadian rhythms of agitation in institutionalized patients with Alzheimer's disease

Agitation is a common problem in institutionalized patients with Alzheimer's disease (AD). "Sundowning," or agitation that occurs primarily in the evening, is estimated to occur in 10-25% of nursing home patients. The current study examined circadian patterns of agitation in 85 patients with AD living in nursing homes in the San Diego, California, area. Agitation was assessed using behavioral ratings collected every 15 minutes over 3 days, and activity and light exposure data were collected continuously using Actillume recorders. A five-parameter extension of the traditional cosine function was used to describe the circadian rhythms. The mean acrophase for agitation was 14:38, although there was considerable variability in the agitation rhythms displayed by the patients. Agitation rhythms were more robust than activity rhythms. Surprisingly, only 2 patients (2.4%) were "sundowners." In general, patients were exposed to very low levels of illumination, with higher illumination during the night being associated with less robust agitation rhythms with higher rhythm minima (i.e., some agitation present throughout the day and night). Seasonality was examined; however, there were no consistent seasonal patterns found. This is the largest study to date to examine agitation rhythms using behavioral observations over multiple 24 h periods. The results suggest that, although sundowning is uncommon, agitation appears to have a strong circadian component in most patients that is related to light exposure, sleep, and medication use. Further research into the understanding of agitation rhythms is needed to examine the potential effects of interventions targeting sleep and circadian rhythms.