Sundown Syndrome in Older Persons: A Scoping Review.

OBJECTIVES: To map comprehensive investigations of the sundown syndrome (SS), highlighting its key definition and associated characteristics. DESIGN: Scoping review of published articles on SS in PubMed, OVID, EMBASE, Scopus, CINAHL, and Science Direct. SETTING: Post-acute and long-term health care settings. PARTICIPANTS: Older adults aged ≥60 years. MEASURES: Articles must present primary data on specific SS behavior, with explicit psychopathological and quantitative outcomes; and/or evening disruptive behavior. RESULTS: From a total number of 460 articles focusing on psychopathology and standardized outcomes of SS, 23 were retained for the final analysis (n = 1210 subjects). The mean age of participants was 63.2 years, and slightly more participants were women. The samples were recruited by convenience from long-term care facilities and tertiary outpatient clinics. The frequency of SS varied from 2% to 82%, without evident difference between genders and race/ethnicity. Generally, the sundown episode occurred during later daytime, when psychomotor alterations and cognitive disturbance manifested repeatedly. The symptomatic manifestations of SS were heterogeneous across the studies. Demographic risk factors were inconsistent. Although some authors have viewed cognitive impairment as a substantive predisposing factor to SS, others supported SS as a predictor of looming cognitive decline. The disrupted circadian rhythm was the most accepted pathophysiology. To date, clinical trials to guide the management of SS with specific pharmacologic and nonpharmacologic approaches are scant. CONCLUSIONS AND IMPLICATIONS: SS can be viewed as a cyclic delirium-like condition affecting the older population around the sunset hour that may last for a few hours. The scarcity of comprehensive studies makes it difficult to determine whether and to what extent it can represent a distinct disease, a prodromal stage of dementia, or an epiphenomenon of incipient or worsening dementia. Extensive gathering of clinical data from multiple health care settings, using uniform measurement tools, is much needed.

Evaluation of Bipolar Disorder in Children and Adolescents Referred to a Mood Service: Diagnostic Pathways and Manic Dimensions.

OBJECTIVES: Few studies have examined pediatric mental health services for early-onset bipolar disorder (BD). The goal of this study was to describe diagnostic pathways and manic dimensions in BD among referred children and adolescents. METHODS: Data were obtained from a review of the charts of 814 subjects, 2 to 17 years of age, with a complaint of mood disturbances who were referred between 2003 and 2012 to a university-based child and adolescent clinic that specializes in mood disorders. After screening, eligible participants (N=494) were systematically assessed and followed to determine diagnoses on the basis of criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision in accordance with the best-estimate approach. Manic symptoms were subjected to principal component analysis to investigate the dimensional bipolar profile of the sample. RESULTS: Among the total help-seeking sample, approximately one third of the participants dropped out at intake and, after an average follow-up of 1.7 years, one third had been determined to meet criteria for BD and one third did not fulfill operational criteria for BD. The diagnostic status was changed in 35% of patients: approximately 10% were false positive (going from any bipolar diagnosis to a nonbipolar diagnosis) and approximately 25% were false negative (going from a nonbipolar diagnosis to any bipolar diagnosis). Most patients who converted to a bipolar diagnosis were initially labeled with major depressive disorder or attention-deficit/hyperactivity disorder and had a longer follow-up period. Relevant manic dimensions were elation, grandiosity, and disruption, which explained 41.4% of total variance. CONCLUSIONS: Regular reappraisal and follow-up of children and adolescents with mood disturbances provides a window for detection of BD (eg, of core manic dimensions). A coordinated and hierarchical connection among pediatric mental health services with different degrees of specialization is recommended.

Sleep Complaints as Risk Factor for Suicidal Behavior in Severely Depressed Children and Adolescents.

OBJECTIVES: To investigate the association between sleep complaints and suicidal behaviors among severely depressed children and adolescents. METHODS: The sample was 214 youths (56.1% males, mean age 12.5 years) with diagnosis of DSM-IV major depressive disorder consecutively recruited from a university-based outpatient clinic specialized in mood disorders. The structured interview for children and adolescents was applied to participants. The Children's Depression Rating Scale-revised version-scored the severity of depression, and the Children's Global Assessment Scale assessed the global functioning. Subgroups of patients were compared for psychopathological association by means of logistic regression, in accordance with presence and absence of sleep complaints and suicidality. RESULTS: The frequency of sleep complaints and suicidal behaviors was, respectively, 66.4% and 52.3%, and both symptoms were observed in 37.9% of patients. Initial insomnia was the most frequent manifestation (58%), followed by night awakening (36%), daytime sleepiness (31%), and early awakening (29.9%). Significant association between sleep disturbance and suicidal behavior was found (odds ratio range of 2.3-10.8). CONCLUSION: Sleep disturbances are potential warning manifestations of suicidal behaviors in depressed youth. Possibly, the severity of the active affective episode likely underlies in both sleep complaints and suicidal behaviors among depressed underage patients.