Tell Me a Bedtime Story

Something happens to my son when he gets tired. Besides the normal responses, like rubbing his eyes and occasional yawning, he starts to act crazy. He’ll start running across the room, yelling gibberish, laughing hysterically. It happens without fail. It’s as if he is trying to fight off the oncoming sleepiness. My other theory is that it’s possibly a pre-sleep psychosis. Whatever the case is, it gets tiring. To calm him, we will usually read him a bedtime story or two. He reads pretty well for a four year old, so he enjoys it and follows along. It seems to calm his brain and eventually he nods off to sleep. The house grows silent and peace returns if only briefly.

This reminds me of my patient Doris. Doris is a ninety year-old white patient of mine that was recently discharged from the hospital. She apparently got involved in an altercation with another resident at the assisted living facility that she was attending. As a result of the altercation, she sustained bruising on her arms and legs. In terms of a medical history, she has hypertension and a history of smoking. She has never been formally diagnosed with dementia, but she does have some memory issues that her family had mentioned in the past.

Ninety-year old white women usually never get into a fist fight unless there is good reason. Doris was apparently minding her own business in the middle of the night. She was on her way to the restroom, when she saw three assailants in the hall. One of them attacked her, so she fought back. There was a bit of a struggle, resulting in a few residents of the facility getting hurt. Fortunately, nobody was killed. At least that’s what she told the staff.

What actually happened, according to her family, was that Doris got up to go to the bathroom. Another resident was sitting in the hall and he was attacked by Doris, unprovoked. The two of them had to be separated, resulting in both of them having to be sent to the hospital for minor injuries.

While Doris had never been diagnosed with dementia, it’s very likely that she does have it. Why she hallucinated the entire event may be possibly related to a phenomenon known as sundowning. Causes for sundowning, much like my Dylan’s agitation, are unknown but it is usually associated with dementia, specifically Alzheimer’s. The theory is that there is a change in the circadian rhythm that disrupts the way these patients function. Symptoms include late day confusion, aggression, anxiety, and ignoring directions (which sounds like a lot of four year olds around bedtime).

There are factors that may aggravate sundowning, like low lighting, fatigue, increase in shadows, pre-existing anxiety or depression. Patient’s tend to have difficulty separating dreams from reality and can experience disorienting confusion that lead to the type of behavior Doris exhibited. To try and avoid it, try to accommodate the patient’s space and routine around their internal clock. For instance, try to make bedtime a set time and make the space as comfortable as possible. Increase the light intensity during the day to help regulate the sleep-wake cycle. Avoid daytime napping as well as too much caffeine during the day. Using a night light may also help to avoid night time confusion. Make sure that the patient is familiar with their surroundings to help anchor them in reality. Finally, it’s always important to make sure another condition, like a urinary tract infection or psychiatric condition are not responsible for the symptom.

“Can you tell me a bedtime story?,” Dylan asks when I put him to bed. I always oblige willingly but I always make a deal. If I read this last story to him, he has to promise to close his eyes and go to bed immediately. “Okay,” he replies. I read the story to him, and peace returns to the house, if only briefly.

By: Dr. Juan Borja
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