Air under the skin, shadows in the mind: an enigmatic case report on hyperactive delirium or Sundowning triggered by subcutaneous emphysema postpneumothorax

Sundowning Syndrome (SS) is a clinically observed phenomenon, primarily associated with Alzheimer’s disease (AD), characterized by the exacerbation of neuropsychiatric symptoms during the late afternoon or evening, or in conditions of reduced ambient illumination. These symptoms may include, but are not limited to, agitation, anxiety, confusion, hallucinations, and altered sleep-wake cycles. The absence of a universally accepted definition and standardized diagnostic criteria contributes to inconsistencies in clinical assessment and research. Diagnostic approaches frequently utilize behavioral rating scales, such as the Cohen-Mansfield Agitation Inventory and the Neuropsychiatric Inventory (NPI), which are often caregiver-reported. A proposed operational definition emphasizes the acute onset of disruptive behavioral changes in individuals with dementia during evening hours, with a focus on symptoms that significantly impact caregiving. Environmental modifications, particularly optimized ambient lighting, are considered a key nonpharmacological intervention for symptom management. In this work, we present an interesting case report of a patient who developed SS following hospitalization in a thoracic surgery unit for a pneumothorax complicated by subcutaneous emphysema. The emphysema extended from the thorax to the face, involving the periorbital region and resulting in the patient’s inability to open their eyes. This sensory deafferentation triggered the onset of symptoms associated with SS in a patient with no prior history of psychiatric disorders.