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Air under the skin, shadows in the mind: an enigmatic case report on hyperactive delirium or Sundowning triggered by subcutaneous emphysema postpneumothorax
Thomas Fraccalini, Beatrice TAROZZO, Alessandro Maraschi, Luciano CARDINALE, Giorgio Garofalo, Julia Michelin Vecchini, Laura SANTOS RIBEIRO, Stefania Gioia et al.. Minerva Psychiatry, 2025-12-01
Topic: Brain proteins, microglia and lab models
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.
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
APA 7th
Fraccalini, T., TAROZZO, B., Maraschi, A., CARDINALE, L., Garofalo, G., Vecchini, J. M., et al. (2025). Air under the skin, shadows in the mind: an enigmatic case report on hyperactive delirium or Sundowning triggered by subcutaneous emphysema postpneumothorax. Minerva Psychiatry. https://doi.org/10.23736/s2724-6612.25.02639-9
Vancouver
Fraccalini T, TAROZZO B, Maraschi A, CARDINALE L, Garofalo G, Vecchini JM, et al. Air under the skin, shadows in the mind: an enigmatic case report on hyperactive delirium or Sundowning triggered by subcutaneous emphysema postpneumothorax. Minerva Psychiatry. 2025. doi:10.23736/s2724-6612.25.02639-9.
BibTeX
@article{fraccalini2025-994cdaf0,
author = {Fraccalini, Thomas and TAROZZO, Beatrice and Maraschi, Alessandro and CARDINALE, Luciano and Garofalo, Giorgio and Vecchini, Julia Michelin and RIBEIRO, Laura SANTOS and Gioia, Stefania and others},
title = {{Air under the skin, shadows in the mind: an enigmatic case report on hyperactive delirium or Sundowning triggered by subcutaneous emphysema postpneumothorax}},
journal = {Minerva Psychiatry},
year = {2025},
doi = {10.23736/s2724-6612.25.02639-9},
url = {https://doi.org/10.23736/s2724-6612.25.02639-9}
}
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Key findings
- 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.
- 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.
- This sensory deafferentation triggered the onset of symptoms associated with SS in a patient with no prior history of psychiatric disorders.
Why it matters
This is a single case report of a patient who developed Sundowning Syndrome following hospitalization for a pneumothorax complicated by subcutaneous emphysema. As a case report, it cannot establish causation or provide generalizable evidence about treating, curing, or preventing Alzheimer's disease.
Study details
- Study designcase report
- Evidence strengthLow
How this study scored 31/100
Published in a peer-reviewed journal. Scored zero for study design, sample size, effect reported, studied in people and randomized / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Minerva Psychiatry) |
| Journal's citation record | 0 / 4 | Minerva Psychiatry: journal h-index 9 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | Design recorded as “case report”, which our rubric does not rank (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 4 / 5 | 2025 — within 3 year(s) of the newest study here |
| Sample size | 0 / 4 | Participant count not stated — scores zero (not stated in the record — scored 0) |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 0 / 3 | Not stated whether this was studied in people — scores zero (not stated in the record — scored 0) |
| Randomized / blinded | 0 / 2 | No randomization or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 1 / 7 | Cited 2 times (OpenAlex, 2026-10-10) |
| Citations per year | 0 / 5 | 0.7 citations a year over 3 year(s) since 2025 |
| Impact for its field and year | 2 / 6 | Cited 1.2× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 2 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 1 / 4 | Last-listed author Giovanni Volpicelli: h-index 5 (OpenAlex, whole career) |
| Institution's track record | 2 / 3 | University College London: institution h-index 2,029 (OpenAlex) |
| Multicenter collaboration | 2 / 3 | OpenAlex lists 7 institution(s) in 2 countries |
| Indexed in PubMed | 1 / 2 | Not in PubMed, but has a DOI |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 31 / 100 | — |
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