Effects of bright light at lunchtime on sleep of patients in a geriatric hospital I

Light therapy in insomnia disorder: A systematic review and meta-analysis

In the management of insomnia, physicians and patients are seeking alternative therapeutics to sleeping pills, in addition to sleep hygiene and cognitive behavioural therapy. Bright light therapy (LT) has proven its efficacy in circadian and mood disorders. We conducted a systematic literature review and meta-analysis according to Cochrane and PRISMA guidelines and using the databases Medline, Cochrane, and Web of Science, with a special focus on light therapy and insomnia. Twenty-two studies with a total of 685 participants were included, five of which with a high level of proof. Meta-analysis was performed with 13 of them: light therapy for insomnia compared with control conditions significantly improved wake after sleep onset (WASO: SMD = -0.61 [-1.11, -0.11]; p = 0.017; weighted difference of 11.2 min ±11.5 based on actigraphy, and SMD = -1.09 [-1.43, -0.74] (p < 0.001) weighted difference of -36.4 min ±15.05) based on sleep diary, but no other sleep measures such as sleep latency, total sleep time (TST), or sleep efficiency. Qualitative analysis of the review showed some improvement mainly in subjective measures. Morning light exposure advanced sleep-wake rhythms and evening exposure led to a delay. No worsening was observed in objective nor subjective measures, except for TST in one study with evening exposure. A light dose-response may exist but the studies' heterogeneity and publication bias limit the interpretation. To conclude, light therapy shows some effectiveness for sleep maintenance in insomnia disorders, but further research is needed to refine the light parameters to be chosen according to the type of insomnia, in the hope of developing personalised therapeutics.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Clinical outcomes of light therapy in hospitalized patients - A systematic review

Light therapy and the effects on biological function have been known and investigated for decades. Light therapy is used to compensate for the lack of exposure to sunlight, which is thought to be linked to major depressive disorder with seasonal patterns. It is applied as sessions with bright light mimicking natural sunlight. Lack of bright light during daytime is not the only factor to maintain the circadian rhythm, also lack of exposure to bright light at night is important. A new modality called naturalistic light shows promise, mimicking daylight by dynamically changing intensity and wavelengths throughout the day. Evidence of clinical effects, besides bright light effects on depression, is still limited, especially in hospital populations, and present review aims to extract results of the effect of any optical light intervention on hospitalized patients. Through database search, 29 trials were included, of which 8 trials used a variation of naturalistic light. Trials were heterogeneous regarding designs, populations, interventions, methods and outcomes. In 14 out of 17 studies investigating sleep duration, quality and circadian alignment, along with decreased fatigue and improved mood in daytime, light therapy had a significant effect. Circadian rhythm and rhythmicity were affected as well. The effect on mood and cognition was inconsistent across studies. Trials showed more significant outcomes when conducted in non-intensive care units and with duration >5 days. Lux was reported in and compared across 24 studies and did not appear to be correlated to outcome, rather the distribution of wavelengths should be considered when conducting trials in the future. Of the 8 trials investigating naturalistic light, 4 trials had significant outcomes and 3 had adverse outcomes compared to one in the standard light regime. The overall effect of light therapy is beneficial, but evidence for the effect of naturalistic light is still insufficient to be recommended before other modalities. Future research in this area should be conducted in facilities where naturalistic light is installed, with a focus on the spectral distribution.

Adherence and acceptability of light therapies to improve sleep in intrinsic circadian rhythm sleep disorders and neuropsychiatric illness: a systematic review

Sleep problems and circadian misalignment affect health and well-being and are highly prevalent in those with co-morbid neuropsychiatric disorders. Interventions altering light exposure patterns of affected individuals are a promising non-pharmacological treatment option, shown by previous meta-analyses to improve sleep, and often described as minimally invasive. To best translate laboratory-based mechanistic research into effective treatments, acceptability and barriers to adherence should be understood, but these have not yet been systematically evaluated. Here, we examined evidence regarding adherence and acceptability in studies of light or dark interventions using various delivery devices and protocols to improve sleep in intrinsic circadian rhythm sleep-wake disorders and neuropsychiatric illness. Attrition during intervention was low, and reported experiences were largely positive, but measurement and reporting of self-reported experiences, expectations, and adverse effects were poor. Approaches to management and measurement of adherence were varied, and available light monitoring technology appeared under-exploited, as did mobile technology to prompt or track adherence. Based on these findings we suggest recommended reporting items on acceptability and adherence for future investigations. Few studies assessed baseline light exposure patterns, and few personalised interventions. Overall, many applied studies exhibited an approach to light schedule interventions still reminiscent of laboratory protocols; this is unlikely to maximise acceptability and clinical effectiveness. For the next phase of translational research, user acceptability and adherence should receive increased attention during intervention design and study design. We suggest framing light therapies as complex interventions, and emphasise the occupationally embedded (daily activity routine embedded) context in which they occur.

An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial

BACKGROUND

Daylight entrains the central circadian pacemaker to the 24-hour day and is crucial for optimal alertness and sleep-quality. Rehabilitation patients tend to lack exposure to sufficient natural light.

OBJECTIVE

Installed diurnal naturalistic light may reduce the known disrupted sleep quality and fatigue seen in post stroke patients.

METHODS

Stroke patients were randomized to either an intervention rehabilitation unit (IU) equipped with naturalistic lighting (artificial sunlight spectrum) or to a control rehabilitation unit (CU) with standard indoor lighting. At inclusion and discharge, fatigue and subjective sleep quality were measured.

RESULTS

Ninety stroke patients were included between May 2014, and June 2015. At discharge, patients from the IU experienced less fatigue than the CU patients, based on the Multidimensional Fatigue Inventory questionnaire general (IU, n = 28; CU, n = 30; diff - 20.6%, 95% confidence interval (CI) [- 35.0%; - 3.0%]; P = 0.025) and the Rested Statement (IU, n = 28; CU, n = 30; diff + 41.6%, 95% CI [+4.6%; +91.8%]; P =  0.025). No differences were detected between groups in sleepiness or subjective sleep quality by the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Fatigue was significantly reduced in rehabilitation patients exposed to naturalistic lighting during admission.

Resetting the Aging Clock: Implications for Managing Age-Related Diseases

Worldwide, individuals are living longer due to medical and scientific advances, increased availability of medical care and changes in public health policies. Consequently, increasing attention has been focused on managing chronic conditions and age-related diseases to ensure healthy aging. The endogenous circadian system regulates molecular, physiological and behavioral rhythms orchestrating functional coordination and processes across tissues and organs. Circadian disruption or desynchronization of circadian oscillators increases disease risk and appears to accelerate aging. Reciprocally, aging weakens circadian function aggravating age-related diseases and pathologies. In this review, we summarize the molecular composition and structural organization of the circadian system in mammals and humans, and evaluate the technological and societal factors contributing to the increasing incidence of circadian disorders. Furthermore, we discuss the adverse effects of circadian dysfunction on aging and longevity and the bidirectional interactions through which aging affects circadian function using examples from mammalian research models and humans. Additionally, we review promising methods for managing healthy aging through behavioral and pharmacological reinforcement of the circadian system. Understanding age-related changes in the circadian clock and minimizing circadian dysfunction may be crucial components to promote healthy aging.

Betwixt and between: a surgical post-acute treatment unit (SPA) for the optimal care of elderly patients with isolated hip fractures

BACKGROUND

A performance improved project identified elderly trauma patients to have a disproportionate incidence of complications.

AIMS

The purpose of this study was to assess the efficacy of a small specialty care unit to decrease complications in patients who no longer warrant care in an intensive care unit (ICU).

METHODS

A surgical post-acute treatment unit (SPA) was developed with focused attention to cognition, nutrition, respiration, and mobilization needs of patients who no longer had physiologic need for an intensive care unit environment, but were still in need of increased attention at the bedside.

RESULTS

While ICU and hospital lengths of stay were unchanged, patients placed in the SPA experienced less complications and required less unplanned ICU re-admissions.

DISCUSSION

Geriatric patients, especially the elderly, are not simply old adults. They have unique needs as a consequence of the aging process, which can be encompassed by four pillars of intercession: cognition, nutrition, respiration, and mobilization.

CONCLUSIONS

By adapting a physical environment supported by bedside attention to address the interwoven needs of geriatric and elderly patients who no longer care in an ICU, complications and unplanned return admissions to the ICU can be decreased.

LEVEL OF EVIDENCE

III.

Sleepless in the hospital: A systematic review of non-pharmacological sleep interventions

OBJECTIVE

Poor sleep is highly prevalent in inpatient medical settings and has been associated with attenuated healing and worsened outcomes following hospitalization. Although nonpharmacological interventions are preferred, little is known about the best way to intervene in hospital settings.

METHOD

A systematic review of published literature examining nonpharmacological sleep interventions among inpatients in Embase, PsycINFO and PubMed in accordance with PRISMA guidelines.

RESULTS

Forty-three of the 1529 originally identified manuscripts met inclusion criteria, encompassing 2713 hospitalized participants from 18 countries comprised of psychiatric and older adult patients living in hospital settings. Main outcomes were subjective and objective measures of sleep duration, quality, and insomnia.

CONCLUSIONS

Overall, the review was unable to recommend any specific intervention due to the current state of the literature. The majority of included research was limited in quality due to lack of controls, lack of blinding, and reliance on self-reported outcomes. However, the literature suggests melatonin and CBT-I likely have the most promise to improve sleep in inpatient medical settings. Additionally, environmental modifications, including designated quiet time and ear plugs/eye masks, could be easily adopted in the care environment and may support sleep improvement. More rigorous research in nonpharmacological sleep interventions for hospitalized individuals is required to inform clinical recommendations.

Non-pharmacological treatments for sleep disturbance in mild cognitive impairment and dementia: A systematic review and meta-analysis

No disease-modifying treatments for dementia are available. Sleep disturbance is strongly associated with cognitive impairment. Non-pharmacological treatments targeting sleep may offer an alternative therapeutic approach. We searched PubMed, CINAHL, EMBASE and the Cochrane library for non-pharmacological treatments for sleep disturbance in mild cognitive impairment (MCI) and dementia, published in English from October 1965 to 2018, including all designs, excluding studies of drug therapies. In all, 53 papers representing 48 studies were included. Participant age ranged from 67.3 to 89.4 years. Most studies (79%) had small samples (<50 participants, range 1-173) and were conducted in long-term/residential care (62%). The majority (85%) recruited participants with moderate-severe dementia; mean MMSE scores ranged from 0 to 28.3/30. Four studies examined MCI. Light therapy delivered over 1-10 weeks was the most studied stand-alone intervention (n = 27), and the majority (81.5%) of these studies found improvements on objective or subjective sleep measures, though the evidence was inconclusive with significant clinical and methodological heterogeneity. Seven multi-modal intervention studies were identified, all incorporating light exposure, and six of these reported improved sleep. Other interventions included electrotherapy stimulation (n = 4), physical exercises/activities (n = 4), acupressure/acupuncture (n = 3) and mindfulness/cognitive behavioural therapy (n = 3). Those examining MCI utilised different mono-modal approaches. A meta-analysis of data from randomised controlled trials showed a statistically significant (mean difference = 3.44, 95% CI: 0.89-5.99, I²=0%; p = 0.008) improvement in sleep efficiency between interventions and controls, favouring the pooled interventions (bright light, multi-domain and other therapies). No other significant differences in sleep or non-sleep outcomes were found. While evidence is available for non-pharmacological sleep interventions, particularly multi-domain approaches, studies were diverse and had small samples. More research examining multi-modal interventions, community-dwellers and those with MCI is required.

The Effect of Light on Sleep and Sleep-Related Physiological Factors Among Patients in Healthcare Facilities: A Systematic Review

OBJECTIVES

Lighting is one of the environmental factors which can improve patient sleep in healthcare environments. Due to the high degree of variation in study designs and results on this topic, the implications have been difficult to interpret. This review consolidates studies on the impact of bright light exposure on sleep to identify lighting conditions that can be applied and researched in future healthcare environments.

METHODS

We searched for peer-reviewed articles on the impact of light on sleep or sleep-related outcomes in healthcare settings. We provided detailed analysis of the direct links between light and sleep, and a more cursory analysis of links between light and sleep-related factors, from 34 articles which met our inclusion criteria.

RESULTS

The current state of the literature includes evidence on how various durations and intensities of morning, midday, and evening bright light exposure, as well as whole-day light exposure interventions can improve specific aspects of sleep. Lighting interventions differed in all attributes (illuminance levels, exposure time, exposure duration, and spectral qualities) but showed promising results in improving patients' sleep.

CONCLUSIONS

Short-term bright light exposure in the morning, up to 2 hr of moderate (3,000-10,000 lux) morning exposures, up to 4 hr of moderate evening exposure, and whole-day exposures to lower illuminance levels (<3,000 lux) can improve patient sleep outcomes. Based on new findings on the mechanism through which light impacts sleep, future studies should be more specific about the spectral qualities of light sources.

Light therapy: is it safe for the eyes?

OBJECTIVE

Light therapy has become an increasingly popular treatment for depression and a range of other neuropsychiatric conditions. Yet, concerns have been raised about the ocular safety of light therapy.

METHOD

We conducted the first systematic review into the ocular safety of light therapy. A PubMed search on January 4, 2017, identified 6708 articles, of which 161 were full-text reviewed. In total, 43 articles reporting on ocular complaints and ocular examinations were included in the analyses.

RESULTS

Ocular complaints, including ocular discomfort and vision problems, were reported in about 0% to 45% of the participants of studies involving light therapy. Based on individual studies, no evident relationship between the occurrence of complaints and light therapy dose was found. There was no evidence for ocular damage due to light therapy, with the exception of one case report that documented the development of a maculopathy in a person treated with the photosensitizing antidepressant clomipramine.

CONCLUSION

Results suggest that light therapy is safe for the eyes in physically healthy, unmedicated persons. The ocular safety of light therapy in persons with preexisting ocular abnormalities or increased photosensitivity warrants further study. However, theoretical considerations do not substantiate stringent ocular safety-related contraindications for light therapy.

Treatment of Sleep Disorders in Dementia

OPINION STATEMENT

Sleep and circadian disorders occur frequently in all types of dementia. Due to the multifactorial nature of sleep problems in dementia, we propose a structured approach to the evaluation and treatment of these patients. Primary sleep disorders such as obstructive sleep apnea should be treated first. Comorbid conditions and medications that impact sleep should be optimally managed to minimize negative effects on sleep. Patients and caregivers should maintain good sleep hygiene, and social and physical activity should be encouraged during the daytime. Given the generally benign nature of bright light therapy and melatonin, these treatments should be tried first. Pharmacological treatments should be added cautiously, due to the risk of cognitive side effects, sedation, and falls in the demented and older population. Regardless of treatment modality, it is essential to follow patients with dementia and sleep disorders closely, with serial monitoring of individual response to treatment.

Buying time: a rationale for examining the use of circadian rhythm and sleep interventions to delay progression of mild cognitive impairment to Alzheimer's disease

As of 2010, the worldwide economic impact of dementia was estimated at $604 billion USD; and without discovery of a cure or effective interventions to delay disease progression, dementia's annual global economic impact is expected to surpass $1 trillion USD as early as 2030. Alzheimer's disease (AD) is the leading cause of dementia accounting for over 75% of all cases. Toxic accumulation of amyloid beta (Aβ), either by overproduction or some clearance failure, is thought to be an underlying mechanism of the neuronal cell death characteristic of AD-though this amyloid hypothesis has been increasingly challenged in recent years. A compelling alternative hypothesis points to chronic neuroinflammation as a common root in late-life degenerative diseases including AD. Apolipoprotein-E (APOE) genotype is the strongest genetic risk factor for AD: APOE-ε4 is proinflammatory and individuals with this genotype accumulate more Aβ, are at high risk of developing AD, and almost half of all AD patients have at least one ε4 allele. Recent studies suggest a bidirectional relationship exists between sleep and AD pathology. Sleep may play an important role in Aβ clearance, and getting good quality sleep vs. poor quality sleep might reduce the AD risk associated with neuroinflammation and the ε4 allele. Taken together, these findings are particularly important given the sleep disruptions commonly associated with AD and the increased burden disrupted sleep poses for AD caregivers. The current review aims to: (1) identify individuals at high risk for dementia who may benefit most from sleep interventions; (2) explore the role poor sleep quality plays in exacerbating AD type dementia; (3) examine the science of sleep interventions to date; and (4) provide a road map in pursuit of comprehensive sleep interventions, specifically targeted to promote cognitive function and delay progression of dementia.

Methodological challenges in studies of bright light therapy to treat sleep disorders in nursing home residents with dementia

AIM

Numerous studies have explored the effectiveness of bright light therapy as a treatment of sleep disorders in nursing home and long-stay geriatric hospital residents, most of whom have dementia. A recent Cochrane Collaboration meta-analysis of 10 selected studies concluded that there was insufficient evidence to assess its therapeutic efficacy as most available studies had methodological problems. We sought to remedy this situation by developing proposals to guide research methods in future studies.

METHODS

Based on the literature and our own clinical and research experience, we developed a series of proposals relating to study design, participant selection, light delivery modalities and outcome measures that we believe will maximize the chances of identifying a bright light treatment effect. We then checked adherence to these proposals in all relevant published experimental studies.

RESULTS

Of the 18 studies published in the last two decades that met our selection criteria, only half the studies had selected participants with a sleep disorder. Eleven studies excluded people with severe vision loss; seven included a clinical rating of sleep, and five measured baseline lighting levels. Most checked psychoactive medication prescriptions but few reported changes in prescriptions over the course of the study. Most also checked treatment adherence and included some control for differences in amount of social contact.

CONCLUSIONS

Evidence for the effectiveness of bright white light treatment in people residing in nursing homes is equivocal. We anticipate that the quality of this evidence will be improved if researchers refine their study methods and adopt a more uniform approach.

Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia

BACKGROUND

Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light.

OBJECTIVES

The review examines the effectiveness of light therapy in improving cognition, activities of daily living (ADLs), sleep, challenging behaviour, and psychiatric symptoms associated with dementia.

SEARCH METHODS

ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 20 January 2014 using the terms: "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy, "photo therapy", "light therapy" "light treatment", light* . The CDCIG Specialized Register contains records from all major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources.

SELECTION CRITERIA

All relevant, randomized controlled trials were included in which light therapy, at any intensity and duration, was compared with a control group for the effect of improving cognition, ADLs, sleep, challenging behaviour, and psychiatric symptoms associated with dementia (as well as institutionalization rates or cost of care). Included were people with dementia of any type and degree of severity.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the retrieved articles for relevance, and four review authors independently assessed the selected studies for risk of bias and extracted the data. Statistically significant differences in outcomes between the treatment and control groups at the end of treatment and follow-up were examined. Each study was summarized using a measure of effect (for example mean difference).

MAIN RESULTS

Eleven trials (13 articles) met the inclusion criteria. However, three of the studies could not be included in the analyses either because the reported data could not be used in the meta-analysis or we were unable to retrieve the required data from the authors.This updated review found no effect of light therapy on cognitive function, sleep, challenging behaviour (for example agitation), or psychiatric symptoms associated with dementia. Reduction in the development of ADL limitations was reported in one study, at three of five time points, and light therapy was found to have an effect after six weeks and two years but not after one year.

AUTHORS' CONCLUSIONS

There is insufficient evidence to justify the use of bright light therapy in dementia. Further research should concentrate on replicating the suggested effect on ADLs, and establishing the biological mechanism for how light therapy improves these important outcomes.

Bright light therapy as an adjunctive treatment with risperidone in patients with delirium: a randomized, open, parallel group study

OBJECTIVE

The purpose of this study was to determine the effect of adjuvant light therapy with antipsychotic treatment in patients with delirium.

METHODS

Thirty-six patients were referred to the consulting psychiatry division of our hospital for a disturbance in consciousness. The patients were randomized to risperidone (n=16) or risperidone with light therapy (n=20). They were evaluated on Day 0 (baseline) and on Days 1 to 5 with the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS). Sleep parameters were measured using a sleep log.

RESULTS

Mean DRS and MDAS scores decreased significantly over time in both treatment groups. Risperidone with light therapy group showed a significantly greater decrease in the DRS score than the risperidone-only group (F=2.87, P=.025), but the MDAS score was not significantly different between the two groups. There was a significant improvement in total sleep time (F=2.07, P=.037) and sleep efficiency (F=2.79, P=.029) in the risperidone with light therapy group than in the risperidone-only group.

CONCLUSIONS

Our results indicate that risperidone with light therapy may be a helpful adjuvant treatment for patients with delirium. Adequately powered studies with a head-to-head comparison design are mandatory to confirm our findings.

Therapeutic lighting design for the elderly: a review

AIMS

Research suggests that specialised lighting design is essential to cater for the elderly users of a building because of reduced visual performance with increased age. This review aims to document what is known of the physical and psychological aspects of lighting and their role in promoting a healthy and safe environment for the elderly.

METHODS

A methodical review was carried out of published literature on the physical and psychological impacts of light on the elderly. Design standards and guides from professional organizations were evaluated to identify synergies and gaps between the evidence base and current practice.

RESULTS

Lighting has been identified as a significant environmental attribute responsible for promoting physical and mental health of the elderly. The evidence related to visual performance was found to be robust. However, guides and standards appeared to have focused mostly on illumination requirements for specific tasks and have lacked detailed guidelines on vertical lighting and luminance design. This review has identified a growing body of evidence on the therapeutic benefits of lighting and its use in treating psychological disorders among the elderly. The experiments using light as a therapy have improved our understanding of the underlying principles, but the integration of therapeutic aspects of lighting in design practice and guidelines is lacking.

CONCLUSIONS

While design guidelines discuss the physical needs of lighting for the elderly fairly well, they lack incorporation of photobiological impacts. Despite positive outcomes from research, the implementation of therapeutic aspects of lighting in buildings is still debatable due to insufficient relevant investigations and robustness of their findings. Collaborations between designers and physicians can contribute in delivering customised lighting solutions by considering disease types and needs. Further investigation needs to be carried out for translating therapeutic benefits to photometric units to implement them in building lighting design.

The usefulness of bright light therapy for patients after oesophagectomy

OBJECTIVES

The prevention of delirium is an important issue in the field of perioperative nursing. The objective of this study was to verify the usefulness of acute-stage bright light exposure on patients following oesophagectomy.

METHODS

The participants were oesophagectomy patients that were removed from their ventilators the day after surgery. After extubation, we assigned the participants to either the exposure group or control group. At Day 2 after surgery, the exposure group underwent two hours of bright light exposure for four days. In both groups, we monitored physical activity and autonomic activity. In addition, we scored the participants on the NEECHAM Scale and evaluated their postoperative delirium and postoperative arrhythmia.

RESULTS

On the nights of Days 4 and 5, the amount of activity of the exposure group was significantly lower and The sympathetic nervous index was significantly lower on the night of Day 5. The level of arrhythmia was lower in the exposure group and we observed a significant difference on the night of Day 4 and the daytime of Day 5 after surgery. The occurrence rate of postoperative delirium tended to be lower in the exposure group, but there was no significant difference. None of the participants in the exposure group had NEECHAM Scale scores below the cut-off value from the night of Day 4 onwards.

CONCLUSION

We conclude that postoperative bright light exposure adjusted the sleep-wakefulness cycle and improved the bed rest of patients. It was also indicated that bright light therapy is useful for reducing postoperative delirium.

Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia

BACKGROUND

Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light.

OBJECTIVES

The review assesses the evidence of effectiveness of light therapy in managing cognitive, sleep, functional, behavioural, or psychiatric disturbances associated with dementia.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 4 March 2008 using the terms: "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy, "photo therapy", "light therapy" "light treatment", light* . The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources.

SELECTION CRITERIA

All relevant, randomized clinical trials in which light therapy, at any intensity and duration, was compared with a control group for the effect on managing cognition, sleep, function, behavioural, or psychiatric disturbances (as well as changes in institutionalization rates or cost of care) in people with dementia of any type and degree of severity.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected studies. Statistically significant differences in outcomes between the treatment and control groups at end of treatment and follow-up were examined. Each study was summarized using a measure of effect (e.g. mean difference).

MAIN RESULTS

Eight trials met the inclusion criteria. However, three of the studies could not be included in the analyses because of inappropriate reported study analyses or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of light therapy in managing cognition, sleep, function, behaviour, or psychiatric disturbances associated with dementia.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the value of light therapy for people with dementia. Most of the available studies are not of high methodological quality and further research is required.

Influence of bright light therapy on postoperative patients: A pilot study

Bright light therapy is a method of maintaining or restoring the natural circadian rhythm by assisting daytime awakening using bright lights. Postoperative delirium is one of the potential complications encountered by patients receiving postoperative care in the intensive care unit (ICU), but there have been no studies on the use of light for the prevention of postoperative delirium. The objective of this study was to examine whether the circadian rhythms of patients after surgery for oesophageal cancer can be adjusted and whether the postoperative delirium crisis rate can be reduced by bright light therapy. The subjects were 11 patients operated on for oesophageal cancer in Osaka University Hospital. After informed consent was obtained, they were divided into a study group and a control group by a random sampling method. After removal of the endotracheal tube, the study group was exposed to light. The light intensity was about 5000lx immediately before the eyes, and the distance from the light source was about 100 cm. The control group was placed in a natural lighting environment after extubation. In both groups, the rhythms of physical activities and autonomic activities were monitored after surgery, and delirium was evaluated. A significant difference was observed in the delirium score between the study group and control group on the morning of day 3 of bright light therapy by the Mann-Whitney U-test (P=0.014). The study group could begin ambulation about 2 days earlier than the control group. Bright light therapy may reduce the rate of postoperative delirium and make early ambulation possible. However, our study involved a very small sample size. We want to increase the sample in the future after having reviewed clinical application methods.

Light therapy for managing sleep, behaviour, and mood disturbances in dementia

BACKGROUND

Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light.

OBJECTIVES

The review assesses the efficacy of bright light therapy (BLT) in managing sleep, behaviour, mood, and cognitive disturbances associated with dementia.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 27 January 2004 using the terms "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy (MESH), phototherapy, "photo therapy", "light therapy" "light treatment", light*.

SELECTION CRITERIA

All relevant, randomized controlled trials in which BLT, at any intensity and duration, was compared with a control group for the effect on managing sleep, behavioural, mood, and cognitive disturbances (as well as changes in institutionalization rates and cost of care) on people with dementia of any degree of severity.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed the retrieved articles for relevance, methodological quality, and extracted data from the selected studies. The statistically significant differences in changes in outcomes from baseline to end of treatment and from baseline to follow-up between the light therapy and control groups were examined. Each study was summarized using a measure of effect (e.g. mean difference). Owing to lack of homogeneity between studies, their results were not combined.

MAIN RESULTS

Five studies met the inclusion criteria. However, only three were included in the analyses because of inappropriate analyses reported or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of BLT in managing sleep, behaviour, and mood disturbances associated with dementia.

REVIEWERS' CONCLUSIONS

There is insufficient evidence to assess the value of BLT for people with dementia. The available studies are of poor quality and further research is required.

Use of an infrared sensor system to take long-term bedside measurements of rest-activity patterns in the elderly with dementia

In order to study long-term rest-activity patterns of elderly residents in care facilities, an infrared sensor system was developed. This sensor system detects a resident's presence or absence from their bed and their activity with little inconvenience. Using this system, the rest-activity patterns of two elderly people with dementia was assessed over a period of 3 months. For both subjects, frequent activity peaks and absences from their beds were often observed during the night. Such a sensor system will be useful for evaluating the sleep-wake rhythms of people with sleep disorders.

Bright light therapy for sleep problems in adults aged 60+

BACKGROUND

The prevalence of sleep problems in adulthood increases with age. While not all sleep changes are pathological in later life, severe disturbances may lead to depression, cognitive impairments, deterioration of quality of life, significant stresses for carers and increased healthcare costs. The most common treatment for sleep disorders (particularly insomnia) is pharmacological. The efficacy of non-drug interventions has been suggested to be slower than pharmacological methods, but with no risk of drug-related tolerance or dependency. Bright light treatment involves participants sitting in front of a "light box" which emits very high (typically 10,000 lux) fluorescent light for periods of around two hours daily. The timing of this light treatment will depend on the irregular timing of the participant's sleep pattern.

OBJECTIVES

To assess the efficacy of bright light therapy in improving sleep quality (sleep timing in particular) amongst adults aged 60 and above.

SEARCH STRATEGY

The following databases were searched: MEDLINE (1966 - January 2001); EMBASE (1980 - January 2001), CINAHL ( 1982 - January 2001; PsychINFO 1970 to 2001; The Cochrane Library (Issue 1, 2001); National Research Register (NRR [2001]). Bibliographies of existing reviews in the area, as well as of all trial reports obtained, were searched. Experts in the field were consulted.

SELECTION CRITERIA

Randomised controlled trials of bright light therapy for primary sleep problems where 80% or more of participants were over 60. Participants must have been screened to exclude those with dementia and/or depression.

DATA COLLECTION AND ANALYSIS

Abstracts of studies identified in searches of electronic databases were read and assessed to determine whether they might meet the inclusion criteria.

MAIN RESULTS

Reviewers found no trials on which to base conclusions for the effectiveness of this treatment.

REVIEWER'S CONCLUSIONS

When the possible side-effects of standard treatment (hypnotics) are considered, there is a reasonable argument to be made for clinical use of non-pharmacological treatments. In view of the promising results of bright light therapy in other populations with problems of sleep timing, further research into their effectiveness with older adults would seem justifiable.