Background and Literature Review

Discuss about the Master of Science in Dementia Care.

Dementia patients are at increased risk of suffering from circadian and sleep disturbances that gradually get worse with age. Sleep disturbances have a direct negative impact in the quality of life of the patients, also contributing to caregiver burden. Disrupted sleep has been linked with increased confusion, agitation, increased risk of injury and falls. Given the impact of sleep disturbances in patients, it is important to understand different interventional strategies that can have a positive impact on the patient in relation to sleep quality and contribute to better quality of life in patients. Light therapy has been indicated to be a potential non-pharmacological tool that can improve sleep efficacy and consolidation. A systematic literature review was therefore conducted that aimed at assessing the effectiveness of therapy in improving sleep quality in dementia patients. The results of the project are presented in the present report. Such a review summarizes the main results of the healthcare studies and provides evidence level on the usefulness of the intervention. Recommendations are outlined on the basis of the results that inform future practice.

The first section of the paper provides the background to the study along with a brief literature review on the research topic. This section covers the problem being addressed, previous research on the same topic, the shortcomings and problems of the research, the rationale for the present study and the study objectives. The next section of the paper provides the details of the project undertaken. The steps and methods undertaken for completing the project are mentioned. The outcomes of the project are then highlighted. The following section is a discussion of the overall project including project limitations and barriers and recommendations. A summary is provided to draw together the previous sections of the project. A logical conclusion brings in end to the report.

Dementia is the umbrella term encompassing varied conditions affecting thinking, memory, behavior and ability to carry out daily activities of life in patients suffering from it. Patients with dementia experience impairments in social and occupational functioning and present distinct behavioral disturbances. Though dementia is common in adults, it is not an inevitable part of the normal aging process. The most frequently occurring forms of dementia are Alzheimer’s disease, vascular dementia, dementia with Lewy body, frontotemporal dementia and mixed dementia. Rather than being considered as a subject for active attention dementia is often ignored in terms of care provision. It is a leading cause of dependency and disability among older patients (Harvey et al. 2018). Dementia is one of the leading causes of death in Australia. As per the reports of Laver et al. (2016) dementia was the fourth most common cause of death in Australia in the year 2011. Dementia accounted for 6 per cent of all deaths in the same year. It is also to be noted that patients suffering from dementia are also at increased risk of dying due to other illnesses. According to Nay et al. (2015) dementia brings about significant implications for patient’s families, care givers and health care professionals. For them, dementia imposes stress and economic burden.

Project Details and Outcomes

Sleep disturbances are commonly found among dementia patients as a neurobehavioral symptom, leading to negative impact on the daytime functioning of the patient. In addition, the wellbeing of the caregiver is also directly influenced by the sleep pattern of the patients. The risk of falling asleep at the daytime and increased wakefulness at night contributes to such concerns. Behavioral challenges arise in the form of agitation, arguments, violence, wandering and increased falls (Wilfing 2015). Though risk of falling is an indirect impact, it holds much significance since patient falls further bring in decline to the patient condition and add to the burden on the care giver. Recovery of such dementia patients is challenging and takes more time as compared to patients not suffering from dementia. Research highlights that the driving factors for sleep disturbances are lack of social support, reduced circadian rhythm, eye problems as a result of age, and limited exposure to sunlight (Sekiguchi, Iritani & Fujita 2017). Patients with dementia spend 40% of their night time being awake and a considerable portion of the day asleep.

As highlighted by Spira et al. (2014), the availability of dementia care together with respite services is crucial for the maintenance of quality of life of patients that focuses on both physical and mental health status. Recent and advanced treatment options have been continually assessed for understanding whether they are capable of slowing the course of cognitive decline and other health concerns. The primary aim is to enhance the quality of life of patients and decrease the costs of institutional care. Despite growing research on the potential psychological and pharmacological interventions across countries, their application to real life settings are limited.

According to Ploeg and O’Connor (2014) normal circadian rhythm works by synchronizing with the 24-hourcycle and it has been found that light is elementary for maintaining this rhythm. Maintenance of normal circadian rhythm is supported when there is an active exposure to 24-hour light/dark cycle. For elder dementia patients, the need of light exposure is more for maintaining normal circadian rhythm. However, in patients who are institutionalized, the scope of being exposed to sunlight is minimal. A rich pool of studies has established the positive impact of bright light in dementia patients. Nevertheless, the outcomes of the studies are not similar. The main findings of the paper indicate improved mood and sleep patterns among patients (Most, Scheltens & Van Someren 2010).

Discussion and Recommendations

The researchers brought into limelight how light therapy might work for dementia patients. The hypothalamic suprachiasmatic nucleus (SCN) has the function of being a circadian pacemaker. This implied that there is a synchronization with the day and night cycle through light. This synchronization is to be perceived as extremely sensitive. For dementia patients, there is a considerable reduction in SCN since the activity and sensitivity is reduced. The ultimate outcome is disturbed sleep patterns due to severe disruption in sleep. Such disturbances are rerated to loss of vasopressin in SCN. Thus, exposure to light on a regular basis helps in reactivating the SCN and stabilizing the 24-hour light dark cycle. The intervention has been widely assessed for its benefits and effectiveness in dementia patients, mainly those who reside in care facilities. The researchers highlighted how lighting characteristics affect circadian rhythms. The neural machinery in the mammalian retina provides light information to both the visual and circadian system. The quantity of polychromatic light required for activating the circadian system is at least two orders of magnitude more than the amount that activates the visual system. The circadian system is dependent on the timing of light exposure. The higher exposure to light at the time of day the lower is the sensitivity of the circadian system to light. Light information is known to travel from the retina to the SCN through the retinohypothalamic tract (RHT). When there are considerable disturbances in the circadian rhythms, older adults undergo poor sleeping pattern as the pathway is dysfunctional, leading to poor processing of light information, marked by low fidelity (Most, Scheltens & Van Someren 2010).

The importance of dementia care giving has been reported by healthcare professionals across settings, who mainly point out the challenges faced in delivering care. Caregivers are often subjected to increased amount of stress and physical exhaustion as a result of addressing the varied needs of the patients. The strength of healthcare workforce caring for dementia patients in Australia is noteworthy. Understanding the concerns faced by dementia caregivers is therefore of prime importance.

Admission to care facilities as a result of sleep disturbance among dementia patients is noted. This indicates that effective interventions are to be found out that can address sleep disturbances and enhance quality of life. A number of studies have been undertaken in this regard across different countries. However, there have been distinct limitations in such studies (Forbes 2014). This is mainly attributed to the methodology used in such studies and limited generalisability. Researchers have identified bias in those studies due to inclusion and exclusion criteria. Primary studies on understanding effect of light exposure on dementia patients are limited (Wilfling 2015). An urgent need of identify research literaturewith accurate methodology in this respect forms the rationale for the present paper.

Dementia and Sleep Disturbances

The present systematic review had the objective of understanding the effectiveness of light therapy in improving sleep quality among dementia patients. The research question addressed was-

‘Is light therapy effective in improving sleep quality (duration of sleep) among the dementia patients?”

Research design:  Systematic review method guided by PRISMA checklist has been used as the research design for the study. The PRISMA checklist is an appropriate framework that covers items to be covered while writing a systematic review (Moher et al. 2015). Specific inclusion and exclusion criteria guided the search process and relevant electronic databases were the main resource to search for articles.

• Study design: As the main purpose of systematic review is to determine effectiveness of light therapy in improving sleep quality among dementia patients, all primary research articles based on qualitative and quantitative approach were included in the review.
• Study participants: Those research articles were taken which had dementia patients (such as people with vascular dementia, Lewy body dementia, Alzheimer’s disease and frontotemporal dementia) as the participants for the study. Studies done with dementia patient were included irrespective of severity of the condition.
• Date of publication: Studies published within 7 years (from 2010 to 2017) were taken for the review.
• Type of intervention: For all selected research articles, light therapy should be used as intervention for research. Studies with combination intervention such as light therapy along with pharmacological interventions or artificial light were also included in the review.
• Research question: All research studies must address the research question for the study and should have similar research objective.
• Outcome variable: The main outcome variable for the study should include variables that give indication about sleep quality and sleep efficiency such as duration of sleep, nocturnal sleep time and number of night awakenings.
• Language: Included research articles must be published in English language.

Relevant articles related to the research questions were reviewed from online databases like CINAHL Plus, MEDLINE Plus, Cochrane Library and PubMed. Google scholar was also used as a search engine to identify additional articles relevant to the research question. Advanced search for additional articles were also done from UOW online library. The search process by refined by setting filters by choosing peer-reviewed full-text journal articles and using date filter The research publication was limited to those published within 2010-2017 by modifying date filter. The inclusion and exclusion criteria were applied to narrow down the search process.

The primary search terms for selection of articles included dementia, light therapy, sleep disturbance/disorder, interventions, Alzheimer’s disease, morning light, cognitive impairment. Boolean operators like AND or OR was also used to combine terms similar in meaning.

Data abstraction: A PRISMA flow diagram was used to summarize the research process and number of articles included or excluded for the review. The PRISMA flow diagram can give idea about number of articles identified from database search, articles screened by title and abstract and number of final articles included for the studies (Booth, Sutton and Papaioannou 2016). After final selection of articles for the review, all the articles were extracted by making a table on author, year of publication, details of intervention, study finding and implications of research. Use of specific method to extract data is necessary as it helps in better interpretation of systematic review results and provides good overview about the contribution of each included studies in addressing the research question (Jonnalagadda, Goyal and Huffman 2015).

Data analysis: The analysis of research articles were done first by the reviewing title and abstract of journal articles. The data analysis process was done by two reviewers to maintain reliability of study and prevent influence of selection bias on study outcome. This approach also eliminated sources of bias. After the selection of research articles based on review of title and abstract, the second phase of analysis included review of full text article to collect findings related to the effect of intervention, strength of methodology and application of study findings. The reference list of articles was also reviewed to find other articles that address the research question. Article which does not met inclusion criteria were excluded during the first phase of data analysis.

Light Therapy and Circadian Rhythm

Appraisal of research articles: The appraisal of the research article was done by the use of Cochrane Risk of Bias Assessment tool. The advantage of the tool is that help to identify methodological rigour in the study by identifying risk of different kinds of bias in studies. The tool helps to categorize research articles on the basis of selection bias, performance bias, detection bias, attrition bias and reporting bias. It covers six domains to give an overview about types of bias observed in studies. This includes random sequence generation, blinding participants, blinding of outcome analysis, incomplete outcome data, selective reporting and other source of bias. The advantage of using relevant and evidence based quality assessment tool in systematic review is that it supports research to assess the validity and credibility of research based on methodological rigour and complete reporting of study findings (Ahmed, Sutton and Riley, 2012).

The research findings have presented in the form of thematic analysis and reporting of the review is in relevance with the PRISMA guideline. The advantage of using thematic analysis in systematic review is that it helps to integrate the findings of multiple studies. Thematic synthesis is done by the development of descriptive themes and analytical themes. The descriptive themes gives clear idea about findings of the primary research studies and the analytical themes lead to generation of new interpretive constructs and hypotheses.

The initial search process in different databases after entering search terms returned 80 studies for analysis. However, after removal of duplicate, 50 articles were screened for suitability on the basis of inclusion and exclusion criteria. The summary of the search process and the final number of articles obtained for systematic has been provided in Flowchart below.

The systematic review of research literature helped in identification of different themes as per the research findings. The theme that has been generated from the literature review process are follows:

There were two studies which specifically covered the effectiveness of light therapy on dementia patient and seven studies  that used light therapy along with other intervention to assess the effectiveness of the intervention on sleep quality in dementia patient. McCurry et al. (2011) investigated about the use of walking and light treatment on community dwelling persons with Alzheimer’s disease. The research used randomized controlled trial to randomly assign participants to walking intervention, light intervention and combination treatment. The participants for the study included Alzheimer’s disease patient and the intervention group participated in three one-hour in-home training visits. Subjects in the intervention group received a SunRay light box and patients sat in front of the light box for one hour/day. To eliminate influence of confounding factors like bed timing in outcome, light session was provided 2 hours before patient’s habitual bedtime. The total reduced for all group. However, wake time for light group was 39.0 fewer minutes compared to 33.1 minutes for walking group. The study proved that both walking and light exposure alone or in combination can improve sleep problems in dementia patient. However, strategies to maintain adherence overtime and caregiver assistance are necessary to maximize effectiveness of the intervention.

Challenges of Dementia Caregiving

Dowling et al. (2008) evaluated the efficacy of melatonin and bright light therapy on treatment of circardian disruption in institutionalized patients with Alzheimer’s disease. By the use of randomized controlled trial, the research compared rest-activity outcome for people in morning bright-light exposure plus evening melatonin administration (LM) group with morning bright light exposure plus evening placebo (LP) group. The duration of intervention was one hour. The study revealed that daytime sleep decreased significantly in the LM group and it increases for patient in the LP group. Hence, morning bright light plus evening melatonin was associated with more daytime activity compared in patients with dementia compared to other group. However, LM intervention did not improved night time sleep variables. Therefore, the study showed that 1 hour of morning light treatment cannot improve nighttime sleep, but combination therapy with melatonin can improve rest activity rhythm in patients with Alzheimers dementia. Riemersma-Van Der Lek et al. (2008) also evaluated the effect of bright light and melatonin on patients with dementia. This gave contrasting result by proving that combined treatment increased sleep efficiency and improved nocturnal restlessness for patient. Hence, valid conclusion cannot be made regarding effectiveness of combined therapy due to contrasting evidence on efficacy of the intervention.

Three studies used bright light intervention to address sleep disturbance in people with dementia. Sekiguchi, Iritani and Fujita (2017) considered using bright light therapy in the morning to as a non-pharmacological intervention to treat sleep disorders after identifying high risk side-effects of hypnotic agents. As there was lack of understanding regarding the effectiveness of bright light therapy on types of dementia, the research explored the efficacy of the intervention in patients with Lewy Bodies dementia, vascular dementia and Alzheimer’s type dementia. Each patients were exposed to light box for 1 hour/day and this continued everyday for 2 weeks. The study showed that the therapy contributed to sleep improvement only in Alzheimer’s type dementia. Hence, type and grade of dementia affected the efficacy of bright light therapy. The review of a systematic review on interventions for dementia patient with sleep problems also revealed the effect of bright light therapy on improvement in sleep symptoms of patient (Salami, Lyketsos & Rao, 2011).

Bright light intervention is most studies intervention in research studies. Research has been done to evaluate the impact of the intervention on patients with severity of dementia. However, effect of timed bright light treatment for rest-activity disruption was addressed by Dowling et al. (2005). The intervention group received either morning or evening bright light exposure whereas the control group received indoor light for 1 hour. The outcome of the study revealed no improvement in nighttime sleep or daytime awakeness in bright light group compared to intervention group. Hence, clear evidence was lacking.

Limitations of Previous Studies

Another novel idea was presented by Figueiro et al. (2014) who explored the effectiveness of a tailored lighting intervention for individuals with Alzheimer’s and related dementias people living in nursing homes. Rest-activity data was used to measure sleep time and sleep efficiency. Custom luminaieres was used to illuminate rooms of participant and it was installed in rooms of participant for a period of 4 weeks. The findings of the study revealed improvement of global sleep scores and increase in total sleep time and efficiency. This result was obtained due to the effect of lighting intervention on increasing daytime circardian stimulation. Hence, circardian stimulation at daytime was targeted to improve sleep in patient.

Another research gave idea about the effect of home-based light treatment on sleep quality of patient with dementia. Intervention group was exposed to blue-white compact fluorescent light bulbs whereas the control group received yellow-white compact fluorescent light bulbs. The research hypothesis was that blue-white light source will stimulate the circardian system more than five times compared to yellow-white lighting. Data from participants were collected regarding total sleep time, sleep latency, sleep efficiency and number of sleep bouts. The actigraph measures of sleep quality in intervention group revealed that total sleep time and sleep efficiency was similar to that of control group (Sloane et al. 2015). The study showed poor efficacy of blue-white light on sleep quality in patients with dementia. Hence, light as an effective treatment for sleep disturbance in dementia was not established. It pointed out to the need for more studies to prove the efficacy of light therapy on sleep improvement in dementia patient.

From the review of research literature on the basis of inclusion and exclusion criteria, a total of 8 interventions were found relevant to give an overview about impact of light therapy on sleep quality of patients with dementia. The review gave idea about different forms of light intervention and its effect on patient. There were two studies that specifically investigated about the effect of light intervention with other intervention (combined treatment) to evaluate sleep outcomes of patients. Seven studies gave overview about singles interventions. Among 9 research articles included in the systematic review, majority of the research covered data on efficacy of light intervention and other studies evaluated impact of tailored lighting, blue-white lighting and home based light treatment on dementia patient.

As bright therapy was the most researched intervention evaluated in research, this section provides an overview view about the quality of studies covering bright light intervention in terms of research question and methodogical rigour. Four authors namely Dowling et al. (2008); Riemersma-Van Der Lek et al. (2008); Salami, Lyketsos and Rao 2(011); Dowling et al. (2005) evaluated the effect of bright light therapy on sleep improvement in dementia patient. Two author evaluated effect of bright light along with melatonin on sleep quality in patient. Riemersma-Van Der Lek et al. (2008) used combined intervention to investigate about daily treatment with whole day along with evening melatonin on patient. Dowling et al. (2005) also used timing as a parameter to determine the efficacy of combination therapy on treatment. Both the studies gave contrasting evidence regarding the effectiveness of light treatment plus melatonin on sleep quality. Riemersma-Van Der Lek et al. (2008) gave positive outcome regarding sleep improvement and efficiency, whereas negative outcome was observed for the study by Dowling et al. (2005). The difference in outcome might be due to difference in methodological rigour of both studies. The strength of the evidence by Riemersma-Van Der Lek et al. (2008) was that it evaluated the effect for a 15 year time period, however the other studies evaluated effect only for 6 months period. It proved efficacy of combination intervention in inducing positive effects for patient. Dowling et al. (2005) may not have achieved the same outcome because of delayed effect of melatonin. However, selection biases were seen in the study. Hence, combination intervention may be useful for dementia patient.

Research Question and Design

The other studies covered tailored intervention, lighting system and blue-white intervention. The negative outcome of blue-white light was proved. The study used appropriate measures to improve the fidelity of outcome. The selection of caregivers as well as dementia patient was a strong point of the study as effective of blue-white light level on neurologically normal and neurologically impaired patient was proved. It pointed to the need for future studies to evaluate whether longer exposure time in dementia patient can yield desired outcome or not. In addition, tailored light intervention also showed promise (Figueiro et al. 2018). However, process biases such as lack of consideration related to circadian light exposure at baseline and during intervention affected the quality of study. In future, effect of sex and treatment interaction is necessary to check whether tailored lighting system can work or not.

Conclusion:

The main aim of the systematic review was to judge the effectiveness of light therapy on reducing sleep disturbance in patients with dementia. The review of research literature suggested efficacy of bright light therapy in combination with other intervention to treat sleeping problem in patient. Although dynamic lighting system showed potential, however its application has been restricted because of poor evidence regarding efficacy in all groups of patient and in terms of timing of exposure. Despite evidence regarding bright light therapy on sleep improvement, the results were found inconsistent across studies. Hence, to increase application of bright light therapy on treatment of sleep problem in dementia patient, it is recommended that large studies with all types of dementia patient with other promising combination intervention should be done to maximize positive sleeping patterns for dementia patient.

Reference:

Ahmed, I., Sutton, A. J., & Riley, R. D. 2012. Assessment of publication bias, selection bias, and unavailable data in meta-analyses using individual participant data: a database survey. Bmj, 344, d7762, doi: https://doi.org/10.1136/bmj.d7762

Booth, A., Sutton, A., & Papaioannou, D. 2016. Systematic approaches to a successful literature review. Sage.

Dowling, G.A., Burr, R.L., Van Someren, E.J., Hubbard, E.M., Luxenberg, J.S., Mastick, J. and Cooper, B.A., 2008. Melatonin and Bright?Light Treatment for Rest–Activity Disruption in Institutionalized Patients with Alzheimer’s Disease. Journal of the American Geriatrics Society, 56(2), pp.239-246.

Dowling, G.A., Mastick, J., Hubbard, E.M., Luxenberg, J.S. and Burr, R.L., 2005. Effect of timed bright light treatment for rest?activity disruption in institutionalized patients with Alzheimer’s disease. International journal of geriatric psychiatry, 20(8), pp.738-743.

Figueiro, M.G., Plitnick, B.A., Lok, A., Jones, G.E., Higgins, P., Hornick, T.R. and Rea, M.S., 2014. Tailored lighting intervention improves measures of sleep, depression, and agitation in persons with Alzheimer’s disease and related dementia living in long-term care facilities. Clinical interventions in aging, 9, p.1527.

Search Process and Criteria

Forbes, D 2014, ‘Light therapy for improving cognition, activities of daily living, sleep, challenging behavior, and psychiatric disturbances in dementia’, Cochrane Database Of Systematic Reviews, 2, Cochrane Database of Systematic Reviews, EBSCOhost, viewed 29 March 2018.

Harvey, L., Mitchell, R., Brodaty, H., Draper, B. & Close, J., 2017. The impact of dementia and other comorbidities on increased risk of subsequent hip fracture following hip fracture in Australia: a competing risk approach. International Journal for Population Data Science, 1(1).

Jonnalagadda, S. R., Goyal, P., & Huffman, M. D. 2015. Automating data extraction in systematic reviews: a systematic review. Systematic reviews, 4(1), 78, doi:  10.1186/s13643-015-0066-7

Laver, K., Cumming, R.G., Dyer, S.M., Agar, M.R., Anstey, K.J., Beattie, E., Brodaty, H., Broe, T., Clemson, L., Crotty, M. & Dietz, M., 2016. Clinical practice guidelines for dementia in Australia. The Medical Journal of Australia, 204(5), pp.191-193.

McCurry, S.M., Pike, K.C., Vitiello, M.V., Logsdon, R.G., Larson, E.B. and Teri, L., 2011. Increasing walking and bright light exposure to improve sleep in community?dwelling persons with Alzheimer’s Disease: results of a randomized, controlled trial. Journal of the American Geriatrics Society, 59(8), pp.1393-1402.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. & Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.

Most, E, Scheltens, P, & Van Someren, E 2010, ‘Prevention of depression and sleep disturbances in elderly with memory-problems by activation of the biological clock with light–a randomized clinical trial’, Trials, 11, p. 19

Nay, R., Bauer, M., Fetherstonhaugh, D., Moyle, W., Tarzia, L. & McAuliffe, L., 2015. Social participation and family carers of people living with dementia in Australia. Health & social care in the community, 23(5), pp.550-558.

Riemersma-Van Der Lek, R.F., Swaab, D.F., Twisk, J., Hol, E.M., Hoogendijk, W.J. and Van Someren, E.J., 2008. Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: a randomized controlled trial. Jama, 299(22), pp.2642-2655.

Salami, O., Lyketsos, C., & Rao, V. (2011). Treatment of Sleep Disturbance in Alzheimer’s Dementia. International Journal of Geriatric Psychiatry, 26(8), 771–782.

Sekiguchi, H, Iritani, S, & Fujita, K 2017, ‘Bright light therapy for sleep disturbance in dementia is most effective for mild to moderate Alzheimer’s type dementia: a case series’, Psychogeriatrics, 17, 5, pp. 275-281

Sekiguchi, H., Iritani, S. and Fujita, K., 2017. Bright light therapy for sleep disturbance in dementia is most effective for mild to moderate Alzheimer’s type dementia: a case series. Psychogeriatrics, 17(5), pp.275-281.

Sloane, P.D., Figueiro, M., Garg, S., Cohen, L.W., Reed, D., Williams, C.S., Preisser, J. and Zimmerman, S., 2015. Effect of home-based light treatment on persons with dementia and their caregivers. Lighting Research & Technology, 47(2), pp.161-176.

Spira, A. P., Chen-Edinboro, L. P., Wu, M. N., & Yaffe, K. (2014). Impact of Sleep on the Risk of Cognitive Decline and Dementia. Current Opinion in Psychiatry, 27(6), pp.478–483.

van der Ploeg, E, & O’Connor, D 2014, ‘Methodological challenges in studies of bright light therapy to treat sleep disorders in nursing home residents with dementia’, Psychiatry and Clinical Neurosciences, 68, 11, pp. 777-784

Wilfling, D 2015, ‘Non-pharmacological interventions for sleep disturbances in people with dementia’, Cochrane Database of Systematic Reviews, 9, Cochrane Database of Systematic Reviews, EBSCOhost, viewed 29 March 2018.