Post on 31-Mar-2015
transcript
Rest-Activity and Light Exposure Patterns
in Older Adults: Methodological Implications
Thomas Hornick MD
Patricia Higgins RN, PhD
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Objectives
Understand the influence of circadian rhythm disruptions on overall health.
Identify clinical characteristics of circadian rhythm disturbances in older adults
Recognize the importance of chronobiology in elders’ sleep-wake disturbances.
Describe results from preliminary studies assessing the use of circadian light therapy in a nursing home unit and measurement of circadian light exposure in a case study of home-dwelling older adults.
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Types of rhythms
1. Ultradian (heart beat, respirations, appetite)
2. Infradian (menstrual cycle)
3. Circannual (annual breeding cycles)
4. Circadian (sleep-wake cycle)
Rhythms allow organisms to time events and anticipate change!
Biological Rhythms
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Arendt 2006 4
With Zeitgeber
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Disruption of circadian rhythm
• Poor performance/fatigue (Reinberg et al, 2007, Laposky et al 2008)
• Weight gain(Knutson et al, 2007)• Breast cancer (Stevens et al 2001)• Other conditions
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Why older adults?
• Sleep disorders are common• Complaints among caregivers of persons
with dementia frequently revolve around disordered day/night cycles
• Medications for sleep are less safe in this population
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Aging and light
• Older adults spend much of their time in muted indoor lighting.
• 35 minutes/day of bright light exposure compared to approximately 58 minutes of bright light per day for middle-aged adults. (Sanchez 1993)
• Reduced light exposure compounded due to physiologic changes
• senile meiosis, cataract formation, and/or increased light absorption by the crystalline lens. (Charmin 2003)
• Attenuation of light exposure by more than 80% in normal older adults relative to young adults.
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Age related losses in retinal illumination
Turner et al Br J Ophthalmol. 2008 November; 92(11): 1439–1444 9
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Wikipedia, accessed 10/30/09
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Role of Retinal Receptors
Three known retinal receptors: process visual and circadian timing information
Rods and cones: visual data Intrinsically photosensitive retinal ganglion
cells (iPRGC): primarily light-dark data
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Turner et al Br J Ophthalmol. 2008 November; 92(11): 1439–1444
Spectral sensitivity of photopic, scotopic and circadian (melatonin suppression) photoreception
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iPRGCs: History
1998: Melanopsin in light-sensitive cells on frog skin (Provencio et al, Proc Natl Acad Sci )
2000: Melanopsin-containing cells found in retinal ganglion cell layer (Provencio et al, J Neuroscience)
Most likely comprise the retinohypothalamic tract Sensitive to wavelengths in the 484-500 nm (blue
light) 2002: Light responses from melanopsin-
containing ganglion cells in humans (Berson et al, Science)
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Intrinsically photosensitive retinal ganglion cells (iPRGCs)
Timing Photoreceptors• Located throughout retina (~3000)• Express melanopsin
• Blue light sensitive(peak 460nm)• Regulate photoperiodism (sensitivity to length
of day and night)• Higher excitatory threshold than rods/cones• Transmits to SCN
24-hour light-dark pattern on the retina is the most efficient stimulus for entrainment of circadian rhythms in humans
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Suprachiasmatic nucleus (SCN) is master
pacemaker
1. Activity in SCN correlates with circadian rhythms2. Lesions of SCN abolish free-running rhythms3. Isolated SCN continues to cycle4. Transplanted SCN imparts rhythm of the donor on
the host5. SCN is known to be compromised in older adults with
dementia. (Harper et al 2008)
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Role of Melatonin
Melatonin• Primary role in humans is to convey
information about the daily light-dark cycle to physiological systems
• Peaks during sleep, suppressed by light.
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Melatonin Rhythms and Aging
Zeitzer et al Sleep. 2007 November 1; 30(11): 1437–1443.
Average (±SEM) plasma melatonin in young (top, n=90) and older (bottom, n=29) subjects during a normally phased sleep episode (closed boxes) and a constant routine where they remained awake at the same clock hours (open circles). Data were aligned such that each subject's wake time was graphically adjusted to 08:00 and the data from the baseline day and night and from the CR(constant routine) expressed relative to wake time; sleep time is from 24:00 to 08:00. Melatonin data were averaged hourly within and then across subjects
Age 65-81, mean 68
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Plasma melatonin suppression by bright light in 65 year old man
Duffy et al Neurobiol Aging. 2007 May; 28(5): 799–807.
Plasma melatonin data from subject 19G7, a 65 year old man who was exposed to a 3,527 lux light stimulus. Upper panel: plasma melatonin data from the initial circadian phase estimation procedure (CR1); middle panel: plasma melatonin data from the intervention day, with the 6.5-h experimental light exposure indicated by the open box; lower panel: plasma melatonin data from the final circadian phase estimation procedure (CR2) shown in the solid symbols, with data from CR1 replotted from above in the open symbols. During CR1, the fitted peak of the melatonin secretion (MELmax) occurred at 03:45, 3.5 h before habitual wake time. During CR2 MELmax occurred at 06:30, a 3.5 h phase delay. Melatonin was suppressed by 78% during the 6.5-h 3,527 lux light stimulus.
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Melatonin suppression with bright light
Duffy et al Neurobiol Aging. 2007 May; 28(5): 799–807.
Phase shift of fitted plasma melatonin peak (MELmax) vs. illuminance of experimental light stimulus. Data from each of the ten subjects are plotted individually and shown with square symbols. Solid line represents the 4-parameter logistic model fit to the data, with the 95% confidence interval of the model shown in the dotted lines. For comparison, the 4-parameter logistic model fit to the data from our previous study in younger adults [64] is shown in the dashed line.
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Circadian light transfer function
Figueiro, et al. 2006
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Clinical applications
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Turner et al Br J Ophthalmol. 2008 November; 92(11): 1439–1444
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Therapeutic light 2 Hours bright light in AM
Improved sleep efficiency in NH residents Fetveit et al, 2003
30 minutes sunlight for five days Decreased napping Increased participation Alessi et al, 2005
Daytime bright light Improved sleep/wake cycle in persons with
dementia (van Someren et al,1997)23
Riemersma-van de Lek et alJAMA 2008
6/12 Homes randomized for lighting intervention Installed fluorescent fixtures, both real and
sham 1000 lux horizontal at eyes in intervention Caregivers unaware which arm randomized to
Melatonin randomized by patient 3.5 year follow up
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Riemersma-van der Lek, R. F. et al. JAMA 2008;299:2642-2655.
MMSE, Depression
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Schedule change: Shift work
Light at night (LAN) Nurses’ Health Study (Willet, PI) Effects of Light at Night on Circadian System in
Nurses (Schernhammer, PI, RO1-OH008171)
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Circadian phase shifters
Can have negative effects on health Abrupt: jet lag, shift work Gradual: institutionalization
Timed light exposure: reset clock Sensitivity age-related Bright light in morning advances the clock Bright light in evening delays the clock Delays easier than advances
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Circadian Lighting in Long-term Care: A feasibility
study
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Methods 3 participants, residents of Ward 62B Lighting: GE fluorescent ceiling lamps
14,000 K Instruments
Sleepwatch-L© (AMI, Ardsley, NY) Neuropsychiatric Inventory-Nursing Home
Version DaysimeterTM (Lighting Research Center,
Rensselear Polytechnic Institute)
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Methods/Instrumentation for Sleep/Light Data
Subject wore Sleep Watch-L© for 7 days
Wrist-worn electronic measure of body movement and light
Software calculates activity/inactivity and light
© Ambulatory Monitoring Inc
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Lighting Installation
VAMC safety standards 1st phase: 3 ‘blue lamp’ prototypes by GE:
8000 Kelvin (K); 14,000K;16,000K 2nd: 13 standard fluorescent lighting ceiling
light fixtures in Dayroom 7 of 13 changed to 14,000 K (6 remained @
5000 K) Timer controlled blue lighting on, 8a-6p Lighting after 6pm: sufficient for visual acuity
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Mean of light measurements taken at eye level (horizontally) at 8 points in the room in the 4 cardinal directions, using PMA 2200 Photoradiometer, SnP Meter Photopic SL3103-001, S/N 9829
Light Conditions
Photopic (cones)
Lux
Scotopic (rods)
LuxS/P
Ratio BrightnessVisual
Effectiveness
all on 517 1178 2.24 781 1818
14,000 K only 381 918 2.26 606 759
standard 333 725 2.14 491 609
all off 222 489 2.17 328 412
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Results & Conclusions
Wrist actigraph well accepted Light sensor on wrist covered much of the
time by clothing? New blue lighting well received 3 subjects exposure to blue lighting (time
in Dayroom/ 10 hr period): 77 minutes, 371 mins, 373 mins
Next time: Change installation pattern?, use DaysimeterTM
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Rest-Activity and Light Exposure Patterns in the Home
Setting: A Methodological Study
P. Higgins, T. Hornick, M. Figueiro
American J Alzheimer’s Disease and Other Dementias, 2010
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Purpose
Assess the feasibility and reliability of using a circadian light meter (DaysimeterTM) in a field setting and use the human circadian phototransduction model’s analyses to provide clinically relevant results
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Dyad
Caregiver – Wife, 73 years, “good health”, no vision problems, no sleep-aid meds. Primary caregiver
Elder – Husband, 80 years, vascular dementia plus multiple co-morbidities, continent, needed assistance for all ADL’s and IADL’s, multiple meds included antidepressant but no sleep-aid
Elder received all primary care from the Cleveland VA Geriatrics Clinical team.
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Methods
Procedure - Light exposure and rest-activity data were collected over 7 consecutive days in November, 2007
Instruments Assessment of sleep quality and habits Home visit Sleepwatch-L© (AMI, Ardsley, NY) DaysimeterTM (Lighting Research Center,
Rensselear Polytechnic Institute)
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DaysimeterTM
Research prototype Two light meters measure photopic and
circadian light exposure Actigraph measures movement
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Results
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Built Environment
Independent living complex for seniors Apartment: 640 square feet
Brown paneling and beige paint and carpet One south facing window in bedroom Sliding glass door onto porch (south facing) Standard florescent lighting: kitchen and bath Incandescent lighting: floor and table lamps
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Ambient light exposure/24 hrs when out of bed (lux)
Light Norms (in lux)*
Sunlight/reflective surfaces 150,000Overcast Day 1,000Avg nursing home 50Avg living room 50-200Twilight 10Full Moon 1
*From Turner, 2008. Br J Opthalmology
Range
Mean mins: > 20 lux > 500 lux >1000 lux
Elder
0-449
191.5 0.0
0.0
Caregiver
0-3990
635.5 18.0 8.0
Dyad data
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ACTIGRAPHY Caregiver
wifeDemented
husband
Sleep-rest
- Mean sleep efficiency % - Mean night sleep (mins) - Mean sleep latency
(mins) - Mean wake after sleep
onset [WASO] (mins) - Mean napping/24 hr
(mins)
70 257
81 119
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81446
17105
96
Intra-daily variability (0-2) 0.71 0.95
Inter-daily stability (0-1) 0.69 0.7644
Caregiver
Elder
24-hour Sleep and Light
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Caregiver
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Entrained vs Disrupted Entrained Disrupted
Human
Conclusions
Daily light levels are very low Little variation in light levels Sleep
Neither caregiver or elder sleep well Caregiver: poor circadian entrainment
Sleep disruption causes Low lighting, little contrast Frequent wake times at night
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Support
VISN 10 GRECC, Cleveland VAMC Frances Payne Bolton School of Nursing,
Case Western Reserve University, Cleveland, OH
Lighting Research Center, Rensselear Polytechnic Institute, Troy NY
General Electric Company, Nela Park, East Cleveland, OH
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Team
Tom Hornick, MD1,2
Patricia Higgins, PhD1,2 Mariana Figueiro, PhD3
Mark Rea, PhD3
Andy Bierman, MS3
John Bullough, PhD3
Bill Biers, PhD4 Mark Duffy, PhD4
Ed Yandek, BS4
1Case Western Reserve University
2Cleveland Veterans Affairs Medical Center
3Lighting Research Center, Rensselaer Polytechnic Institute
4General Electric Lighting, Nela Park
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Next Steps
“Methodology issues in a tailored light treatment for persons with
dementia" R01 – M. Figueiro, PI
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Wikipedia, accessed 5/2010 52
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