Intelligent bright lighting for people with dementia
Dr. Kenneth FONG, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University
Dr. K. H. Ting, Senior Scientific Officer, University Research Facility in Behavioral and Systems Neuroscience (UBSN)
Dr. Hilda Cheung, Instructor, Department of Building Services Engineering
Dr. Minchen Wei, Assistant Professor, Department of Building Services Engineering
Acknowledgements
• Collaborators:• (1) Mind Delight Memory
& Cognitive Training Centre, Christian Family Service Centre (CFSC)
• (2) Smart Club, The Evangelical Lutheran Church of Hong Kong (ELCHK)
• (3) Tai Po Multi-service Centre for senior citizens, The Salvation Army
• People:• NG Ka Yu Lulu, MOT student• CHEUNG Ka Hing, MOT student• LAU Yan Gi Sarah, MOT student• CHAN, Sofina, Research Assistant• SIU Chung Pong, BScOT student• OR Sonia, BScOT student• CHAN Colette, BScOT student
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This project was granted by Innovation and Technology Fund – Mid-stream Research Programme for Universities, Innovation and Technology Commission, Government of Hong Kong SAR (Ref: MRP/011/17X)
Light stimulates the photoreceptors in the eye which send signals to the Suprachiasmatic Nuclei (SCN) in the hypothalamus of the brain and the SCN synchronizes the biological clock to the 24-hour day.
HypothalamusSuprachiasmatic Nuclei (SCN)
Pineal gland
Light stimulates the photoreceptors in the eye which send signals to the Suprachiasmatic Nuclei (SCN) in the hypothalamus of the brain & the SCN synchronizes the biological clock to the 24-hour day
What happens to inadequate lighting to older people with dementia?
Effect on biological clock
Disruption of sleep patterns,
40% of their time awake
Increasing the frequency of
daytime napping
Wandering at night
Older adults with dementia and Alzheimer’s
Confusion in daily routines and
Reduce in alertness and activity
Agitation, anxiety and depression can be exacerbated
Behavioural and psychological symptomsof dementia (BPSD)
Sleep disturbance
Approx. 40% of their night awake and a large portion of the day time asleep, they will wander around their home at night, with or without some aggressive/agitated behavior during the day because of poor sleep at night
disrupted circadian rhythm
Sleep disturbance
Behavioural and psychological symptoms of dementia (BPSD)
Background
Quality of life of
clients and their
caregivers
Intelligent bright light therapy
Non-pharmacological
therapies
Pharmacological therapies
Bright light exposure is one of the most widely studied non-pharmacological interventions for sleep disturbance/ behavioural problems in PwD
Systematic review & meta-analysis• Inclusion: (1) Participants: diagnosed with
dementia; (2) Intervention: various sensory stimulation interventions, including music therapy, MSS therapy, and light therapy, etc.; (3) Comparison: participants were assigned to either a sensory stimulation group or a control group that adopted standard care or other conventional treatments and did not receive sensory stimulation intervention; (4) Outcomes measures included the overall BPSD, depression, agitation, and QoL; (5) RCTs only
• Search terms “dementia, Alzheimer, tactile, visual, olfactory, auditory gustatory, sensory stimulation, multisensory stimulation, music therapy, & light therapy”
• 36 randomized controlled trials, with 1821 participants, were eligible for this current systematic review and 31 of them were included in meta-analysis.
ResultsStudy Design Diagnosis Sample
size
Age (years) Gender
(male,
female)
Intervention(E,C) Dosage Outcome Measures Follow-up
(period )
McCurry et
al., 2011
RCT dementia E=34;
C=33
E=80.6 ± 7.3;
C=81.2 ± 8.0
NA E:bright light therapy; C:
placebo normal light
2500 lux for 1
h/day, 8 weeks
Actigraphy: number of
Night awakenings
YES
(4 months)
Burns et al.,
2009
RCT dementia E=22;
C=26
E=82.5; C=84.5 (16,32) E:bright light therapy;
C:placebo normal light
10000 lux for 2
h/day, 2 weeks
CMAI; CSDD YES
(4 weeks)
Riemersma-
van et al.,
2008
RCT dementia E=49;
C=45
E=85.0 ± 6.0;
C=85.0 ± 5.0
(9,85) E:bright light therapy;
C:placebo normal light
1000 lux for 8
h/day, 6 weeks
Actigraphy: number of
Night awakenings;
CSDD; CMAI
NO
Dowling et
al., 2008
RCT Alzheimer’ s
disease
E=18;
C=17
E=89.0 ± 7.0;
C=82.0 ± 10.0
NA E:bright light therapy;
C:placebo normal light
2500 lux for 1
h/day, 5days per
week, 10 weeks
Actigraphy: Number of
awakenings at night
NO
Dowling et
al., 2007
RCT Alzheimer‘ s
disease
E1=29;
E2=24;
C=17
mean=84.0 ±
10.0
(13,57) E1:bright light therapy at
morning; E2:bright light
therapy at afternoon;
C:placebo normal light
2500 lux for 1
h/day, 5days per
week, 10 weeks
NPI-NH NO
Dowling et
al., 2005
RCT Alzheimer‘ s
disease
E=29;
C=17
mean=84.0 ±
10.0
(10,36) E:bright light therapy;
C:placebo normal light
2500 lux for 1
h/day, 5days per
week, 10 weeks
Actigraphy:Number of
awakenings at night
NO
Fontana et
al., 2003
RCT dementia E=9; C=4 E=86.8 ± 4.5;
C=83.0 ± 5.2
(1,12) E:light therapy; C:placebo
normal light
280 lux for 1
h/day, 3 weeks
Actiwatch: Number of
awakenings at night;
YES
(3 weeks)
The effects of light therapy on reducing the number of awakenings
Ge, X. & Fong, K. N. K. (in preparation). The effectiveness of sensory stimulations on behavioral and psychological symptoms of dementia (BPSD), sleep disturbances and quality of life in people with dementia: a systematic review and meta-analysis.
Funnel plot of light therapy on reducing the number of awakenings
- N=242 in 4 studies
- 1 study (Fontana et al., 2003) on low intensity “dawn - dusk simulations" was excluded
- SMD = -0.31; 95%CI = -0.56, -0.05; I²= 0%; P=0.02; Fixed-effect model
- Only 1 study carrying out the analysis on long-term effects
The effects of light therapy on reducing agitation
Funnel plot of light therapy on agitation
Ge, X. & Fong, K. N. K. (in preparation). The effectiveness of sensory stimulations on behavioral and psychological symptoms of dementia (BPSD), sleep disturbances and quality of life in people with dementia: a systematic review and meta-analysis.
- N=212 in 3 studies- SMD = 0.04; 95%CI = -0.57, -0.64; I²=76%;
P=0.91; Random-effect model- There was no studies evaluating its long-term
effect
The effects of light therapy on reducing depression
Funnel plot of light therapy on depression
Ge, X. & Fong, K. N. K. (in preparation). The effectiveness of sensory stimulations on behavioral and psychological symptoms of dementia (BPSD), sleep disturbances and quality of life in people with dementia: a systematic review and meta-analysis.
- N=220 in 3 studies- SMD = 0.16; 95%CI = -0.54, -0.86; I²=82%;
P=0.65; Random-effect model- There was no studies evaluating its long-term
effect
Conclusion
• Light therapy had a significant effect on improving sleep but was not significant in reducing agitation and depression.
• No analysis on its long-term effect could be done
• Insufficient studies on the effect of bright light therapy
• Ambient Assisted Technologies (AAT) refer to the use of an array of electronic devices – sensors and actuators or effectors – incorporated into everyday objects in a transparent way, meaning that they are not visible to the user, in order to monitor the user’s status and provide assistance as needed (Ramos et al., 2008).
Phase I (Screening)
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Wearable light sensor LYS 1.0
Recorded information of:
❖ Light illuminance (Lux)
❖ Light temperature (Kelvin / K),
❖ Light colours - Red (R), Green (G), Blue (B)
❖ Infrared radiation (IR)
Recruitment Phase 1Phase 2: Light
data
Process of collection of light data with LYS 1.0 technology
LYS 1.0
wearable
device
LYS app
on
smartphone
LYS
database
in the UK
➢ Developed in Imperial College
➢ Sensor positioned at a similar level equivalent to the shoulder of the elders, to measure the ambient and direct light Illuminance received by the client, light temperature as well as their wavelengths in terms of UVA, UVB and UV.
➢ The measurements will be carried out on one typical weekday per week so that an average result of ambient light exposure can be obtained.
➢ Moreover, the weather conditions from the Hong Kong Observatory will be record on the day of assessment as a reference.
Objective (Phase I)
• To examine the relationship between:
• Ambient light exposure in terms of light intensity, light temperature and light color.
• Sleep quality with behavioural and psychological symptoms of dementia (BPSD), including aggression, anxiety, agitation, irritability, etc.
• Cognitive function.
• Psychological well-beings.
• In PwD living in community dwellings and their caregivers
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Methods
• Design: Cross-sectional field study
• Subjects:
• Participants (N=50), aged 65 years old or above, diagnosed with dementia, and their caregivers were recruited from local community centers by convenience sampling.
• Groups: • PwDs (N = 46, x̄ age = 81).• Caregivers (N = 43, x̄ age = 59).
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Inclusion and Exclusion
• Inclusion criteria of PwD:• >65 year old• Resided in community• Mild to severe grade of dementia• With/without behavioral problems at night
• Inclusion criteria of caregivers:• >18 year old• Take care of PwD in last 3 months• Non-paid caregivers
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Procedures
• Convenience sampling from 3 centres
• Questionnaires: PwDs (N = 46) & caregivers (N = 43).
• 3 caregivers dropped out due to personal issues.
• Light data collected: PwDs (N = 30).
• 16 dropped out due to medical, personal and technical issues.
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Outcome measures
• Questionnaires for PwDs:
• Cognitive function:• Montreal Cognitive Assessment – Hong Kong version (MoCA-
HK)1.
• Psychological well-being:• Geriatric Depression Scale 4 (GDS-4)2.• Quality of Life Index for Alzheimer’s Disease (QOL-AD)3.
• Questionnaires for Caregivers:• Sleep quality (of PwD): • Pittsburgh Sleep Quality Index (PSQI)4.• BPSD (of PwD): • Cohen-Mansfield Agitation Inventory (CMAI)5.• Neuropsychiatric Inventory (NPI)6.
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Pittsburgh Sleep Quality
Index (PSQI) (Buysse et al., 1989)
➢ Developed by a self-report questionnaire that
assesses sleep quality over a 1-month time
interval. ➢ In this study, may also ask staff to complete.
➢ 19 individual items with a 4-point scale (0-3), creating 7 components (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction) that produce
one global score
➢ Time: 5–10 minutes
Ref: Chong, A. M. L., & Cheung, C. K. J. (2012). Factor structure of a
Cantonese-version Pittsburgh Sleep Quality Index. Sleep and Biological
Rhythms, 10(2), 118-125. doi: 10.1111/j.1479-8425.2011.00532.x.
Cohen-Mansfield Agitation Inventory (CMAI) (Cohen-
Mansfield, 1986) ➢ a caregivers’ rating
questionnaire ➢ 29 agitated behaviours,
each rated on a 7-point scale of frequency. It assesses the frequency of agitated behaviours in elderly persons in the long-term care setting.
➢ Breadth of behaviourscovered
➢ Time: 15 min
Ref: Lin, L.-C., Kao, C.-C., Tzeng, Y.-L. and Lin, Y.-J. (2007), Equivalence of Chinese version of the Cohen-Mansfield Agitation Inventory. Journal of Advanced Nursing, 59: 178–185.
Domains Delusions (paranoia) Hallucinations Agitation / aggression Dysphoria Anxiety Apathy
Frequency 1. O = Nil2. Occasionally, less than 1/week 3. Often, about 1/week 4. Frequently, several times per
week, but less than every day 5. Very frequently, once or more/
daySeverity 1. Mild (noticeable, but not a
significant change)2. Moderate (significant, but not a
dramatic change) 3. Severe (very marked, a dramatic
change)
Neuropsychiatric Inventory (Cummings et al., 1994)
IrritabilityEuphoria DisinhibitionAberrant motor behavior Nighttime behavior disturbance Appetite/ eating abnormalities
Ref: Leung, V. P., Lam, L. C., Chiu, H. F., Cummings, J. L.,& Chen Q. L. (2001). Validation study of the ChineseVersion of the neuropsychiatric inventory (CNPI). Int J Geriatr Psychiatry, 16(8), 789-93.
The Montreal Cognitive Assessment (MoCA) (Ziad Nasreddine, 1996)
➢ screening assessment for detecting cognitive impairment, conceptualized in MCI patients.
➢ one-page 30-point test ➢ Time: approximately 10 minutes
The MoCA assesses several cognitive domains:• The short-term memory recall task• Visuospatial abilities• Multiple aspects of executive functions• Attention, concentration, and working memory • Language• orientation to time and place is evaluated by asking the
subject for the date and the city in which the test is occurring (6 points).
• Hong Kong cut-off: 21/22• +1 point: 12 years of education or less
Ref: Wong, A., Xiong, Y. Y., Kwan, P. W. L., Chan, A. Y. Y., Lam, W. W. M., Wang, K., Chu, W. C. W.,
Nyenhuis, D. L., Nasreddine, Z., Wong, L. K. S., and Mok, V. C. T. (2009). The validity, reliability and
clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral
small vessel disease. Dementia and Geriatric Cognitive Disorders, 28(1), 81-87.
快速簡易長者抑鬱篩選量表 Chinese Geriatric Depression Scale (4-item version)
指示：請先說出題目「問〈a〉」，若長者對於問題內容未能掌握清楚，或在評分方面出
現問題，則需依次序讀出「問〈b〉」。
問題：以下的問題是人們對一些事物的感受，答案沒有對與不對。請想一想，在過去一
星期內，你是否曾有以下的感受。如有的話，請說出「是」；若無的話，請說出
「否」。
問 題 是 否
1. a) 喺上個禮拜 面，你滿唔滿意自己嘅生活呢？ 0 1
b) 咁你係滿意多啲，抑或唔滿意多啲呢？
2. a) 喺過去呢個禮拜裡面，你係咪覺得生活空虚呢？ 1 0
b) 喺上個禮拜 面，你係咪覺得做人都幾百無聊呢？
3. a) 喺上個禮拜 面，你有無擔心有啲唔好嘅嘢會發生喺你身上
呢？ 1 0
4. a) 喺上個禮拜 面，你係咪成日都覺得開心呢？ 0 1
b) 咁你喺上個禮拜 面，係開心多啲，抑或唔開心多啲呢？
總分：
Date: _________________________
Name of Researcher: _________________________________
Geriatric Depression Scale - 4 (GDS-4)(Almeida & Almeida, 1999)
➢ 4-item standardized screening instrument for major depression with good sensitivity.
➢ The higher the score, the higher will be the possibility of having a depression.
Ref: Cheng, S., & Chan A. C. M. (2005). Comparative performance of long and short forms of the Geriatric Depression Scale in mildly demented Chinese. International Journal of Geriatric Psychiatry, 20, 1131-1137.
Quality of life Index for Alzheimer’s disease (QOL-AD) (Logsdon et al., 1999)
➢ 13-item scale rated on four point scale (1-4) to assess quality of life of participants, based on aspects of environment, energy, family and etc.,
➢ Both caregivers (5 min) and in patient interview (10-15 min)
➢ with good internal consistency, test-retest reliability and inter-rater reliability in Cantonese version. (Chan, Chu, Lee, Li & Yu, 2011).
➢ The higher the score, the higher will be the quality of life of the client with AD.
Ref: Chan, I. W. P., Chu, L. W., Lee, P. W., Li, S. W., & Yu, K. K. (2011). Effects of cognitive function and depressive mood on the quality of life in Chinese Alzheimer's disease patients in Hong Kong. Geriatrics & Gerontology International, 11(1), 69-76.
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Mean sleeping time21:45
Mean waking time6:54
00:00
12:00
06:0018:00
Actual sleep duration 6.4 hours
Average time on bed: 10.21 hours
❖ Stratified into 4 timepoints for calculation:❖ (1) 00:00 - 05:59❖ (2) 06:00 – 11:59❖ (3) 12:00 – 17:59❖ (4) 18:00 – 23:59
74% (n=30) of PwD had sleep problem (as indicated by PSQI)
Repetitive sentences, calls, questions or words
TYPES of DEMENTIA COMORBIDITIES
SEVERITY in BPSD of PwD (NPI)
Time on bed: average 10.21 hours
Light data
• Ambient light data and intensity:• Wearable light sensor: LYS 1.0 technology.• 24-hr monitoring in a typical day.• Stratified into 4 time-points for calculation:
• 00:00 – 05:59• 06:00 – 11:59• 12:00 – 17:59• 18:00 – 23:59
• Recorded information of: • Light illuminance (Lux)• Light temperature (Kelvin / K)• Light colors in red, green, blue (R,G,B)• Movement (3-axis accelerometer)
25
Results• Sleep quality were significantly related to BPSD,
particularly physical aggressive behaviours including grabbing, scratching people or objects, anxiety and apathy.
26
Results
• Sleep duration was significantly associated with cognitive function
Sleep duration
Results
• Although light received in general was not related to disturbed sleeping pattern, light intensity and light temperature between morning and night time were significantly correlated to, respectively, BPSD and sleep problem.
-ve+ve
Results• Depression and cooler
light temperature was correlated.
-ve
Conclusion
• Our findings suggested that sleep quality are related to BPSD and depression of PwD, while partially associated with ambient light intensity and light color received from the environment.
• Bright light therapy can be applied more intelligently in terms of design and environmental modification for the older people in home settings.
• Benefits targeting to improve sleep, cognitive ability, physical and psychological behaviours of PwD can be optimized.
• Better quality of life for both PwD and caregivers with easier management can also be achieved.
Objective (Phase II)
• To design and develop an intellectual dynamic 24-hour lighting system, which change according to the time of the day, for older people with AD, at residential dwellings.
• To investigate the response of older people with AD after use of the bright light continuously for 3 months.
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Infrared camera
Schematic diagram (Phase II)
3 months3 months
EEGMelatoninBehavioral
EEGMelatoninBehavioral
EEGMelatoninBehavioral
Infrared camera
Longitudinal
Intelligent bright light therapy
Infrared camera
Collect 6 times in a typical day:1) Morning after wake up2) Lunch3) 4:00pm4) Evening at 8:00pm5) Before sleep6) Midnight (?)
Evidence of altered circadian rhythm with a reduced nocturnal melatonin response at 4:00AM in middle-aged men with cognitive impairments.
(Ref: Waller et al. Melatonin and cortisol profiles in late midlife and their association with age-related changes in cognition. Nature and Science of Sleep 2016; 8:47-53.)
Pineal Gland - Melatonin
EEG• Ant-neuro eego system
waveguard touch 64-channel dry electrode EEG cap
Implement 2 times in a typical day:1) Daytime around noon2) Evening
Luminaire development
35
Desk fixture Ceiling fixture
Desk fixture
• It includes two types of white-light LEDs (i.e., a low CCT and a high CCT).
36
Desk fixture
37
• It automatically adjusts the intensities of the two types to create mixed white light at different CCTs based on the time in a day.
Before 8:00 AM After 8:00 PM
Desk fixture
38
• A photosensor is placed in the base, which automatically adjusts the intensity of the light to achieve 1000 lx.
Ceiling fixture
• It includes five types of LEDs (i.e., four chromatic and one white-light LED).
39
• It automatically adjusts the intensities of the LEDs to create mixed white light at different CCTs based on the time in a day and date in a year.
40
Before 8:00 AM After 8:00 PM
Ceiling fixture
• A photosensor is installed on the fixture, which can adjust the intensities based on the amount of light. The present mode is to ambient light level to maintain the workplane illuminance at 1000 lx
• Since the light level received by the photosensor is not the same as that on the work plane and also depends on the space, different levels can be selected based on actual condition.
41
Ceiling fixture
References• Burns, A., et al., Bright light therapy for agitation in dementia: a randomized controlled trial. Int Psychogeriatr, 2009. 21(4):
711-21.
• Cheng, et al. Comparative performance of long and short forms of the Geriatric Depression Scale in mildly demented Chinese. International Journal of Geriatric Psychiatry, 2005; 20: 1131-1137.
• Chan, et al. Effects of cognitive function and depressive mood on the quality of life in Chinese Alzheimer's disease patients in Hong Kong. Geriatrics & Gerontology International, 2011; 11(1): 69-76.
• Chong, et al. Factor structure of a Cantonese-version Pittsburgh Sleep Quality Index. Sleep and Biological Rhythms, 2012; 10(2): 118-125. doi: 10.1111/j.1479-8425.2011.00532.x.
• Dowling, G.A., et al., Effect of timed bright light treatment for rest-activity disruption in institutionalized patients with Alzheimer's disease. Int J Geriatr Psychiatry, 2005. 20(8): p. 738-43.
• Dowling, G.A., et al., Light treatment for neuropsychiatric behaviors in Alzheimer's disease. West J Nurs Res, 2007. 29(8): p. 961-75.
• Dowling, G.A., et al., Melatonin and bright-light treatment for rest-activity disruption in institutionalized patients with Alzheimer's disease. J Am Geriatr Soc, 2008. 56(2): p. 239-46.
• Fontana Gasio, P., et al., Dawn-dusk simulation light therapy of disturbed circadian rest-activity cycles in demented elderly. Exp Gerontol, 2003. 38(1-2): p. 207-16.
• Lin, et al. Equivalence of Chinese version of the Cohen-Mansfield Agitation Inventory. Journal of Advanced Nursing, 2007; 59: 178–185.
• Leung, et al. Validation study of the Chinese Version of the neuropsychiatric inventory (CNPI). Int J Geriatr Psychiatry, 2001; 16(8): 789-93.
• McCurry, S.M., et al., Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: results of a randomized, controlled trial. J Am Geriatr Soc, 2011. 59(8): p. 1393-402.
• Riemersma-van der Lek, R.F., et al., Effect of Bright Light and Melatonin on Cognitive and Noncognitive Function in Elderly Residents of Group Care Facilities: A Randomized Controlled Trial. JAMA, 2008. 299(22): p. 2642-2655.
• Wong, et al. The validity, reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease. Dementia and Geriatric Cognitive Disorders, 2009; 28(1): 81-87. 42
