Light As an Intervention to Manage Distressing Symptoms in Dementia: a Literature Review

Dementia special Light as an intervention to manage distressing symptoms in dementia: a literature review Grahame Smith presents a summary of the evidence base for light therapy in dementia Grahame Smith Introduction Health, 2009). Based on the work of Innovate Subject head – allied health With the right support, living well with Dementia, a European-funded project, this John Moores University, Liverpool dementia can become a reality – particularly paper aims to provide a summarised overview Correspondence: where a mental health nurse’s practice is of the literature and evidence related to the [email protected] underpinned by the best available evidence use of light within the dementia field. Abstract (Woods et al, 2013; Department of Health, Innovate Dementia is three-year project This paper presents a literature review 2012). that started in April 2012. It aims to explore, on the use of light as an intervention Contemporary evidence suggests that a identify and develop sustainable solutions to manage distressing symptoms in comprehensive and integrated package of to the everyday challenges of living with dementia. interventions should be offered to a person dementia (Woods et al, 2013; WHO, 2012; who is diagnosed with dementia and should Prince et al, 2011). Key words include ‘light’ as one of these interventions Light is a potential solution the project Dementia, symptoms, light, interventions, therapy, literature review, (Department of Health, 2012; NCCMH, was keen to explore due to its increased use evidence base 2007/2011; NICE, 2011). across North West Europe, specifically in the Netherlands and in some parts of the UK Reference Good practice (Woods et al, 2013). The first phase of the Smith G. (2014) Light as an intervention Good practice guidance suggests that light project was to undertake a literature review of to manage distressing symptoms in can be used in a number of different ways the evidence, presented in a ‘baseline’ report dementia: a literature review. Mental in the care of people with dementia, and in in March 2013. The second phase, based Health Nursing 34(5): XX. addition to this guidance there is increasing on the recommendations from the baseline evidence that light has a specific role to play report, was to use and evaluate an intelligent in the management of distressing symptoms lighting system within a dementia ward such as agitation and aggression and environment, and this work is still ongoing disordered sleep (Woods et al, 2013; Vardy (Woods et al, 2013). and Robinson, 2011; Azermaia et al, 2012; The interest in using light as an intervention NCCMH, 2007/2011; NICE, 2011). or light as therapy has arisen from noticing It is important to note that using light as an that distressing symptoms in dementia such intervention in dementia is in its early stages. as agitation and aggression can be worse at There is some promising evidence, but as certain times of the day, commonly the late yet not enough evidence for it to be formally afternoon to evening – also known as the and robustly recommended, though due to ‘sundowning phenomena’ (Vardy and Robinson, its increasing use it is essential that mental 2011; Ballard et al, 2009; Ballard et al, 2008; health nurses understand its value within their Bachman and Rabins, 2006). practice (Woods et al, 2013; Forbes et al, Traditionally these symptoms have been 2004; The Scottish Intercollegiate Guidelines managed through the use of pharmacological Network, 2006; Dijkstra et al, 2006; NCCMH, treatments, but due to the side-effects of 2007/2011; NICE, 2011; Department of these treatments there has been a move 01 Dementia special towards using non-pharmacological treatments induces drowsiness and this action is inhibited In terms of using light to manage agitation (Snowden et al, 2003; Ballard et al, 2009; by daylight (de Jonghe et al, 2010; Hanania in dementia research, studies to date have Ballard et al, 2008 Corey-Bloom et al, 2006; and Kitain, 2002; Hatfield et al, 2004; Wirz- struggled with the complex nature of this type Douglas et al, 2004; Hogan et al, 2008; Justice, 2006; Riemersma, 2004). of research. Eun-Hi Kong et al 2009; Sadowsky and Galvin, A study by de Jonghe et al (2010) A study Ancoli-Israel et al (2003) promisingly 2012, NICE, 2011). indicates that agitated behaviour in dementia, found a ‘shift in the peak of agitated Using non-pharmacological interventions specifically the sundowning phenomena, can behaviour’ – more so in mild dementia than that includes light is a fairly recent improve when treated with melatonin and on severe dementia, though a randomised development and on this basis there is a need this basis it is postulated that sundowning trial by Dowling et al (2007) concluded that for more rigorous research (Baillon, 2002; behaviour is explicitly related to a ‘disturbance ‘bright light therapy did not clinically affect Azermaia et al, 2012; Livingston et al, 2005; of the circadian rhythm’. neuropsychiatric behaviours (pp971). NCCMH, 2007/2011; NICE, 2011). This study concurs with Hanania and Kitain’s The Dowling et al study also noted that it Some of the most promising research has (2002: 338) view that ‘plasma melatonin levels was difficult to control complex factors that been in the use of light as a way of managing play an important role in the regulation of the may have adversely impacted upon their disordered sleep, which is another common sleep-wake cycle’. This disruption has a cyclic findings such as not being able to clearly symptom of dementia, though disordered effect in that circadian disruption in dementia quantify agitated behaviour and not being sleep is not uncommon among older people can in turn exacerbate existing behavioural able to discount the impact of prescribed (Brown et al, 2011; Wolkove et al, 2007; problems. medication (Dowling et al, 2007). Morton et al, 2005). The significance for mental health nursing Interestingly some studies focusing on sleep This age-related occurrence is be linked to practice is that to effectively manage the have also looked at restlessness, a form of the ageing process. A study by Turner and rest-wake cycle of a person with dementia, agitated behaviour in dementia. Studies by Van Mainster (2008) highlights that age-related including any related behavioural difficulties, Someren et al (1997), Sloane et al (2005) and changes in the eye can adversely affect the the mental health nurse also needs to Sloane et al (2007) highlight the potential of older adult’s capacity to receive the required effectively manage their exposure to light high intensity light in the management of sleep light levels throughout the day, and this in turn (Turner and Mainster, 2008; Mishima et al, problems and also restlessness behaviour in may negatively impact upon an individual’s 2001; Shirani and St Louis, 2009). dementia. sleep-wake cycle. At a holistic level Carvalho-Bos et al (2007: Further to this a study by Van Hoof et Turner and Mainster also make the point 92) argues that ‘treatments that enhance al (2009) exploring the intensity of light that if an individual is reliant on artificial daytime activity and the stability of the in managing restlessness suggests that lighting then this can compound the problem rest-activity rhythm may improve wellbeing’, ‘high-intensity bluish light may play a role in as artificial lighting is ‘dimmer and less enabling people with dementia to live well. managing restless behaviour and improving blueweighted than natural daylight’ (2008: In relation to the specific and controlled use circadian rhythmicity in institutionalised older 1439). The implication for mental health of light Terman and Terman (2005) highlight adults with dementia’ (pp146). nursing practice is that people with dementia that timed light exposure has some promise for Using light as an intervention in dementia require exposure to natural daylight that is the treatment of sleep disorders in dementia. is not just to confined to managing sleep consistent with a normal rest-wake cycle, Terman (2007: 497) makes the point that ‘the disturbances and agitated type behaviour. light in the day and less light at night, and rest-activity disturbance of dementia has been Teresi et al (2000: 417) highlights the where access to daylight is restricted then partially allayed under light therapy’. ‘environment is an area that is critical to artificial light should be equivalent to daylight Wirz-Justice (2006) and Skjerve et al specialised dementia care’, which includes the (Torrington and Tregenza, 2007). (2004) also point out that there is some use of lighting; while Boyce (2003) specifically A systematic review by Dijkstra et al promise in using light therapy. Further to stresses the importance of lighting quality. (2006) to ‘determine the effects of physical 2006, a systematic literature by Brown et al Voermans et al (2007: 158) makes a further environmental stimuli in healthcare settings (2011) suggests that light therapy of all the point that ‘falls in older people are a common, on the health and wellbeing of patients’, non-pharmacological interventions has more dangerous and frequently incapacitating supports this view indicating that ‘there were ‘conclusive’ evidence in reducing disorder problem’. On this basis good environmental predominantly positive effects found for sleep than other interventions. lighting can help to prevent falls and it can sunlight’ (pp166). Aarts et al (2006: 47) also A study by Sloane et al (2007: 1524) using potentially reduce agitation by enabling highlights that there is a ‘positive correlation ‘a cluster-unit crossover intervention trial orientation and helping people with dementia between sleep efficiency and exposure involving four conditions: morning bright light, make sense of their environment (Chang, duration to high intensity light, meaning that evening bright light, all-day bright light, and 2004; Hughes and Adams, 2012; NCCMH, more light is related to efficient sleep’.

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