Tilburg University

Biodynamic effects on the sleep pattern of people with van Lieshout-van Dal, E.; Snaphaan, L.; Bongers, I.

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DOI: 10.1016/j.buildenv.2019.01.010

Publication date: 2019

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Citation for published version (APA): van Lieshout-van Dal, E., Snaphaan, L., & Bongers, I. (2019). Biodynamic lighting effects on the sleep pattern of people with dementia. Building and Environment, 150, 245-253. https://doi.org/10.1016/j.buildenv.2019.01.010

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Biodynamic lighting effects on the sleep pattern of people with dementia T ∗ Ellen van Lieshout-van Dala,b, , Liselore Snaphaana, Inge Bongersa,b a Mental Health Care Institute Eindhoven (GGzE), Eindhoven, the Netherlands b Tranzo, School of Social and Behavioural Science, Tilburg University, Tilburg, the Netherlands

ARTICLE INFO ABSTRACT

Keywords: Dementia can disturb the more than in normal ageing people. And their biological clock is Dementia often not enough stimulated by light. Sleep disturbances form a high burden for informal caregivers and is the Sleep disorders main reason for institutionalization. The effect of biodynamic lighting with varying intensity and colour re- Biodynamic light sembling a daylight curve has hardly been objectively researched. In this study, we evaluate the exposure to Circadian rhythm biodynamic lighting on circadian functioning of 13 patients with dementia admitted to a psychiatric hospital. Three biodynamic lighting armatures designed for home use were placed in the common area for a period of three weeks and then removed for the same period. These periods were intermittent in an AB-phase design. Objective data of the sleeping pattern were collected using a bed sensor. During exposure the average frequency of night-time bed wandering significantly decreased from 11 to 5 times (P = 0.002). The average frequency of daytime napping significantly decreased from 16 to 7 times (P = 0.004). The average total night-time sleep significantly increased from 408 to 495 min (P = 0.007). The average total time out of bed at night significantly decreased from 180 to 104 min (P = 0.006). This pilot study found promising evidence (effect sizes > 0.5) that biodynamic lighting, tailored to stimulate circadian entrainment, could be helpful in decreasing sleeping dis- turbances in patients with dementia. This biodynamic lighting setup could easily be used as a non-pharmaco- logical intervention in a home situation.

1. Introduction on the biological clock depends on several factors, such as light-in- tensity (≥1000lux) [6], colour temperature (> 4500 K) [7], colour The number of people living with dementia worldwide is currently rendering index (CRI) and the absorption spectrum of the lighting estimated at 35.6 million. This number will be doubled by 2030. sources. Due to sensitivity for the light spectrum and a greater sensi- Dementia is the leading psychiatric condition for people over 60 [1]. It tivity for the blinding of light (due to degeneration of the ganglion cells) is of great importance that elderly people with dementia stay as healthy several methods are not suitable for nor appreciated by and vital as possible so that their quality of life remains high. In turn, it elderly [8]. The elderly between 62 and 76 years of age best appreciate will also reduce the number of people going to care homes. Innovative a lighting intensity level around 1000 lux [9] and are more sensitive to care models for people living with dementia are promising to be ef- indirect light. fective in improving their health, quality of life and reducing care Dementia can disturb the biological clock even more than in normal homes admission rates. One of these innovations is lighting [2–4]. ageing. Several mechanisms have been postulated for this effect such as Lighting has important visual but also non-visual aspects as light a more severe degeneration of the retinal ganglion cells and greater loss synchronizes physiological and behavioural rhythms in our body and of functionality of the biological clock located in the suprachiasmatic influences the biological clock [5] which is located in the suprachias- nuclei. Therefore, people with dementia are at increased risk for a matic nucleus (SCN) in the brain. The SCN stimulates the production of distortion of the circadian rhythm. In addition, people also tend to go sleep-wake hormones (cortisol and ) and follows a circadian less outside when they get older, especially people with dementia, so rhythm. Warm colour temperatures are associated with stimulation of the biological clock is less stimulated by light. On the average young the secretion of melatonin, also known as sleep hormone. Cool colour people spend five hours a day outside, older people 1 h and people with temperatures are associated with the inhibition of melatonin and sti- dementia in a nursing home only 1,6 min. In combination with the age- mulation of the production of cortisol. This hormone is responsible for related optical changes to the eye, particularly smaller pupils and alertness and activity during the day [8,10]. The effectiveness of light denser lenses, elderly people need far more light input than younger

∗ Corresponding author. GGZ Eindhoven, Doctor Poletlaan 40, 5626 ND, Eindhoven, the Netherlands. E-mail addresses: [email protected] (E. van Lieshout-van Dal), [email protected] (L. Snaphaan), [email protected] (I. Bongers). https://doi.org/10.1016/j.buildenv.2019.01.010 Received 22 August 2018; Received in revised form 21 November 2018; Accepted 7 January 2019 Available online 12 January 2019 0360-1323/ © 2019 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253 people [11,12]. They are actually double handicapped [13]. Further- The aim of this study is to investigate if biodynamic lighting, re- more, numerous studies show that the indoor light conditions in home sembling a normal daylight curve in light intensity and colour in a fixed or nursing care facilities for the elderly are not sufficient for the visual programme, objectively improves the sleeping pattern of in- and the non-visual aspects of light [6,14–16]. stitutionalized patients with dementia. All these together leads to a biological clock that is not stimulated enough by light, which can have huge consequences for the person with 2. Materials and methods dementia and the informal carer. The disruptions of the circadian rhythm can lead to problems in the sleeping pattern manifested in 2.1. Participants symptoms such as nightly wandering, daytime sleepiness and daytime napping [17]. These symptoms form a high burden for caregivers and The participants were recruited from a treatment facility for pa- are among the main reasons for institutionalization. It increases the tients with neurocognitive disorders in psychiatric hospital GGzE in chance of hospitalization ten times [18–21]. Eindhoven, the Netherlands within the period of January 2016 to Several studies have demonstrated that light is a promising non- January 2017. The attending physician and the formal caregivers pharmacological intervention to improve the sleeping pattern of elderly working at the ward identified potential participants for the study. The people with and without dementia. A review study of White et al. [22] inclusion criteria for the study were a primary diagnosis of dementia including 18 cited articles of randomized controlled trial studies, con- diagnosed by a geriatrician, neurologist or psychiatrist, based on the cludes that dynamic lighting interventions may mitigate symptoms of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition circadian disruption in elderly people living in senior living environ- (DSM-IV) [32] criteria. We excluded patients from participation in the ments. study if diagnosed with any other neurological disorder, including Not all studies show a significant positive effect of light exposure in narcolepsy, sleep apnoea or restless legs syndrome or a serious eye people with dementia. Forbes and colleagues [23] and Van Hoof and disease incompatible with light therapy, such as retinitis pigmentosa. colleagues [24] both conclude in their review articles that there is Patients were also excluded if they were physically disabled or if their limited statistic proof for the health effects of daylight. Fontana Gasio acute psychiatric condition was not suitable for participation, like a et al. [25] did not see an effect of a dawn simulator on circadian rhythm manic episode, addiction or severe aggression in a psychotic episode. disturbances in people with dementia. Sloane et al. [26] also did not see No restrictions are made for medication use. During the study medi- a significant effect of a tailored lighting system on measures of sleep in cation was monitored. people with dementia, however they did demonstrate a significant The study protocol was approved by the Institutional Review Board improvement in sleep quality in the caregivers. Both authors hypothe- of the psychiatric hospital GGzE. All participants signed a written in- sized that the used light sources did not seem to have a high enough formed consent to participate in this study, accordance with the light output to stimulate circadian entrainment. A field study of Aarts Declaration of Helsinki (Seoul Revision, 2008) and the General Data et al. [27] confirms this hypotheses as they found a significant effect of Protection Regulation (AVG) www.eugdpr.org. Applies at 2018. high illuminance natural daylight exposure in summer on the sleep of healthy elderly but did not found an effect in winter. Not only the illuminance quantity, but also the spectrum of visible 2.2. Procedure light is an important factor in light exposure. The different wavelengths of the visible light spectrum are seen by the eye as different colours. The 2.2.1. Lighting intervention use of short-wavelength light (460–470 nm), also referred to as bluish Three biodynamic lighting armatures were placed in the common light, lowers the threshold for circadian stimulation [28]. In addition to room of the ward. In biodynamic lighting the illuminance level and the quantity and spectrum, the timing and duration of light exposure are colour temperature are combined in the right proportion and varied also important. Light affects this system for the full 24 h in a day [29]. It throughout the whole day from 7:30 a.m. to 10:30 p.m. resembling a is important to note that the authors of both review articles analyzed daylight curve. All these aspects are accounted for in the designation of studies that used a variety of light therapy approaches and it is not clear the Sparckel, type Bright Brenda [33]. This lamp has been developed how the light doses received by the participants were measured or after extensive research in a co-production with lighting specialists and monitored. Figueiro et al. [12] extends the studies by Sloane et al. [26] users. A fixed daycurve programme was installed and used in our study. and Figueiro et al. [30]. They used light sources with a high short- Fig. 1 illustrates the situation in a clinical ward of GGzE and Fig. 2 wavelength (bluish) and high light output in the homes of people with shows the floorplan of the used common room with the location of the dementia and found that this lighting intervention significantly in- three biodynamic lighting armatures. creased sleep time and reduced depression and agitation scores. The One lamp can produce to 7500 lumen, five times more than usual in authors then observed that people with dementia in nursing homes respectively an office or living room. It also produces a colour tem- spend much time in the common area and tested the effectiveness of a perature of 2700–6500 K (indirect-direct) and the spectrum of the light table and found positive effects on sleep quality and mood after biodynamic lighting simulates a regular daylight curve by following four weeks of exposure [31]. Recently, Figueiro et al. [29] state that it is one of the biggest challenges to find a practical method for effectively delivering the lighting intervention to the eyes of people with dementia. Our study takes this into account by using a floor lamp that is designed for home use. This lamp exposes people to biodynamic lighting, lighting that follows a daylight curve in intensity, spectrum and temporal characteristics, to stimulating circadian entrainment. The lamp pro- duces direct and indirect light with a high illuminance and bluish colour (high short-wavelength content) in the morning and lower levels in the evening. In order to make the robustness of the results of our study as optimal as possible, we have chosen a within subjects design and performed the study in an inpatient ward. Often results are ob- tained through subjective sleeping questionnaires or studies show lot of diversity in participants and used lighting programmes. In this study objective measures are used to obtain results. Fig. 1. Patient exposed to biodynamic lighting.

246 E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253

condition, the amount of lux was measured manually at least three times a week at three fixed locations in the common room at three fixed moments a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.). Vertical mea- surements were obtained at eye level because they approach the real life situation of light collected by the ganglion cells in the eye the most. The lighting measurements were collected with a Voltcraft MS-200LED- luxmeter. According to the European standards, 500 lux is re- commended for adult people, not elderly, to be able to type, read and write [35].

2.2.3. Design The design of this study focused on a within subjects design. The advantage of a within subjects design is that individual differences between participants have no influence as participants are their own control. Participants start in the condition that is present at the moment Fig. 2. Floorplan of the common room. of admittance. Conditions of exposure to biodynamic lighting (condi- tion A) and no exposure to biodynamic lighting (condition B) are in- Table 1 termittent during a study period of 12 months. All participants will Measurement data of one lamp from Olino measurement report. minimal undergo a condition A and B. Parameter Lamp measurement Remark The study design is shown in Fig. 6. Condition A represents exposure to biodynamic lighting and condition B represents no exposure to bio- Colour temperature 4847K Direct light dynamic lighting, both for the duration of 3 consecutive weeks. It takes 4750K Indirect light Light intensity 1984.2Cd 0,1 m distance about 2 weeks to adjust the biological clock in people with dementia. A Colour Rendering Index 87 CRI_Ra recent study of Sekiguchi et al. [36] shows effects of bright light S/P ratio 2.0 1 m distance therapy within 2 weeks. To minimize carry-over effects the first two Melanopic Effect Factor 0.682 According to standard DIN weeks of each condition were marked as wash-out and adjustment SPEC 5031-100:2015-08 period and the last week (3rd week) is used for data collection [37]. Light spectrum 465-480 Nm Melanopic lux Luminous Flux 6818lm 1 m distance The quality of sleep is determined by outcome measures of the time Blue light hazard risk 0 No risk in bed during day and night, and the frequencies of daytime napping group and night-time bed wandering. For this purpose, 6 variables are ob- jectively measured in each condition by the Caremonitor (see Fig. 7). These variables are 1) frequency of night-time bed leave moments, 2) this curve in light colour and intensity. There is no risk of blue light frequency of daytime moments in bed, 3) time in bed during the night hazard and no exposure to UV-radiance. Other important data like the (min), 4) time out of bed during the night (min), 5) time in bed during ff Colour Rendering Index and the Melanopic E ect Factor from the the day (min), 6) time out of bed during the day (min). measurement report [34] are shown in Table 1. A close-up from the topside and screen of the lamp is shown in Fig. 3. The topside of the lamp produces indirect light and contains 12 2.2.4. Sleep pattern measurements high power LED lights producing a maximum of 3 W per piece. It The sleeping pattern is measured with the Caremonitor [38]. The consists of 4 lights producing 6500K, 4 lights producing 2700K and 4 Caremonitor is a thin matrass with sensors that is placed under the lights producing 1800K. The bottom side produces direct light and normal matrass of the participant. An example is shown in Fig. 7. contains 196 medium power Led lights producing a maximum of 0,3 W The Caremonitor, produced by Caredon, is CE-certi fied and avail- per piece. It consists of 98 lights producing 6500K, 49 lights producing able for five years now for health care facilities in different countries. It 2700K and 49 lights producing 1800K. is a reliable (99,5%) bed exit and wandering detection system devel- Because of the sensitivity of the elderly eye, we dimmed the ex- oped for the Caremonitor platform. Via a high-tech sensor, discretely posure to 75%, to increase the comfort of the patients. During the day placed under the conventional mattress, it is being registered whether a the participants received gradually a light intensity from 600 lux at 8 client has left the bed, or hasn't returned to the bed within 5 min. a.m., 1100 lux from 10 a.m. till 2 p.m. and 600 lux at 5 p.m. The Daytime is defined as 7:30 a.m. to 10:30 p.m. and night-time is defined varying colour temperature during the day of the biodynamic lighting as 10:30 p.m. to 7:30 a.m. It manages to measure the exact frequency lamp is shown in Fig. 4. During the day the colour temperature is and duration of the participant leaving the bed or going to bed by a around 6500 K, bluish light. During the evening, the colour temperature monitor or pdf-function (Bedleave and Wandering module). A bed leave is warm, around 1800 K. is registered when a patient leaves the bed for more than 5 min. A nap is Fig. 5 shows the power spectrum, the sensitivity curves and re- registered when a patient goes to bed for more than 5 min. It should be sulting night and day spectra at 1 m distance. noted that the sensor does not registrate if the patient is actually sleeping when lying in bed. Data are used of five subsequent days and nights in the last week of 2.2.2. Lux meter each condition (Monday-Monday). Medication use and dosage is regi- In order to have objective measurements of the received amount of strated at the beginning and end of participation in the study. lighting by the participants, lighting measures were collected. In each

Fig. 3. Research design ABABAB.

247 E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253

Fig. 4. Biodynamic colour temperatures of the Sparckel, type Bright Brenda, during a day. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

2.2.5. Analyses analyse the data. The Bonferroni method was used to correct for mul- Sleep pattern measurements and lighting measurements Data were tiple testing. The significance threshold was set at 0.01. The data of four analysed using SPSS version 19 (SPSS, IBM, Armonk NY). When parti- participants that completed more than two intermittent conditions were cipants undergo one biodynamic lighting condition (A) and one normal also analysed using the Wilcoxon non-parametric test and are sepa- lighting condition (B) a within subjects analysis can be performed. All rately described and visually displayed. Effect-sizes were calculated for variables were tested if they were normally distributed to be able to all statistically significant results. Effect-sizes are considered small for perform a t-test. As none of the variables were normally equated, the r < 0.1, moderate for r < 0.3 and large for r > 0.5. The effect sizes are Wilcoxon non-parametric test was chosen (two related samples) to calculated conform Cliff's Delta and absolute values are used as

Fig. 5. Power spectrum, sensitivity curves and resulting night and day spectra (1 m distance).

248 E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253

Fig. 6. Research design ABABAB.

condition compared to the normal lighting condition. The duration in bed at night significantly increased in the biody- namic lighting condition compared to the normal lighting condition and the duration out of bed during the night significantly decreased in the biodynamic lighting condition. The boxplots below show a visual display of the significant results. In Fig. 8 the frequencies of bedleaves at night and daytime napping in normal (B) and biodynamic lighting (A) condition are shown. The fre- quency of bed leaves at night was significantly less in the biodynamic lighting condition (p=0.002). In addition, the frequency of daytime napping was significantly less in the biodynamic lighting condition Fig. 7. Example of a matrass with a bed sensor. (p=0.004). In Fig. 9 the duration in and out of bed during the night is shown. described by Conroy [39]. Duration in bed at night was significantly greater in the biodynamic lighting condition (p=0.007). Duration out of bed at night was sig- nificantly less in the biodynamic lighting condition (p=0.006). 3. Results

3.1. Study population 3.3. Completion of more intermittent conditions

Sixty-one patients and their informal caregivers received informa- Although this study focussed on minimal one A and B condition, one tion about the research project and were invited to participate. Written participant was admitted to the ward during a longer time and com- consent was obtained from 39 patients, a response rate of 63,9%. pleted six conditions during the pilot following an A1B1A2B2A3B3 Twenty-six patients did not complete two conditions due to discharge, order. This data is very interesting because with this data we could also ff fi transition to a specialized nursing home or on account of decease. We investigate whether the hypothesized e ect could be recon rmed. The obtained complete data of 13 patients. The group includes 7 women results of the participant that completed six conditions are shown in and 6 men with a mean age of 74,77 years. Four patients completed Fig. 10. A decrease is visible in bed leaves at night and napping during more than two conditions. Seven participants started in condition B (no daytime in two biodynamic lighting conditions (A1, A2) compared to exposure to biodynamic lighting) and six in condition A (exposure to the normal lighting conditions (B1, B2). biodynamic lighting). The results of the participants that completed three conditions in an A1B1A2 or B1A2B2 order, are visually displayed in Figs. 11–13.In participant 1 and 3 the frequency of bed leaves decreases in the bio- 3.2. Outcome measures dynamic lighting condition, increases in the normal lighting condition and decreases again when the biodynamic lighting returns. For parti- ‘ ’ The mean amount of lux in the biodynamic lighting condition was cipant 2 starting in the normal lighting condition, the frequency of bed 1145, 8 lx ± 562,9 lx with a minimum of 385 lx and a maximum of leaves increases in the normal lighting condition, decreases in the ‘ ’ 1900,4 lx. The mean amount of lux in the normal lighting condition biodynamic lighting condition and increases again when the normal was 384,8 lx ± 281, 2 lx with a minimum of 63,4 lux and a maximum of lighting condition returns. The frequency of daytime napping shows the fi ff 904,3 lux. A two-tailed paired t-test did show a signi cant di erence same pattern in all participants. This is a strong indication of the po- between the amount of lux in both conditions (p < 0.001). sitive effect of biodynamic lighting on night-time bed leaves and day- fi Data of ve subsequent days and nights in the last week (Monday time napping. In participant 1 and 2 the same positive effect is visible in – Monday) of each condition were collected for each participant. Six the duration in and out bed at night. A decrease in time in bed at night fi sleep pattern variables were studied. Signi cance (P < 0.01) was is visible from the biodynamic lighting condition to the normal lighting ff reached in four out of six variables. Conform best practice, e ect sizes condition and an increase again when the biodynamic lighting condi- fi ff fi of each signi cant result are calculated. The e ect sizes of all signi cant tion returns. An increase of minutes out of bed at night is visible from results are r > 0.5. Results are shown in Table 2. the biodynamic lighting condition to the normal lighting condition and The frequency of bed leaves at night and the frequency of daytime a decrease again when the biodynamic lighting condition returns. In fi napping both signi cantly decreased in the biodynamic lighting participant 2 the effect is reversed because as this participant starts in the normal lighting condition. The same effect, however very small, is Table 2 visible in the time participant 1 spends in and out bed during daytime. Results sleep pattern variables in condition A and B. Participant 2 shows no difference in time in and out of bed during Sleeping pattern variables A (SD) B (SD) P r daytime. Participant 3 shows only positive effects on bed leaves and napping and no positive effects on duration in and out of bed. Frequency bedleave night 4,75 (2,98) 10,83 (8,78) 0.002* .610 Frequency daytime napping 7,26 (5,68) 15,97 (12,21) 0.004* .569 Minutes in bed night-time 495,10 (68,54) 407,84 (79,48) 0.007* .528 3.4. Medication Minutes out bed night-time 103,96 (70,19) 179,64 (89,39) 0.006* .541 Minutes in bed daytime 166,05 (109,70) 201,59 (143,10) 0.133 All participants used medication at start (i.e. antipsychotic medi- Minutes out bed daytime 678,34 (99,58) 639,15 (144,24) 0.196 cation, sedative medication, antidepressant medication, melatonin, vi- * indicates significance (P < 0.01), A = exposure biodynamic light, B = no tamin D, and pain medication). The medication use and dosage intake exposure biodynamic light but normal light. was registrated at the beginning and end of participation in the study.

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Fig. 8. Frequencies of bed leaves at night and napping during daytime in condition B (normal lighting) and A (biodynamic light exposure).

Fig. 9. Time in and out of bed in minutes during the night (A = biodynamic lighting condition, B = normal lighting condition).

In nine participants the medication did not change during the study. In It should further be noted that most previous studies did not spe- two participants antipsychotic medication was removed at the end of cifically examine the biodynamic aspect of lighting. Previous studies, the normal lighting condition. In one participant sedative medication like the study from Riemersma-van der Lek [6] demonstrated the po- was removed at the end of the normal lighting condition and in one sitive effects of the exposure to vertical bright light on the sleeping participant antidepressive medication was added at the end of the pattern of people with dementia. normal lighting condition. In our study one participant even completed six conditions and showed positive effects in the first four conditions. In the last condition 4. Discussion the effect is not reconfirmed. A possible explanation is that at that moment this participant was told that a transition to a care home was The present study found positive effects of a fixed biodynamic needed. It is well known that older people with dementia react to stress lighting programme resembling a daylight curve on the sleeping pattern with more problem behaviour such as restlessness and nightly bed of 13 patients with dementia admitted in a clinical ward of a psychiatric wandering due to declining coping skills [41]. Taken together, the re- hospital. sults of this study indicate that it is possible to improve the sleeping In this study three weeks of exposure to biodynamic lighting de- pattern in people with dementia by exposure to biodynamic lighting. It creases the mean frequency of bed leave moments during the night from is important to note that we used biodynamic floorlamps that are sui- 11 to 5 times with a large effect size of 0.610. The mean frequency of table for home use. daytime napping decreases from 16 naps a day to 7 naps a day. Positive Some important methodological limitations should be considered in effects were also found on the duration in and out bed during the night. interpreting the present results. First, the study design included a The time in bed during the night increased 77 min and the time out of within subjects design. This design is chosen to control for most of the bed during the night decreased 76 min. This indicates that people are possible non-specific treatment effects. But not every non-specificeffect more active during the day improving their circadian rhythm. can be controlled for (like for instance seasonal impact). In addition, a These results are consistent with the conclusion of a review study of significant difference between the amount of lux in both conditions White et al. [22] including 18 cited articles of RCT studies that dynamic (p < 0.001) can be seen, the exact amount of lux a specific participant lighting interventions may mitigate symptoms of circadian disruption received, has not been measured. A personalized lighting measurement in elderly people living in senior living environments. device placed close to the eye of the participant could approach this A recent study of Giménez et al. [40] showed that in 196 hospita- more closely. Furthermore, the sample of this study is small mainly due lized patients the objective sleep improved after five days of exposure to to the fact that it is a vulnerable group (elderly with dementia in a crisis dynamic lighting. The sleeping duration at night increases with 30 min. situation) to participate in long-term (max 6 weeks if they want to This is consistent with our finding that after 21 days of exposure the succeed in both conditions) research. Another limitation is the used sleeping duration at night increases with 77 min. duration of three weeks for each condition. Experienced light

250 E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253

Fig. 10. Results of the participant that completed six conditions A1 (biodynamic lighting), B1 (normal lighting), A2 (biodynamic lighting), B2 (normal lighting), A3 (biodynamic lighting), B3 (normal lighting). researchers as Figueiro et al. [30] used 4 weeks to reset the biological are comparable in frequency and time in both conditions and despite clock. However, we were able to find significant results in three weeks. these improvements in sleeping pattern are shown in the biodynamic Furthermore, a wash-in or wash-out effect of the biodynamic lighting lighting condition(s). condition is not completely excludable. However, it is not likely as in Medication is often used in psychiatric hospitals. Only four single four participants that completed more than two conditions, the effect of medication changes were registrated in this study. No conclusions can the biodynamic lighting is reversible. be drawn from these medication changes, due to the often long inser- Sleeping patterns were measured by a censored mattress in the bed. tion time of these types of medication (i.e. antipsychotic and anti- Participants possibly also napped in a chair in the common room. These depressive medication). Medication may have an impact on the naps were not registrated. Still we can assume that these naps in a chair sleeping pattern [42], but due to the study design, the offered

251 E. van Lieshout-van Dal et al. Building and Environment 150 (2019) 245–253

Fig. 11. Results of participant 1 that completed three conditions (A1 (biodynamic lighting) B1 (no exposure) A2 (biodynamic lighting).

Fig. 12. Results of participant 2 that completed three conditions (B1 (no exposure) A2 (biodynamic lighting) B2 (no exposure)).

Fig. 13. Results of participant 3 that completed three conditions (A1 (biodynamic lighting) B1 (no exposure) A2 (biodynamic lighting).

“treatment as usual” and the inclusion criteria, we may assume our be expected in other areas. study group is an accurate reflection of the general population. In closing, the present findings obviously have some important implications for clinical practice. Biodynamic lighting interventions 4.1. Conclusions directed at improving circadian functioning might be a valuable addi- tion to more traditional interventions, like pharmacotherapy. Based on In conclusion, the results of this study is promising to improve the the current results, biodynamic lighting interventions suitable for home sleeping pattern in people with dementia by exposure to biodynamic use should be considered a promising intervention to support circadian lighting. It supports the premise that biodynamic lighting could be a functioning in patients with dementia living at home, particularly for possible (early) intervention for people with dementia in at home si- patients with sleeping disturbances. tuations. In at home situations biodynamic lighting could also result in less disturbances during the night for the (informal) caregivers. This Declarations of interest night-time behaviour is one of the symptoms which causes a reason for the transition to a more controlled environment because of the impact None. on the primary caregiver [30,43]. Further research in this area is certainly needed. First of all, the Funding current intervention effects have to be replicated in studies that control for possible non-specific treatment effects and expectancy effects. This research did not receive any specific grant from funding Future studies should explore the specific contribution of the duration agencies in the public, commercial, or not-for-profit sectors. of the exposure and the exact received amount of lux per participant. Future research is also needed to reveal which patients with dementia Acknowledgements respond best to this type of intervention and light program. Finally, it could be a potentially valuable direction for future studies to in- We would like to thank all the patients and caregivers who took part vestigate the exact effects of biodynamic lighting on other symptoms of in the study. We also like to thank Maarten Voorhuis (owner Sparckel) dementia, like attention, concentration and behaviour. Given the pre- and Jan Nedvasba (owner Caredon) to make their products available for sent effects on the sleeping pattern, positive effects might possibly also our study and for their non-committal technical and practical assistance

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