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The effect of bright light exposure in elderly

The effect of bright light exposure in elderly. (extended proposal) Supervisor: Dr. Jacquelline Ho. Group members (Group 35). Chen Hiu Hung 02515760T Hui Man Chi 02505986T Kwan Tsui Ying 02514227T Lee Tsz Wing 02513347T

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The effect of bright light exposure in elderly

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  1. The effect of bright light exposure in elderly (extended proposal) Supervisor: Dr. Jacquelline Ho

  2. Group members (Group 35) • Chen Hiu Hung 02515760T • Hui Man Chi 02505986T • Kwan Tsui Ying 02514227T • Lee Tsz Wing 02513347T • Li Kwan Fong 02513520T • Tsang Cheuk Yee Cherry 02514946T • Yeung Lai Kam 02513323T

  3. Introduction • For elderly person, sleep disturbance is a common problem (Foley, et al 1995; Swift, 1993)

  4. Source: Swift, C.G. & Shapiro, C.M. (1993). Sleep and sleep problems in elderly people. BMJ, 306: 1468-1471

  5. Introduction • Loss of sleeping is prone to accidents, and QoL (Foley, et al 1995; Cambell, 1995) • Interventions for such problem include: pharmacological use, psychotherapy, behavioral therapies, sleep hygiene education (Rogers, 1997; Chiu, 2003) and bright light exposure (Campbell, 1995; Dawson & Campbell, 1991; Yoon et al, 2002; Phipps-Nelson et al, 2003)

  6. Introduction (con’t) • However, due to physiology changes, • Medications  alter liver & kidney functions • More time in bed better sleeping quality (Dawson & Campbell,1991;Montgomery & Dennis, 2004) • There is a need for nurses to develop various interventions to promote sleep (Chan et al, 1997)

  7. There were studies shown that light exposure could alter circadian system as well as sleeping time(Campbell SS, 1995; Campbell et al, 1999; Dawson & Campbell,1991; Phipps-Nelson et al, 2003; Yoon et al, 2002) • reduce sleepiness (Phipps-Nelson et al, 2003) • effective in improving sleep in people with dementia, severe Alzheimer’s disease (Ancoli-Israel et al, 1997; Bliwise, 1993; Campbell et al, 1999) • contractindicated to people with mania (Ancoli-Israel, 2004)

  8. Aim • To explore if there are any effects of bright light exposure on sleep in elderly people

  9. Objectives • To study the changes in the sleep efficiency, latency and awaking time in the elderly people after bright light exposure. • To study the sleep satisfaction level in the elderly people after bright light exposure. • To study the duration of bright light effect of sleep in elderly people

  10. Research Questions Are there any changes in the • sleep latency • sleep efficiency • awaking time • sleep satisfaction level in the elderly people after bright light exposure? 5. How long does the effectiveness of the bright light effect last?

  11. Literature reviewSleep definition • A normal state of altered consciousness (Black & Jacobs,1997) • Decrease perception and reaction to environment (Blais et.al,1998) • Minimal physical activity, consciousness level, change in body’s physiological processes

  12. Literature review Sleep function • Restores normal level of activity and normal balance among parts of nervous system • Enhance the muscle tone and protein synthesis (Blais et.al,1998) • Maintain mental activity such as learning, reasoning (Black & Jacobs,1997)

  13. Literature reviewSleep cycle • Each cycle about 70 minutes; 4-6 cycles within 7-8 hours (Blais et.al,1998) [Figure 1. Borbely,A. (1986). Secrets of sleep. New York: Basic books.]

  14. Literature review Sleep cycle (con’t) • Non-rapid eye movement (NREM) • 4 stages: stage 1-3 last about 30 mins; stage 4 lasts about 30 mins (Blais et.al,1998) • Stage 1 and 2 are light sleep; stage 3 and 4 are slow-wave sleep (Black & Jacobs,1997) • Physiological characteristic: lack of eye movement, low and fragmented cognitive activity (Black & Jacobs,1997)

  15. Literature reviewSleep cycle (con’t) • Rapid eye movement (REM) • REM lasts about 10 mins, increase time of REM in later sleep period (Black & Jacobs,1997) • Low voltage, random fast waves, deep sleep (Black & Jacobs,1997) • Characteristic: rapid eye movements, erratic respirations, low muscle tone (Black & Jacobs,1997)

  16. Literature reviewSleep problem in elderly • Little or no NREM stage 4 (Shapiro & Swift,1993), decrease REM, more time in stage 1, sleep latency increases (Black & Jacobs,1997) • Inadequate depth of sleep awaken more often during night, not enough sleep, awaking too early, needing naps (Shapiro & Swift,1993)

  17. Literature reviewSleep problem in elderly(con’t) • Circadian rhythm advances (Ancoli-Israel 2004) • Impairement of melatonin production (Cardinali &Pevet, 1998) • Decrease melatonin rhythm amplitude (Reiter & Robinson, 1995; Schwartz 1997) • Sleep disturbance leads to poor memory, difficult concentration (Ancoli-Israel 2004)

  18. Literature reviewMelatonin • Secreted by human pineal gland and retina (Cardinali & Pevet,1998) • Convey information concerning daily cycle of light and darknss to body physiology. It used for the organization of circadian rhythms (Cardinali & Pevet,1998;Empson, 2002;Schwartz,1997) • Induce circadian phase shift and influence sleep-wake cycle (Cardinali & Pevet,1998; Schwartz,1997)

  19. Literature reviewCircadian rhythm • Internal clocks that control biological rhythms (Hobson,1989) • Internally generated (Hobson,1989), period close to 24 hr (Duffy et al,1996) • Circadian rhythm can be affected by environmental factors such as light and darkness (Blais et.al,1998) • Change in circadian rhythm may cause chronic disruption of sleep (Blazer et al. 1995)

  20. Literature reviewLight • Is an important modulator of circadian rhythm (Kessler et al,1997) • Additional light in the evening can raise melatonin level & delay circadian cycle→ Increase night sleep amount (Cooke et al,1998; Reiter & Robinson,1995)

  21. Literature reviewRelationship between light ,melatonin rhythm and circadian • Light →a person’s light-dark cycle →Melatonin secretion rhythm →circadian rhythm →sleep pattern of a person

  22. Methodology Research design Sampling Selection criteria Study design Instruments and equipments

  23. Research design • Quasi-experimental study • Study the change in the sleep efficiency and latency of elderly after bright light exposure • Light intensity is the independent variable to be manipulated. Subjects can serve as their only control group.

  24. Sampling • Convenience sampling method • Subjects will be recruited on the basis of availability • Economical and efficient • There are difficulties to spend time & resources to study all members of a population (Polit, Beck & Hungler, 2001).

  25. Sampling • Number of subjects (N=30) • Similar researches done before with similar sampling size • E.g. a study was done in Norway on 2001 to study the prevalence and characteristics of sleep disturbances among an entire nursing home population by actigraphy. (N=29), (Sleep Disturbances Among Nursing Home Residents, Actas de Fisiologia 7, 2001).

  26. Sampling • E.g. a study done in HK presenting findings on utilizing bright light to alter sleep-wake cycle in order to improve quality of sleep (N=38) (Ho et. al., 2002).

  27. Sampling • No control group • Subjects will serve as their own control group instead • Comparison is made before & after the bright light exposure, both qualitative & quantitative data.

  28. Selection criteria (inclusion) • Aged 65 or above • Old age home resident with no sleep partner • Conscious & able to answer question • Able to move their limb freely & independently • Have sleep problem and desire to improve

  29. Experimental setting • Room temperature • Video tapes of 50’s TV programs will be broadcasted and research team to chat with the subjects, during the light application period.

  30. Study Procedure • Season for data collection: -August, 2004 -Stable environmental temperature in HK(around 26 degree Celcious) -Less variables, to test bright light effect on sleep (Murphy & Campbell, 1996)

  31. Periodof data collection: • Pre-bright light exposure stage: Day 1 & 2 -150lux red dim light -Day1: baseline data; Day2: Experimental data. • Bright light exposure stage: -Day 3 to Day 7 (2500 lux white bright light) • Post-bright light stage: -Day 8 to Day 14 (150 lux red dim light)

  32. Light intensity applied • 2500lux white bright light • 2500lux can totally suppresses melatonin secretion (Dollins et al,1993) • It is the intensity level of the sunlight daytime intensity during the spring and summer. (Emsinger, 2001) • 150 red dim light • room light intensity:150-300lux(Heil and Mathis, 2002); • little or no suppression in light with long wavelength, red light.(Brainard et. al., 1985 & Wright and Lack, 2001)

  33. Time of light therapy • 1800-2100hours -Phase-delaying of sleep-To help subjects with advanced sleep phase(Kripke, 1989)

  34. Table 1 The Experimental Design

  35. Light On Period • 1800-2100 hours • Bright white light, 2500 lux or Red dim light, 150lux • Light Off period • 2100 hours to get up time(next day) • All experimental lights are switched off • Usual Routine • - Get up time – 1800hours of the day • No experimental light are applied • Subjects perform their usual routine. Data collection procedure

  36. Date 4/8/2004 (Wed) 5/8 (Thu) 6/8 (Fri) 7/8 (Sat) 8/8 (Sun) 9/8 (Mon) 10/8 (Tue) 11/8 (Wed) 12/8 (Thu) 13/8 (Fri) 14/8 (Sat) 15/8 (Sun) 16/8 (Mon) 17/8 (Tue) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Pre-bright light exposure stage (Adaptation) Pre-bright light exposure stage (Baseline) Bright Light Exposure Stage Post-Bright light exposure stage -Subjects will expose to red dim light from 1800 to 2100 -During the light exposure period, the subjects will be watching TV. -Subjects will expose to bright white light from 1800 to 2100 -During the light exposure period, the subjects will be watching TV. -Same as Day 1 & 2. Schedule of the study

  37. Study protocol • Always began and ended on weekdays -due to mood changes caused by the subjects being taken out by relatives • Maintain constant room temperature • Keep subjects’ concentration

  38. Instruments 1. Preliminary screening assessment 2. Sleep log

  39. Instruments • A preliminary screening assessment: • Questionnaire adopted from The Hong Kong polytechnic University sleep research team (Ho et al. 2002) • Content validity index (CVI): 0.92, Pearson r : 0.87 Two parts in the questionnaire: • A screening assessment • A preliminary assessment

  40. Instruments (con’t) 1. Screening assessment: To screen eligible subject - Demographic data: age, sex , height , weight , health status, physical and psychological illness - Sleep history : What, when, how, how long does the sleep problem

  41. Instrument (con’t) 2. Preliminary assessment : Understand the sleep history of the subjects I. Sleep habits II. life style (sleep related)

  42. Appendix 1 • The Hong Kong Polytechnic University Date: ________ • Department of Nursing and Health Sciences Code: ________ • Screening Assessment • Part I Demographic Information • Please put a  in the appropriate box. • 1. Age: _____ • 2. Sex: _____ • 3. Body Height: _____ (cm / ft & in) • 4. Body Weight: _____ (kg / lbs) • 5. How do you describe your present health status? •  Very good •  Good •  Acceptable •  Poor •  Very poor • 6. Do you have any mental, medical or physical illness(es)? • ________________________________________________________________ • Are you taking any medication(s)? Please specify the medication(s) with dosage, frequency, date of commencement & any reaction(s) related to the medication(s). • ________________________________________________________________ • ________________________________________________________________ • 8. How do you describe your sleep status at night? •  Very good •  Good

  43.  Acceptable •  Poor •  Very poor • 9. How do you feel upon arising? •  Refreshed •  Acceptable •  Still tired •  Sleepy • 10. Do you sleep alone? •  Yes •  No • 11. Do you use any sleep aids? Please describe. • ________________________________________________________________ • Part II Sleep History • 1. How long have you been suffering from sleep disturbance? • ____ month(s) / year(s) • 2. How many night(s) a week do you have sleep disturbance? • ____ nights per week • 3. How do you describe the onset of your sleep disturbance? •  Gradual •  Sudden • 4. How do you describe your course of sleep disturbance? •  Recur periodically (eg per week or per month) •  Recur in relation to season (eg especially in spring) •  Persistent without remission periods •  No fixed mode • 5. What will exacerbate your sleep disturbance? •  Go to toilet frequently •  Too Noisy •  Temperature: too cold or too hot •  Physical discomfort

  44.  I don’t know •  Others: ______________________ • Was/Were there any event(s) related to the onset of the sleep disturbance (eg death of loved one, retirement, physical or mental problems, etc)? • ________________________________________________________________ • 7. Do you have any trouble in falling asleep at night? •  Frequently •  Sometimes •  Rarely •  Never • 8. Do you have frequent awakenings during the night? •  Frequently •  Sometimes •  Rarely •  Never • 9. Do you wake up too early in the morning? •  Frequently •  Sometimes •  Rarely •  Never • 10. Do you have any difficulty in staying awake during the day? •  Frequently •  Sometimes •  Rarely •  Never • 11. Do you have any symptoms (eg shortness of breath, nightmare, etc) related to your • sleep disturbance? Please state the rate of occurrence per week. • ________________________________________________________________ • 12. In the last six months, have you been particularly nervous or anxious? •  Yes •  No • 13. In the last six months, had you say been worrying most of the time (more than a • week)? •  Yes •  No • 14. In the last six months, had you been less interested in most of the things (regardless • of your preference) or unable to enjoy nearly every day? •  Yes •  No • 15. For the past couple of years, have you been bothered by depressed mood? •  Frequently •  Sometimes •  Rarely •  Never

  45. InstrumentsPreliminary assessment (con’t) I. Sleep habits: • Bed time • Sleep onset latency (SOL) • Wake after sleep onset (WASO) • Sleep offset time (SoffT) • Rising time and napping

  46. InstrumentsPreliminary assessment (con’t) II. Life style (sleep related): • smoking • caffeinated food, drink • alcohol consumptions • dairy products consumptions • exercise, outdoor sunlight exposure • snack consumptions

  47. Instruments (con’t) • A sleep log (Self-description of sleep) • Only the individual can judge his or her sleep is good or not. (Closs,1997) • Evaluate the subjective sleep condition throughout the study Advantage: sleep efficiency and subjective sleep descriptive data can be estimated. Disadvantage : less validity on sleep durations and sleep-wake activity (Reidk,& Daso,1999)

  48. Instruments Sleep log(Ho et al. 2002) • Subjective reporting of sleep wake parameter • Entries for bedtime, • Arising time, • Sleep latency, • Number and duration of awakenings , • Sleep durations • Naps (Lacks P. 1987) • Self –reported satisfaction of sleep • A five-point subjective rating scale (very good to very poor)

  49. InstrumentsSleep log (con’t) • Data obtained in the sleep log incorporates with the actigraphy, compensate each other • Helps to evaluate the effect of this study.

  50. The sleep log • Appendix II • The Hong Kong Polytechnic University Date: _____________ • School of Nursing Code: _____________ • Sleep Log Day ______________ • Please put a  in the appropriate box. • 1. What was your final awakening time? _________ • 2. What was your final arising time? _________ • 3. Did you go to bed in the morning (before 1200 hours)? • Time Lying Asleep •  No. _________ ___________ min(s) __________ min(s) •  Yes. How often? _________ _________ ___________ min(s) __________ min(s) • 4. Did you doze in the morning (before 1200 hours)? • Time Asleep •  No. ____________ ____________ min(s) •  Yes. How often? _________ ____________ ____________ min(s) • 5. Did you go to bed in the afternoon (before 1800 hours)? • Time Lying Asleep •  No. _________ ___________ min(s) __________ min(s) •  Yes. How often? _________ _________ ___________ min(s) __________ min(s) • 6. Did you doze in the afternoon (before 1800 hours)? • Time Asleep •  No. ____________ ____________ min(s) •  Yes. How often? _________ ____________ ____________ min(s) • 7. Did you go to bed in the evening (after 1800 hours)? • Time Lying Asleep •  No. _________ ___________ min(s) __________ min(s) •  Yes. How often? _________ _________ ___________ min(s) __________ min(s) • 8. Did you doze in the evening (after 1800 hours)? • Time Asleep •  No. ____________ ____________ min(s) •  Yes. How often? _________ ____________ ____________ min(s) • 9. When did you turn off the light? _________ • 10. When did you go to bed? _________ • 11. How long did you take to fall asleep? _______ min(s) / hour(s) • 12. Did you have any trouble in falling asleep? •  No. •  Yes. Why? __________________________________________________________________________________ • 13. Did you awake during the night?

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