lighting for older adults and alzheimer’s disease patientsvan someren ejw, kessler a, mirmiran m,...

© 2014 Rensselaer Polytechnic Institute. All rights reserved.

Lighting for Older Adults and Alzheimer’s Disease Patients

Mariana G. Figueiro, PhDProfessor and Director

Lighting Research CenterRensselaer Polytechnic Institute

November 1, 2018


Acknowledgements

LRC faculty and staff

› Mark Rea, PhD

› Barbara Plitnick, RN

› Sharon Lesage, CLT, ASCP

› Kassandra Gonzales, MS

› Ryan Bromm, BS

› Charlie Roohan, BS

› Rohan Nagare, MS

› Ryan Kutler, MS

› David Pedler, BA

› Andrew Bierman, MS

› Geoffrey Jones, BS

› Jennifer Brons, MS

› Greg Ward, BS

› Jeremy Snyder, MS

› Dennis Guyon, AAS

› Rebekah Mullaney, MS

› Trina Beaudoin

› Bonnie Westlake

› Claudia Hunter, PhD

› Jennifer Taylor, MS

› N. Narendran, PhD

› Russ Leslie, March

› Jean Paul-Freyssinier, MS

› Leora Radetsky, MS

› Martin Overington

› Howard Ohlhous

› Allison Thayer

› Kyle McNeil

› Madison Laks

› Savana Wemette

Light and Health Project Sponsors

› National Institute on Aging

› National Institute on Drug Abuse

› National Institute of Nursing Research

› National Cancer Institute

› National Center for Complementary and Alternative Medicine

› Eunice Shriver National Institute of Child Health and Development

› National Institute of Occupational and Safety Health (CDC/NIOSH)

› General Services Administration (US GSA)

› US Department of State (through GSA)

› Office of Naval Research

› US Navy

› US Green Building Council

› The Swedish Energy Agency

› Boeing

› Google

› McClung Foundation

› Acuity Brands

› Philips Lighting

› Metro Istanbul

Organizers of the eventGlamox (Lars-Fredrik Forberg and Rolf Røsberg)


Light and Health Alliance SponsorsAcuity Brands, Axis Lighting, Cree, Current by GE, Ketra Inc., OSRAM Sylvania, USAI Lighting

MissionTo bridge the science of light and health to practical applications, and to provide objective information based on basic and applied researchGoals: • Conduct evaluations, demonstrations,

and research projects to develop practical devices and applications

• Institutes to educate key audiences on light and health with a particular emphasis on developing quantitative lighting specifications

• Presentations at conferences to promote the topic of light and health, and the Light and Health Alliance

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Lighting for older adults

Older adults, including those with Alzheimer’s disease or other dementia (ADRD)

• Natural changes to the aging eye occurs

• Postural control and stability is more dependent on information from the visual system

• Disturbance in circadian rhythms due to deteriorating SCN function, reduced exposure to light and impaired visual perception

• Prolonged wakefulness at night, compensated by daytime sleep

• Robust light/dark pattern may minimize depression and make circadian rhythms more robust

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Van Someren EJW, Kessler A, Mirmiran M, et al. Indirect bright light improves circadian rest-activity disturbances in demented patients. Biol Psychiatry. 1997;41:955–63

Ancoli-Israel S, Martin JL, Gehrman P, et al. Effects of light on agitation in institutionalized patients with severe Alzheimer disease. Am J Geriatr Psychiatry. 2003;11:194–203

Riemersma-van der Lek R, Swaab D, Twisk J, Hol E, Hoogendijk W, Van Someren E. 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):2642.


The aging visual system

Normal aging› Optical changes (before

age 65)

› Neural changes (after age 65)

Age-related diseases› Cataract (optical

change)

› Glaucoma

› Macular degeneration

› Diabetic retinopathy

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Age-related optical changes

Presbyopia: Loss of accommodation

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10 D = 10 cm (4in)

1 D = 1 m (3 ft)



Reduced retinal illuminance

› Smaller pupil (senile miosis)

› Thicker crystalline lens (absorption and scatter)

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Weale 1961



Reduced retinal contrast and color saturation

Increased disability glare› Scatter by crystalline lens

• Increased stray light due to accumulation of more and larger protein molecules

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Scattered light by lens

Reduced contrast and color saturation

Normal Vision

Graphics: NIH Website

Yellowing of lens

0.5 8 12

25 47 60

70 82 91


Age-related loss of retinal illuminance and contrast

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Aging and the circadian system

Less light reaches the back of the eye Sedentary life; dim indoor environments Reduced number of neurons in retina and SCN Changes of function at molecular level in the SCN

› Less responsive to light

Failure of communication between clock and downstream rhythms

Increased sensitivity to light in the phase advanced portion

Earlier onset of sleepiness, early morning awakening and increased daytime napping (33% of older people) are common with advanced age

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Sleep and Alzheimer’s disease

Sleep–wake disturbances are a common and often debilitating feature of Alzheimer’s disease (AD)

Sleep–wake disturbances may be one of the earliest symptoms in preclinical AD

Evidence from animal and human studies suggests that AD pathology disrupts the sleep–wake cycle, including increased sleep fragmentationand wakefulness, and decreased slow-wave sleep

Evidence from animal and human studies also suggests that prolonged wakefulness may increase levels of soluble Aβ in the brain, and may both exacerbate and accelerate the onset of AD pathology

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Lim MM, Gerstner JR, Holtzman DM. The sleep-wake cycle and Alzheimer's disease: what do we know? Neurodegenerative Disease Management 2014;4(5):351-362.


Aging and the perceptual system

Falls are a major public health concern

It is estimated that the cost of falls and related injuries will reach $32.3 billion in 2020

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The perceptual system

Postural control involves postural orientation and stability

› In order to establish/maintain vertical orientation, we use multiple sensory references

• Gravity (vestibular system)

• The support surface (somatosensory system)

• The relationship of our body to objects in the environment (visual system)

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Lighting and Aging

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Lighting and the aging visual system: Principles

More light on the task area with darker surrounds for the task area

Minimize glare by hiding direct and reflected view of the source and minimizing use of glossy reflections

Softer shadows throughout the space; balance illuminance levels in the space

Increase contrast and improve color discrimination

Importance of each depends upon the person


Lighting and the aging visual system:Techniques

Uplight ceilings or wash walls

Use task lighting

Use shower lights


Lighting and the aging perceptual system

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Lighting and the aging perceptual system: Research

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doorway

night-light

ceiling


Lighting and the aging Perceptual SystemPrinciples

Provide safe nightlights that do not disrupt sleep or increase falls risk

› Nightlights that provide visual and perceptual cues to reduce falls risk

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ACE CenterLighting horizontal and vertical cues

Door frame lights are controlled by a motion sensor and digital timer

Lights turn on from11:00 p.m. to 5:00 a.m.

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Light is the primary synchronizer of circadian rhythms to local position on Earth

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Light is the primary synchronizer of circadian rhythms to local position on Earth

The natural, 24-hour, light-dark cycle

light

retina

suprachiasmatic nucleus

hypothalamus

thalamus

lateral geniculatenucleus

pineal gland

signals to body

optic nerve

24.2

Adapted from National Library of Medicine image, 2007 (public domain)

…also the major disruptor


Spectral and absolute sensitivitiesCircadian light (CLA) and circadian stimulus (CS)

Spectral sensitivity

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Absolute sensitivity

outdoors

nightindoors

home

indoors

office

outdoors daytime

Rea, M. S., Figueiro, M. G., Bullough, J. D., & Bierman, A. (2005). A model of phototransduction by the human circadian system. Brain Research Reviews, 50(2), 213-228.

Rea, M. S., Figueiro, M. G., Bierman, A., & Hamner, R. (2012). Modelling the spectral sensitivity of the human circadian system. Lighting Research and Technology, 44(4), 386-396.


http://www.lrc.rpi.edu/cscalculator/

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Non-visual systemsPhase shifting effects of light

Light can change the timing of sleep and either promote entrainment or cause disruption

› Morning light (after minimum core body temperature) will advance the timing of sleep

› Evening light (before minimum core body temperature) will delay the timing of sleep

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Image: Emens JS and Burgess HJ. (2015) Effect of light and melatonin and other melatonin receptor agonists on human circadian physiology. Sleep Medicine Clinics 10: 435-453.

Adapted from: St Hilaire MA, Gooley JJ, Khalsa SB, et al. (2012) Human phase response curve to a 1 h pulse of bright white light. The Journal of Physiology590: 3035-3045.


Lighting and Alzheimer’s disease (AD)Research: “Bright” white (polychromatic) light

AD subjects

› Alzheimer’s patients exposed to 1136 ±89 lux at the eye during the entire day showed an improvement in the circadian rest-activity rhythms disturbances

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Van Someren et al. 1997. Indirect bright light improves circadian rest-activity

rhythm disturbances in demented patients. Biol Psychiatry 1;41(9):955-63.


Light and Alzheimer’s disease (AD)Research: “Bright” white (polychromatic) light

Riemersma-van der Lek et al. 2008 showed that long term (up to 3.5 years) light therapy delivered to patients with dementia› Attenuated cognitive

deterioration by 5% › Ameliorated depressive

symptoms by 19% › Attenuated the

increase in functional limitations over time by 53%

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JAMA. 2008;299(22):2642-2655. doi:10.1001/jama.299.22.2642.


High circadian stimulus (CS>0.3) during the day, especially in the morning, and low CS (CS<0.1) in the evening

Tailored lighting intervention designed to promote circadian entrainment

Circadian stimulus (CS): Metric for quantifying effectiveness of light sources for activating the circadian system

CS is equivalent to percent melatonin suppression after 1-h exposure to the light source› An indication of how effective the light

source is for the circadian system

› Caveat: it is for 1-h exposure, does not take into account photic history and is based on acute melatonin suppression (not phase shifting of the clock)

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Lighting and the aging circadian system: Principles

During the daytime hours (or at least for 2 hours in the morning)› Provide a circadian stimulus (CS) of at least 0.3-0.4 for at

least 2 h during the morning or between waking and late afternoon (18:00 h)

• Roughly 400 lux at the eye of a 6500 K source or 550 lux at the eye of a 2700 K

• Roughly 40 lux of 470 nm light at the eye

• Promote outdoors activities on a regular schedule

During the evening hours› Provide a CS of less than 0.1 during the evening hours

(while awake)• Roughly less than 50 lux (2700 K) at the eye

Figueiro et al. 2008


Lighting and Alzheimer’s disease (AD)Research: Testing the CS of 0.3 in the field

Study tested the effectiveness of a tailored light treatment on sleep quality, agitation and depression in those with Alzheimer’s disease and related dementias living in nursing homes

High circadian stimulation during daytime hours• 300-400 lux at the cornea from waking to 6 pm

• Bluish-white light, CCT > 9000 K

Results showed increase in sleep efficiency, total sleep time, reduction in agitation and depression

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Sponsor: National Institute on Aging (R01AG034157)Figueiro et al. 2014

Product donation: GE Lighting

Sleep time Depression Scores Agitation scores



Exposed 6 subjects to light table for 4 weeks

Results showed a significant increase in sleep efficiency and duration

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Sponsor: National Institute on Aging (R01AG034157)Figueiro et al. 2015

Product donation: Sharp Corporation

Sleep % Depression Scores Agitation scores


Two aims

› Short-term – randomized, placebo controlled, within subjects protocol

• (4 weeks – washout + 4 weeks)

› Long-term – 6 months – active intervention only

Sponsor: National Institute on Aging (R01AG034157)

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Aim 1: 60 participants (44 completed, 28 female; 7 not reported)

› Mean age: 85.7 years (SD = 6.4)

› Mean MMSE score: 15.9 (SD = 4.7), 23 participants

› Mean BIMS score: 5 (SD = 2.3), 23 participants

Aim 2: 60 participants (46 enrolled, 29 female; 9 not reported)

› Mean Age: 85.4 years (SD = 7.5),

› Mean MMSE score: 14.6 (SD = 3.4), 29 participants

› Mean BIMS score: 5 (SD = 2.5), 8 participants

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Lighting and the aging circadian system: Techniques: Dining Area Day and Evening


Edge-lit LED TVSponsor: Sharp Lighting

Lighting and the aging circadian system: Techniques: Luminous panels

Provide balanced light exposure by vertical illumination using real and/or simulated windows

Provide light at the eye by integrating panel into or onto a table top


Lighting and the aging circadian system: Techniques: Bedrooms Day and Evening

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Internet

The Swedish Healthy Home

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Light Logger

ActivityLogger

TreatmentSchedulingApp

Scene Composer andZigBee Coordinator

iBeacons

LocationSensingApp

ZigBee-EnabledLED Lamps

HubServer

Sponsor: The Swedish Energy AgencyCollaborator: Lund University and IAI, Inc.


Thank you!

www.lrc.rpi.edu

lighting for older adults and alzheimer’s disease patientsvan someren ejw, kessler a, mirmiran m,...

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