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Adaptive circadian lighting can improve senior sleep quality, increase energy levels, alleviate depression, and reduce agitation

Executive Summary With improved physical care, we are living longer, but managing mental and emotional health can be challenging due to increasing rates of dementia-related diseases. Care facilities must manage the risks of residents with a range of health issues while helping them thrive and enabling a high quality of life. An influential variable in a resident’s environment is the intensity, color, and timing of light. According to many studies*, adaptive circadian lighting can help older adults feel more energized during the day, sleep better at night, and reduce mental health issues like depression and agitation, benefiting residents and their caregivers.

* Sources on page 5


Caregiving will soon shift dramatically American demographics are changing; the number of adults over 65 years old is expected to double in the next 40 years, representing almost a quarter of the population. Furthermore, the number of Americans affected by dementia-related diseases is forecast to almost triple by 2050 (1). These factors are expected to place a great deal of stress on care facilities, care staff, and families in terms of financial, physical, and emotional costs. Care facilities will need to mitigate these challenges and risks while simultaneously differentiating themselves by delivering outstanding care for their residents.

Lighting requirements change with age A critically important area of senior care is the lighting in the facility and in residents’ rooms. The human eye changes in two important ways related to darkness and color perception as we age. First, it becomes less sensitive to light so that the dark adaptation threshold increases. Older adults need more light than previously to properly assess depth, distinguish between colors, and see clearly (3). Second, as the number of cones in the Figure 1. Dementia: A global epidemic infographic (2) eye declines, our perception of color changes. It becomes harder to differentiate between colors closer to blue than it is between colors closer to orange, like red and yellow. The aging process also results in a weakened perception of the color blue and an apparent shift toward yellow (3).

“Seniors residing in assisted living facilities are perhaps the best example of a population at risk for circadian disorders.” 5 Dr. Mariana Figueiro

Director of Lighting Research Center

The result is that seniors, especially those in a care community, have different lighting needs than a younger population. In a study managed jointly by Eskaton’s Monroe Lodge, Sacramento Municipal Utility District, and Stack Labs, only 14% of residents who were surveyed responded that their existing non-adaptive lights provided adequate lighting “most or all of the time” (4). When residents spend most of their time indoors, either in the facilities’ common areas or their rooms, the low levels of light in their environment can become an issue. As Dr. Figueiro at the Lighting Research Center has shown, if seniors spend more time where there is perceived or actual limited light, they are at a higher risk for circadian disorders (5).

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Circadian rhythms can influence important innate cycles Circadian rhythms are present in nearly all living organisms. For humans, this rhythm follows a pattern that repeats nearly every 24 hours (6,7). It regulates body temperature, sleep and energy patterns, hormonal cycles, and more, and it operates regardless of outside environmental conditions. However, some factors can help synchronize the rhythm more closely with the daily cycle of the Earth; light in particular has a significant effect on the circadian rhythm (7). The timing and ratio of light versus darkness is especially important for entrainment and can shift the rhythm either backward or forward (6, 9). The presence of dimmer, yellow light in the evenings helps encourage the production of melatonin, which makes us feel sleepier, and the presence of bright blue-white light in the morning suppresses melatonin production, helping us feel awake and alert. Figure 2. Circadian rhythms (10)

Disruptions in an individual’s circadian rhythm can lead to circadian-related disorders. A variety of factors can disrupt the circadian rhythm, including suboptimal intensity, timing, and color of light. For example, working in an environment with dim, static lighting or shifted sleep schedules may cause disruptions in the circadian rhythm. There are immediate and longer-term consequences associated with disrupted a circadian rhythm. Short term ramifications can include sleep disturbances, daytime sleepiness, anomalies in eating patterns, and peripheral rhythm dysfunction (6). Besides these effects, over an extended period, these issues may contribute to or evolve into chronic health problems. Shift workers may experience these negative effects in the form of cardiovascular disease, diabetes, obesity, cancer, depression, bipolar, schizophrenia, or attention deficit disorders (6). Circadian disorders can also affect older populations. For those already diagnosed with Alzheimer’s or other dementia-related diseases, circadian disorders can exacerbate sundowning symptoms like agitation and confusion (11). A common sleep disorder among this population living in care facilities is the irregular sleep wake type. With this form of sleep disorder, a person does not to establish a normal sleeping cycle and prefers to sleep in three or more separate instances in a 24-hour day Figure 3. Circadian rhythm disorders (10) (6). Understandably, sleep disorders and their related consequences are often

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distressing for both residents and care staff, in addition to being potentially dangerous and costly. Agitation is an important concern in facilities caring for patients with dementia-related diseases. An agitated person could be physically or verbally abusive to staff members or themselves, while possibly triggering agitation in other nearby residents. To soothe each agitated person, it costs individualized staff time. Not to mention, an agitated resident’s quality of life could also suffer during this confusing and upsetting episode. Circadian lighting mimics the rhythm of natural sunlight To better address the needs of the senior population in regard to lighting, many organizations are testing and implementing new alternatives to traditional static lights. Circadian lighting plans with automated bright blue-white light in the daytime and soothing, yellow light at night help entrain residents’ bodies to the Earth’s clock, better regulating and resetting the circadian rhythm each day. In a study conducted by Dr. Figueiro at the Lighting Research Center, residents who were exposed to new, brighter lights were more active and engaged during the day and more tired at night, resulting in an increase in sleep quality and duration. In addition to these benefits, caregivers reported that residents were less agitated and significantly less depressed, as shown in the following tables (9).

Figure 4. Depression and Agitation Scores after Circadian Intervention (9)

The researchers conducted two assessments to measure depression using the Cornell Scale for Depression in Dementia and the Cohen-Mansfield Agitation Inventory, two standardized questionnaires to assess the mental wellbeing of residents. The scores for depression as reported for the residents dropped by nearly 50%, while the scores for agitation dropped by over 15%. Interestingly, the scores for depression and agitation Depression scores dropped by stayed lower than the baseline even after 50% and agitation scores by the intervention. Dr. Figueiro expressed almost 20%. 9 interest in replicating the study with a larger population for more time to see if there Dr. Mariana Figueiro would be even greater reductions in Director of Lighting Research Center depression and agitation (9).

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At Aegis Living in Washington, Dr. Claudia Finkelstein, of the University of Washington Medical Center, tested a new lighting system called Life Enhancing Light Therapy, which was intended to prevent sundowning symptoms by providing the necessary lighting stimulus to keep circadian rhythms aligned with the natural solar cycle (12). Though this intervention was primarily intended to benefit the residents with Alzheimer’s disease, preliminary “Even if our intervention results of this system also showed improved quality showed only that the of life for caregivers of the residents. The additional light regulated the caregivers’ circadian rhythms as people working in the well, leading to better job satisfaction. As Dr. setting were happier, Finkelstein pointed out, this secondary effect also that would be good.” has beneficial implications for the residents; it is important to avoid burn-out among employees in a Dr. Claudia Finkelstein 12 stressful and emotionally taxing role (12). University of Washington Medical Center At Eskaton’s Monroe Lodge in Sacramento, Stack Care’s adaptive circadian-entraining lighting plan performed similar functions, resulting in high satisfaction for the residents and 20% energy saving (4). In a survey administered to residents before the intervention, only 14% of the respondents expressed satisfaction with the original lighting. When the residents rated Eskaton Lodge Lighting Intervention: 4 the Stack Care LED system, 90% 72% increase in resident activity of respondents were satisfied. The residents also reported feeling 642% increase in resident satisfaction more energized during the day and 20% energy saving for community having an easier time falling asleep at night (4). Adaptive circadian lighting can provide benefits for all involved In conclusion, LED tunable bulbs with a circadian lighting pattern allows facilities to create a more positive resident experience, facilitate a less stressful working environment for care staff, and save energy. The Stack Care system not only provides adaptive circadian lighting, but also integrates motion sensors to optimize energy savings by automatically switching off lights in unoccupied rooms, as well as provide notifications to caregivers regarding anomalies in resident behavior or potential risk factors. For example, Stack Care can notify the care staff that a resident is not up and about, reducing the need for a time-consuming check-in round to make sure each resident is awake and active. Stack Care also offers an automated nightlight function with customizable brightness levels. This nightlight preserves night vision without disrupting melatonin production, making it easier for seniors to safely navigate to the bathroom in the middle of the night. In summary, this system is designed to provide a natural, comfortable environment for seniors, reducing inconveniences and enhancing their living experience.

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Works Cited 1) Mark Mather, Linda A. Jacobsen, and Kelvin M. Pollard, “Aging in the United States,” Population Bulletin 70, no. 2 (2015). 2) Alzheimer's Disease International. (2015). The Global Impact of Dementia. Retrieved from https://www.alz.co.uk/sites/default/files/pdfs/global-impact-dementiainfographic.pdf 3) Salvi, S. M., Akhtar, S., & Currie, Z. (2006). Ageing changes in the eye. Postgraduate Medical Journal, 82(971), 581–587. http://doi.org/10.1136/pgmj.2005.040857 4) Bisbee, D., & S.M.U.D. (2017, March 27). Eskaton Circadian Lighting Project. Retrieved from https://www.smud.org/-/media/Documents/Business-Solutions-andRebates/Eskaton-Circadian-LightingProject.ashx?la=en&hash=045C91BAAF0EABA93D507519E5C0FDC4281161C2 5) Figueiro, M. G., PhD. (2015, May 4). Light Therapy for Better Sleep. Retrieved December 12, 2017, from http://www.sleepreviewmag.com/2015/05/light-therapybetter-sleep/ 6) Baron, K. G., & Reid, K. J. (2014). Circadian Misalignment and Health. International Review of Psychiatry (Abingdon, England), 26(2), 139–154. http://doi.org/10.3109/09540261.2014.911149 7) Czeisler, C. A., Duffy, J. F., Shanahan, T. L., Brown, E. N., Mitchell, J. F., Rimmer, D. W., . . . Kronauer, R. E. (1999). Stability, Precision, and Near-24-Hour Period of the Human Circadian Pacemaker. Science, 284(5423), 2177-2181. doi:10.1126/science.284.5423.2177 8) UCLA Sleep Disorders Center. (n.d.). Circadian Rhythms. Retrieved December 12, 2017, from http://sleepcenter.ucla.edu/circadian-rhythms 9) Figueiro, M., Plitnick, B., Lok, A., Jones, G., Higgins, P., Hornick, T., & Rea, M. (2014). Tailored lighting intervention improves measures of sleep, depression, and agitation in persons with Alzheimer’s disease and related dementia living in long-term care facilities. Clinical Interventions in Aging, 1527-1537. doi:10.2147/cia.s68557 10) Ross, S. (2015, January 22). Will Poor Sleep and Sleep Deprivation Now Lead to a Lifestyle-Related Dementia Later? [Web log post]. Retrieved January 31, 2018, from https://goinggentleintothatgoodnight.com/2015/01/22/will-poor-sleep-and-sleepdeprivation-now-lead-to-a-lifestyle-related-dementia-later/ 11) Ross, S. (2013, July 11). Sundowning and the Sleep Conundrum of Dementias and Alzheimer’s Disease [Web log post]. Retrieved January 31, 2018, from https://goinggentleintothatgoodnight.com/2013/07/11/sundowning-and-the-sleepconundrum-of-dementias-and-alzheimers-disease/ 12) Aegis Living. (2017, September 20). 4 ways to handle Sundowning disorder. Retrieved January 31, 2018, from https://www.aegisliving.com/resource-center/4-ways-tohandle-sundowning-plus-how-aegis-light-therapy-can-prevent-it/

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To learn more about adaptive circadian lighting plans or request a demo, please reach out to solutions@stack.care.

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