in Older Adults Methodological Implications Thomas Hornick MD Patricia Higgins RN PhD 1 Objectives Understand the influence of circadian rhythm disruptions on overall health Identify clinical characteristics of circadian rhythm disturbances in older adults ID: 238986
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Rest-Activity and Light Exposure Patterns
in Older Adults: Methodological Implications
Thomas Hornick MD
Patricia Higgins RN, PhD
1Slide2
Objectives
Understand the influence of circadian rhythm disruptions on overall health.Identify clinical characteristics of circadian rhythm disturbances in older adultsRecognize the importance of chronobiology
in elders’ sleep-wake disturbances.Describe results from preliminary studies assessing the use of circadian light therapy in a nursing home unit and measurement of circadian light exposure in a case study of home-dwelling older adults.
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Types of rhythms
Ultradian (heart beat, respirations, appetite)Infradian (menstrual cycle)
Circannual (annual breeding cycles) Circadian (sleep-wake cycle)
Rhythms allow organisms to time events and anticipate change!
Biological Rhythms
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Arendt 2006
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With Zeitgeber
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Disruption of circadian rhythm
Poor performance/fatigue (Reinberg et al, 2007, Laposky et al 2008)Weight gain(Knutson et al, 2007)
Breast cancer (Stevens et al 2001)Other conditions
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Why older adults?
Sleep disorders are commonComplaints among caregivers of persons with dementia frequently revolve around disordered day/night cyclesMedications for sleep are less safe in this population
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Aging and light
Older adults spend much of their time in muted indoor lighting. 35 minutes/day of bright light exposure compared to approximately 58 minutes of bright light per day for middle-aged adults. (Sanchez 1993) Reduced light exposure compounded due to physiologic changes
senile meiosis, cataract formation, and/or increased light absorption by the crystalline lens. (Charmin 2003) Attenuation of light exposure by more than 80% in normal older adults relative to young adults.
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Age related losses in retinal illumination
Turner et al Br J
Ophthalmol. 2008 November; 92(11): 1439–1444
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.
Wikipedia, accessed 10/30/09
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Role of Retinal Receptors
Three known retinal receptors: process visual and circadian timing informationRods and cones: visual data
Intrinsically photosensitive retinal ganglion cells (iPRGC): primarily light-dark data
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Turner et al Br J
Ophthalmol. 2008 November; 92(11): 1439–1444
Spectral sensitivity of photopic, scotopic and circadian (melatonin suppression) photoreception
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iPRGCs
: History
1998: Melanopsin in light-sensitive cells on frog skin (Provencio et al, Proc Natl
Acad Sci )
2000: Melanopsin-containing cells found in retinal ganglion cell layer (Provencio et al,
J Neuroscience) Most likely comprise the retinohypothalamic tract
Sensitive to wavelengths in the 484-500 nm (blue light)2002: Light responses from melanopsin
-containing ganglion cells in humans (Berson et al, Science)
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Intrinsically photosensitive retinal ganglion cells (iPRGCs
)
Timing Photoreceptors
Located throughout retina (~3000)
Express melanopsinBlue light sensitive(peak 460nm)
Regulate photoperiodism (sensitivity to length of day and night)
Higher excitatory threshold than rods/conesTransmits to SCN
24-hour light-dark pattern on the retina is the most efficient stimulus for entrainment of circadian rhythms in humans
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Suprachiasmatic nucleus (SCN) is master
pacemaker
Activity in SCN correlates with circadian rhythms
Lesions of SCN abolish free-running rhythmsIsolated SCN continues to cycle
Transplanted SCN imparts rhythm of the donor on the host
SCN is known to be compromised in older adults with dementia. (Harper et al 2008)
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Role of Melatonin
MelatoninPrimary role in humans is to convey information about the daily light-dark cycle to physiological systems
Peaks during sleep, suppressed by light.16Slide17
Melatonin Rhythms and Aging
Zeitzer et al Sleep. 2007 November 1; 30(11): 1437–1443.
Average (±SEM) plasma melatonin in young (top, n=90) and older (bottom, n=29) subjects during a normally phased sleep episode (closed boxes) and a constant routine where they remained awake at the same clock hours (open circles). Data were aligned such that each subject's wake time was graphically adjusted to 08:00 and the data from the baseline day and night and from the CR(constant routine) expressed relative to wake time; sleep time is from 24:00 to 08:00. Melatonin data were averaged hourly within and then across subjects
Age 65-81, mean 68
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Plasma melatonin suppression by bright light in 65 year old man
Duffy et al
Neurobiol Aging. 2007 May; 28(5): 799–807.
Plasma melatonin data from subject 19G7, a 65 year old man who was exposed to a 3,527 lux light stimulus. Upper panel: plasma melatonin data from the initial circadian phase estimation procedure (CR1); middle panel: plasma melatonin data from the intervention day, with the 6.5-h experimental light exposure indicated by the open box; lower panel: plasma melatonin data from the final circadian phase estimation procedure (CR2) shown in the solid symbols, with data from CR1
replotted from above in the open symbols. During CR1, the fitted peak of the melatonin secretion (MELmax) occurred at 03:45, 3.5 h before habitual wake time. During CR2
MELmax occurred at 06:30, a 3.5 h phase delay. Melatonin was suppressed by 78% during the 6.5-h 3,527 lux light stimulus.
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Melatonin suppression with bright light
Duffy et al
Neurobiol Aging. 2007 May; 28(5): 799–807.
Phase shift of fitted plasma melatonin peak (MELmax) vs. illuminance of experimental light stimulus. Data from each of the ten subjects are plotted individually and shown with square symbols. Solid line represents the 4-parameter logistic model fit to the data, with the 95% confidence interval of the model shown in the dotted lines. For comparison, the 4-parameter logistic model fit to the data from our previous study in younger adults [
64] is shown in the dashed line.
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Circadian light transfer function
Figueiro, et al. 2006
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Clinical applications
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Turner et al Br J
Ophthalmol. 2008 November; 92(11): 1439–1444
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Therapeutic light
2 Hours bright light in AM Improved sleep efficiency in NH residentsFetveit et al, 2003
30 minutes sunlight for five daysDecreased nappingIncreased participationAlessi
et al, 2005Daytime bright lightImproved sleep/wake cycle in persons with dementia (van Someren et al,1997)
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Riemersma-van de Lek et alJAMA 2008
6/12 Homes randomized for lighting interventionInstalled fluorescent fixtures, both real and sham1000 lux horizontal at eyes in intervention
Caregivers unaware which arm randomized toMelatonin randomized by patient3.5 year follow up
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Riemersma-van der Lek, R. F. et al. JAMA 2008;299:2642-2655.
MMSE, Depression
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Schedule change: Shift work
Light at night (LAN)
Nurses’ Health Study (Willet, PI)
Effects of Light at Night on Circadian System in Nurses (
Schernhammer
, PI, RO1-OH008171)
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Circadian phase shifters
Can have negative effects on healthAbrupt: jet lag, shift workGradual: institutionalizationTimed light exposure: reset clock
Sensitivity age-related Bright light in morning advances the clockBright light in evening delays the clock
Delays easier than advances
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Circadian Lighting
in Long-term
Care: A feasibility study
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Methods
3 participants, residents of Ward 62B Lighting: GE fluorescent ceiling lamps 14,000 KInstruments
Sleepwatch-L© (AMI, Ardsley, NY)
Neuropsychiatric Inventory-Nursing Home VersionDaysimeterTM (Lighting Research Center, Rensselear
Polytechnic Institute)
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Methods/Instrumentation for Sleep/Light Data
Subject wore Sleep Watch-L
© for 7 daysWrist-worn electronic measure of body movement and light
Software calculates activity/inactivity and light
© Ambulatory Monitoring Inc
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Lighting InstallationVAMC safety standards
1st phase: 3 ‘blue lamp’ prototypes by GE: 8000 Kelvin (K); 14,000K;16,000K 2nd
: 13 standard fluorescent lighting ceiling light fixtures in Dayroom7 of 13 changed to 14,000 K (6 remained @ 5000 K) Timer controlled blue lighting on, 8a-6pLighting after 6pm: sufficient for visual acuity
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Mean of light measurements taken at eye level (horizontally) at 8 points in the room in the 4 cardinal directions, using PMA 2200
Photoradiometer
,
SnP
Meter Photopic SL3103-001, S/N 9829
Light Conditions
Photopic
(cones) Lux
Scotopic
(rods)
Lux
S/P
Ratio
Brightness
Visual Effectiveness
all on
517
1178
2.24
781
1818
14,000 K only
381
918
2.26
606
759
standard
333
725
2.14
491
609
all off
222
489
2.17
328
412
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Results & Conclusions
Wrist actigraph well acceptedLight sensor on wrist covered much of the time by clothing? New blue lighting well received
3 subjects exposure to blue lighting (time in Dayroom/ 10 hr period): 77 minutes, 371 mins, 373 mins
Next time: Change installation pattern?, use DaysimeterTM
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Rest-Activity and Light Exposure Patterns in the Home Setting: A Methodological Study
P. Higgins, T. Hornick, M. Figueiro
American J Alzheimer’s Disease and Other Dementias, 2010
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PurposeAssess the feasibility and reliability of using a circadian light meter (
DaysimeterTM) in a field setting and use the human circadian phototransduction model’s analyses to provide clinically relevant results
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Dyad
Caregiver – Wife, 73 years, “good health”, no vision problems, no sleep-aid meds. Primary caregiverElder – Husband, 80 years, vascular dementia plus multiple co-morbidities, continent, needed assistance for all ADL’s and IADL’s, multiple meds included antidepressant but no sleep-aidElder received all primary care from the Cleveland VA Geriatrics Clinical team.
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MethodsProcedure - Light exposure and rest-activity data were collected over 7 consecutive days in November, 2007
InstrumentsAssessment of sleep quality and habits Home visit
Sleepwatch-L© (AMI, Ardsley, NY)DaysimeterTM (Lighting Research Center, Rensselear Polytechnic Institute)
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DaysimeterTM
Research prototypeTwo light meters measure photopic and circadian light exposureActigraph measures movement
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Results
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Built EnvironmentIndependent living complex for seniors
Apartment: 640 square feetBrown paneling and beige paint and carpetOne south facing window in bedroomSliding glass door onto porch (south facing)Standard florescent lighting: kitchen and bath
Incandescent lighting: floor and table lamps42Slide43
Ambient
light exposure/24 hrs when out of bed (
lux)
Light Norms (in lux)*
Sunlight
/
reflective surfaces 150,000
Overcast Day 1,000
Avg
nursing home 50Avg living room
50-200Twilight 10
Full Moon 1
*From Turner, 2008. Br J Opthalmology
Range
Mean
mins
:
> 20 lux
> 500 lux
>1000 lux
Elder
0-449
191.5
0.0
0.0
Caregiver
0-3990
635.5
18.0
8.0
Dyad data
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ACTIGRAPHY
Caregiver wife
Demented husband
Sleep-rest
-
Mean sleep efficiency %
- Mean night sleep (mins)
- Mean sleep latency (mins)
- Mean wake after sleep onset [WASO] (mins)
- Mean napping/24 hr (mins)
70
257
81
119
31
81
446
17
105
96
Intra-daily variability (0-2)
0.71
0.95
Inter-daily stability (0-1)
0.69
0.76
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Caregiver
Elder
24-hour
Sleep and
Light
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Caregiver
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Entrained
vs Disrupted
Entrained
Disrupted
HumanSlide48
ConclusionsDaily light levels are very low
Little variation in light levelsSleepNeither caregiver or elder sleep wellCaregiver: poor circadian entrainmentSleep disruption causesLow lighting, little contrast
Frequent wake times at night48Slide49
SupportVISN 10 GRECC, Cleveland VAMC
Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OHLighting Research Center, Rensselear Polytechnic Institute, Troy NYGeneral Electric Company, Nela Park, East Cleveland, OH
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Team
Tom Hornick, MD1,2Patricia Higgins, PhD1,2
Mariana Figueiro, PhD3Mark Rea, PhD
3Andy Bierman, MS3John Bullough, PhD3
Bill Biers, PhD4 Mark Duffy, PhD
4Ed Yandek, BS4
1Case Western Reserve University
2Cleveland Veterans Affairs Medical Center 3Lighting Research Center, Rensselaer Polytechnic Institute
4General Electric Lighting, Nela Park50Slide51
Next Steps
“Methodology issues in a tailored light treatment for persons with dementia" R01 – M. Figueiro, PI
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Wikipedia, accessed 5/2010
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