Implementation of Dynamic Lighting in a Nursing Home: Impact on Agitation but not on Rest-Activity Patterns

Author(s): Amely Wahnschaffe*, Claudia Nowozin, Sven Haedel, Andreas Rath, Stefan Appelhof, Mirjam Münch, Dieter Kunz

Journal Name: Current Alzheimer Research

Volume 14 , Issue 10 , 2017

  Journal Home
Translate in Chinese
Become EABM
Become Reviewer
Call for Editor


Objective: Disturbances of circadian rest-activity rhythms in demented patients often culminate in the clinical problem of evening and nighttime agitation. The aim of the current study was to test the impact of a dynamic lighting system on agitation and rest-activity cycles in patients with dementia.

Methods: From midwinter on, a ceiling mounted dynamic lighting system was installed in the common room of a nursing home and programmed to produce high illuminance with higher blue light proportions during the day and lower illuminance without blue light in the evening. Fifteen residents with dementia were regularly assessed with the Cohen Mansfield Agitation Index (CMAI) before and after the lighting intervention. Additionally rest-activity cycles were continuously monitored for 6 months by a wrist worn activity watch. Analysis of CMAI data was performed by using the Wilcoxon-Test for matched pairs (before vs. after the lighting installation). Rest-activity data was compared with t-tests for dependent samples.

The dynamic lighting significantly reduced the CMAI sum-scores from 30.2±5.1 to 27.9±2.6 (mean ± SD; N = 12; p<0.05). Analysis of the CMAI subscores revealed that under the dynamic lighting mainly non-physically aggressive behaviors were reduced.

Results: Results from the rest-activity analysis did not show differences of circadian amplitude and other circadian variables before and after the lighting installation.

The dynamic lighting in the living room significantly reduced agitated behavior in demented patients, indicating short-term benefits from higher daily light exposures. Whether such lighting also impacts long-term (circadian) rest-activity cycles needs to be further investigated.

Keywords: Agitation, circadian rhythms, dementia, light, light treatment, nursing home, rest-activity-pattern.

Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer’s disease. IV: Disorders of behaviour. Br J Psychiatry 157: 86-94. (1990).
Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging 9: 2079-86. (2014).
Altimus CM, Guler AD, Alam NM, Arman AC, Prusky GT, Sampath AP, et al. Rod photoreceptors drive circadian photoentrainment across a wide range of light intensities. Nat Neurosci 13(9): 1107-12. (2010).
Foster RG. Neurobiology: bright blue times. Nature 433(7027): 698-9. (2005).
Cohen-Mansfield J, Werner P, Freedman L. Sleep and agitation in agitated nursing home residents: an observational study. Sleep 18(8): 674-80. (1995).
Witting W, Kwa IH, Eikelenboom P, Mirmiran M, Swaab DF. Alterations in the circadian rest-activity rhythm in aging and Alzheimer’s disease. Biol Psychiatry 27(6): 563-72. (1990).
van Someren EJ, Hagebeuk EE, Lijzenga C, Scheltens P, de Rooij SE, Jonker C, et al. Circadian rest-activity rhythm disturbances in Alzheimer’s disease. Biol Psychiatry 40(4): 259-70. (1996).
van Someren EJ, Mirmiran M, Swaab DF. Non-pharmacological treatment of sleep and wake disturbances in aging and Alzheimer’s disease: chronobiological perspectives. Behav Brain Res 57(2): 235-53. (1993).
Campbell SS, Kripke DF, Gillin JC, Hrubovcak JC. Exposure to light in healthy elderly subjects and Alzheimer’s patients. Physiol Behav 42(2): 141-4. (1988).
Satlin A, Teicher MH, Lieberman HR, Baldessarini RJ, Volicer L, Rheaume Y. Circadian locomotor activity rhythms in Alzheimer’s disease. Neuropsychopharmacology 5(2): 115-26. (1991).
Weitzman ED, Moline ML, Czeisler CA, Zimmerman JC. Chronobiology of aging: temperature, sleep-wake rhythms and entrainment. Neurobiol Aging 3(4): 299-309. (1982).
Vitiello MV, Smallwood RG, Avery DH, Pascualy RA, Martin DC, Prinz PN. Circadian temperature rhythms in young adult and aged men. Neurobiol Aging 7(2): 97-100. (1986).
Touitou Y, Sulon J, Bogdan A, Touitou C, Reinberg A, Beck H, et al. Adrenal circadian system in young and elderly human subjects: a comparative study. J Endocrinol 93(2): 201-10. (1982).
Swaab DF, Fliers E, Fisser B. The vasopressin containing neurons in the human brain; changes during ageing and senile dementia. Br J Clin Pract Suppl 39: 7-10. (1985).
Wu YH, Swaab DF. Disturbance and strategies for reactivation of the circadian rhythm system in aging and Alzheimer’s disease. Sleep Med 8(6): 623-36. (2007).
Mahlberg R, Walther S, Kalus P, Bohner G, Haedel S, Reischies FM, et al. Pineal calcification in Alzheimer’s disease: an in vivo study using computed tomography. Neurobiol Aging 29(2): 203-9. (2008).
Turner PL, Van Someren EJ, Mainster MA. The role of environmental light in sleep and health: effects of ocular aging and cataract surgery. Sleep Med Rev 14(4): 269-80. (2010).
Scherder EJ, Bogen T, Eggermont LH, Hamers JP, Swaab DF. The more physical inactivity, the more agitation in dementia. Int Psychogeriatr 22(8): 1203-8. (2010).
Wever RA, Polasek J, Wildgruber CM. Bright light affects human circadian rhythms. Pflugers Arch 396(1): 85-7. (1983).
Shochat T, Martin J, Marler M, Ancoli-Israel S. Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res 9(4): 373-9. (2000).
Wahnschaffe A, Haedel S, Rodenbeck A, Stoll C, Rudolph H, Kozakov R, et al. Out of the lab and into the bathroom: evening short-term exposure to conventional light suppresses melatonin and increases alertness perception. Int J Mol Sci 14(2): 2573-89. (2013).
Forbes D, Culum I, Lischka AR, Morgan DG, Peacock S, Forbes J, et al. Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia. Cochrane Database Syst Rev (4): CD003946 (2009).
Mishima K, Okawa M, Hishikawa Y, Hozumi S, Hori H, Takahashi K. Morning bright light therapy for sleep and behavior disorders in elderly patients with dementia. Acta Psychiatr Scand 89(1): 1-7. (1994).
Satlin A, Volicer L, Ross V, Herz L, Campbell S. Bright light treatment of behavioral and sleep disturbances in patients with Alzheimer’s disease. Am J Psychiatry 149(8): 1028-32. (1992).
Ancoli-Israel S, Martin JL, Kripke DF, Marler M, and Klauber MR. Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. J Am Geriatr Soc 50(2): 282-9. (2002).
Ancoli-Israel S, Martin JL, Gehrman P, Shochat T, Corey-Bloom J, Marler M, et al. Effect of light on agitation in institutionalized patients with severe Alzheimer disease. Am J Geriatr Psychiatry 11(2): 194-203. (2003).
Dowling GA, Hubbard EM, Mastick J, Luxenberg JS, Burr RL, Van Someren EJ. Effect of morning bright light treatment for rest-activity disruption in institutionalized patients with severe Alzheimer’s disease. Int Psychogeriatr 17(2): 221-36. (2005).
Mishima K, Hishikawa Y, Okawa M. Randomized, dim light controlled, crossover test of morning bright light therapy for rest-activity rhythm disorders in patients with vascular dementia and dementia of Alzheimer’s type. Chronobiol Int 15(6): 647-54. (1998).
Skjerve A, Holsten F, Aarsland D, Bjorvatn B, Nygaard HA, Johansen IM. Improvement in behavioral symptoms and advance of activity acrophase after short-term bright light treatment in severe dementia. Psychiatry Clin Neurosci 58(4): 343-7. (2004).
Burns A, Allen H, Tomenson B, Duignan D, Byrne J. Bright light therapy for agitation in dementia: a randomized controlled trial. Int Psychogeriatr 21(4): 711-21. (2009).
Lovell BB, Ancoli-Israel S, Gevirtz R. Effect of bright light treatment on agitated behavior in institutionalized elderly subjects. Psychiatry Res 57(1): 7-12. (1995).
Fetveit A, and Bjorvatn B. Bright-light treatment reduces actigraphic-measured daytime sleep in nursing home patients with dementia: a pilot study. Am J Geriatr Psychiatry 13(5): 420-3. (2005).
Lyketsos CG, Lindell Veiel L, Baker A, Steele C. A randomized, controlled trial of bright light therapy for agitated behaviors in dementia patients residing in long-term care. Int J Geriatr Psychiatry 14(7): 520-5. (1999).
Sloane PD, Williams CS, Mitchell CM, Preisser JS, Wood W, Barrick AL, et al. High-intensity environmental light in dementia: effect on sleep and activity. J Am Geriatr Soc 55(10): 1524-33. (2007).
Riemersma-van der Lek RF, Swaab DF, Twisk J, Hol EM, Hoogendijk WJ, Van Someren EJ. Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: a randomized controlled trial JAMA299(22): 2642-55 (2008).
Figueiro MG, Plitnick BA, Lok A, Jones GE, Higgins P, Hornick TR, et al. 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. Clin Interv Aging 9: 1527-37. (2014).
van Hoof J. High colour temperature lighting for institutionalised older people with dementia. Build Environ 44: 1959-69. (2009).
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3): 189-98. (1975).
Health) BGMf. Bericht des Beirats zur Überprüfung des Pflegebedürftigkeitsbegriffs. 2009 [cited 2014 12.12.2014]; Available from:
Enezi J, Revell V, Brown T, Wynne J, Schlangen L, Lucas RA. “melanopic” spectral efficiency function predicts the sensitivity of melanopsin photoreceptors to polychromatic lights. J Biol Rhythms 26(4): 314-23. (2011).
Cohen-Mansfield J. Agitation in the elderly. Adv Psychosom Med 19: 101-13. (1989).
Bromundt V, Wirz-Justice A, Kyburz S, Opwis K, Dammann G, Cajochen C. Circadian sleep-wake cycles, well-being, and light therapy in borderline personality disorder. J Pers Disord 27(5): 680-96. (2013).
Sokolove PG, Bushell WN. The chi square periodogram: its utility for analysis of circadian rhythms. J Theor Biol 72(1): 131-60. (1978).
Van Someren EJ, Swaab DF, Colenda CC, Cohen W, McCall WV, Rosenquist PB. Bright light therapy: improved sensitivity to its effects on rest-activity rhythms in Alzheimer patients by application of nonparametric methods. Chronobiol Int 16(4): 505-18. (1999).
[cited 2015 22.05.2015]; Available from:
Roenneberg T, Kuehnle T, Pramstaller PP, Ricken J, Havel M, Guth A, et al. A marker for the end of adolescence. Curr Biol 14(24): R1038-9. (2004).
Volicer L, Frijters DH, Van der Steen JT. Relationship between symptoms of depression and agitation in nursing home residents with dementia. Int J Geriatr Psychiatry 27(7): 749-54. (2012).
Wirz-Justice A, Benedetti F, Berger M, Lam RW, Martiny K, Terman M, et al. Chronotherapeutics (light and wake therapy) in affective disorders. Psychol Med 35(7): 939-44. (2005).

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2017
Published on: 08 September, 2017
Page: [1076 - 1083]
Pages: 8
DOI: 10.2174/1567205014666170608092411
Price: $65

Article Metrics

PDF: 39