1. Abstract
1.1. Introduction: The increase of neuropsychiatric symptoms in people with dementia count for 46% of the transit to more controlled environments. Medication to repress these symptoms is widely used, but the side effects are significant, and the effect at start is not predictable. Research that aims at non-pharmacological interventions is important. One of the promising non-pharmacological interventions is lighting. In this study the effectiveness of biodynamic lighting, lighting with variable intensity and color, on neuropsychiatric symptoms in people with dementia is studied. It was hypothesized that the exposure to biodynamic lighting would decrease the amount and/or the severity of the neuropsychiatric symptoms.
1.2. Method: A biodynamic lighting innovation designed to stimulate a regular and healthy circadian rhythm was installed in the common area of a clinical setting. Two conditions of 21 days with and 21 days without exposure to biodynamic lighting were monitored. After each condition, measures of presence, severity of symptoms and emotional impact were collected using the Neuro Psychiatric Inventory-Questionnaire (NPI-Q).
1.3. Results: Eighteen participants were included in the research and completed a condition with and without exposure to biodynamic lighting. Per respondent the total index of severity of neuropsychiatric symptoms was lower after exposure. Also on a group level a tendency (p=.187) was found for decreasing the total index of severity of the neuropsychiatric symptoms in the condition that received biodynamic lighting. Significance was only found in the severity scores on the symptom disinhibited behavior (p=.01).
1.4. Conclusion: A biodynamic lighting intervention can be used to decrease the severity of neuropsychiatric symptoms, more specific disinhibited behavior. This is important because disinhibited behavior is related to a disturbed circadian rhythm, is distressing for caregivers and can accelerate the process leading to institutionalization . The findings in this study implicate the importance of future research on the possibilities of biodynamic lighting in dementia.
2. Keywords: Biodynamic Lighting; Dementia; Neuropsychiatric Symptoms; Non-Pharmacological
3. Introduction
Dementia is a common mental disorder diagnosed in (mostly) elderly
individuals. It causes deficits in cognitive, behavioral and social functioning
[1]. Dutch Alzheimer society [2] states that the number of
people with dementia in The Netherlands will reach one half million people in
2040. The costs of dementia care are high [2] and admittance in a care home has a lot of impact on
the patients and their informal caregivers. Several studies find that
neuropsychiatric symptoms are the main determinant of caregiver strain and
reported quality of life [3] and hereby an important reason for transition of people with dementia to
a more controlled environment. The reasons for institutionalization are the
need for more skilled care (65%), informal caregivers strain (49%) and neuropsychiatric
symptoms (46%) [4]. Dementia can disturb the circadian rhythm even more than in normal
ageing. Due to a disturbed circadian rhythm, some neuropsychiatric symptoms intensify
in the evening and night. Just then when the informal caregiver needs rest,
leading to high distress on their part [5].
The cardinal symptoms of neuropsychiatric domains are delusions,
hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/euphoria,
apathy/indifference, disinhibition, irritability/lability, motor disturbance,
nighttime behavior, appetite/eating [6]. In The Netherlands 80% of the people with dementia
has one or more neuropsychiatric symptoms [7]. The treatment of these symptoms exists of
pharmacological and/or psychosocial interventions [8]. The use of medication
increases morbidity and mortality in people with dementia and the treatment
effect on the symptoms is not always that clear and predictable [9]. Therefore, researchers became
interested in the possibilities of non-pharmacological interventions such as light
[1].
In a systematic review by Forbes and colleagues [10] the positive effects of light
therapy on cognition, daily functioning, sleep, agitation and neuropsychiatric
symptoms in people with dementia is described. Figueiro et al. [11] also found
positive effects of light on circadian rhythm, agitation and depression in
dementia. Previous research [11-13] showed that the circadian rhythm, the sleeping pattern and nightly
activity improved by employment of a light intensity level of 400-1000 lux and
short wavelength (bluish) light. These researchers all used a constant light
intensity (lux) and color temperature (nanometers). Dynamic lighting offers a
variable range of light intensity, light spectrum and color temperature [14]. Dynamic lighting resembles a
normal daylight curve and is tailored to stimulate circadian rhythm. Due to
age-related changes to the eye and a more disturbed circadian rhythm, dynamic
lighting is more suitable for people with dementia. Research has shown that
people with dementia in a nursing home only spend 1,6 minutes a day outside [15] and that the indoor light
conditions in a nursing home are not sufficient for the visual and the
non-visual aspects of light [16-18]. Also, neuropsychiatric symptoms tend to intensify in the
evening and night. This nighttime behavior is one of the symptoms which causes
a reason for the transition to a more controlled environment because of the
impact on the primary caregiver [11]. Thus, people with dementia, especially those living in a nursing home,
could benefit highly from dynamic light input [19]. In this study
we will focus on the impact of biodynamic lighting on the neuropsychiatric
symptoms in people with dementia.
Light therapy has repeatedly shown to reduce agitation behavior in this
population [20,21]. It has hardly been investigated whether biodynamic
lighting with its characteristic variation in light intensity and color
temperature can have a positive effect on neuropsychiatric symptoms in
people with dementia. A very recent study [22] that did use
biodynamic lighting showed a significant decrease in agitated behavior in
people with dementia in a nursing home. In the present study the impact of biodynamic
lighting on neuropsychiatric symptoms in people with dementia is investigated
in a clinical setting. It was hypothesized that the exposure to biodynamic
light would decrease the amount and/or the severity of the neuropsychiatric
symptoms.
4. Methods
4.1. Participants and Setting
The participants were recruited from a treatment facility for patients
with neurocognitive disorders in psychiatric hospital GGzE in Eindhoven. In the
period of January 2016 to January 2017 every new admitted patient was approached
to participate. The inclusion criteria for the study were a primary diagnosis
of dementia diagnosed by a geriatrician or psychiatrist, based on the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [23] criteria and the participants
had to be identified with neuropsychiatric symptoms. The exclusion criteria
were any other
neurological disorder, including narcolepsy, sleep apnoea or restless legs
syndrome or a serious eye disease incompatible with light therapy, such as
retinitis pigmentosa. Patients were also excluded if there is severe
comorbidity of psychiatric disorders, like a manic episode, addiction or severe
aggression in a psychotic episode, or if they were physically disabled and
cannot leave their bed by themselves. No restrictions were made for medication
use. All study materials and procedures were approved by
the Scientific Board of Mental Health Care Institution, GGzE, Eindhoven, The
Netherlands. The METC did not need to be consulted. Informed consent was
obtained from participant family members after full explanation of the
procedures, in accordance with the Declaration of Helsinki [24].
4.2. Methods and Design
The study was
performed using a quantitative prospective quasi experimental cross-over design [25]. The Vitaallichtlamp (VLL,
type Bright Brenda) [26] showed in (Figure 1) is used in this study as lighting intervention. The
VLL can produce up to 7500 Lux and 2700-6500 Kelvin, direct and indirect exposure
of light [26]. During morning and daytime hours, the lamp produces more bright and
bluish light and during the evening warm and reddish light. Hereby it resembles
a normal “real life” daylight curve to stimulate a normal day-night rhythm. The VLL exposure
was dimmed at 75%, approximately 5625 lux, so the amount of lux was endurable
by the elderly eye.
In total three VitaalLicht lamps (see section on intervention
for details) producing biodynamic lighting were placed at the same time in the
common area for 21 days. The whole group is exposed to the biodynamic lighting
during that period. The lamps were programmed and started each day at 7.00 a.m.
and finished at 23.00 p.m. After 21 days the biodynamic lighting lamps are
removed from the common area and the group receives the regular lighting
condition during the next 21 days. Participants spend most
of their time in this common area. In this room they eat all their meals, play
games, read, watch television, listen to music and receive visitors. Dependent on the date of
admittance subjects started their condition with or without exposure. The first
two weeks of the condition were marked as wash-out period to minimize
carry-over effects [27].
When a
condition of 21 days with or without exposure to biodynamic lighting was
finalized, the neuropsychiatric symptoms of each participant were measured with
a standardized questionnaire, the Neuro Psychiatric Inventory Questionnaire
(NPI-Q) by the primary formal personal caregiver of each participant [28]. The Neuro
Psychiatric Inventory-Questionnaire is a standardized 12-item tool designed to
rate the presence of symptoms (present or absent), the severity of the present
symptoms (3-point scale) and the caregiver distress of these symptoms (5-point
scale) by the primary formal caregiver. A higher score on the NPI-Q is associated with a
greater severity of symptoms and greater impact of the symptom manifestation on
caregivers [29,30]. The NPI-Q is recently used in a
3-year longitudinal study of 514 patients to confirm the association between
dementia severity and neuropsychiatric symptoms [31]. NPI-Q were completed for all participants in both conditions.
Medication dosage and use were monitored during the study by checking
the pharmacotherapy data in the electronic patient files by start and end of
the participation in the study. (Figure 2) shows the
flow chart of the study protocol.
4.3.
Statistical Analyses
Data were
analysed using SPSS, version 19 [32,33]. The sum scores in condition A and B were compared at
symptom level, group level and participant level. As the data were not normally
equated, non-parametric testing was applied.
5. Results
From January 2016 to January 2017 sixty-one patients with dementia were
admitted to psychiatric hospital GGzE. Two patients did not sign the informed
consent, nineteen patients could not be included because of severe comorbidity
of psychiatric disorders (i.e. manic episode, psychotic episode, aggression
caused by detox of substance abuse) and/or physical complications (i.e.
wheelchair dependence, kidney dialysis) and twenty-two patients did not
complete two conditions (i.e. transition, discharge, death). Eighteen participants were included in this
study (nine men, nine females; mean age was 76.4 ± 11.7 years) and completed two
conditions. Four participants completed four conditions in an ABAB-design. All
participants used medication at start (i.e. antipsychotic medication,
antidepressant medication, melatonin, vitamin D, pain medication). In four participant’s
medication was changed during the study. Two participants received no
antipsychotic medication during the condition with exposure and did in the
condition without exposure. One participant received no sedating medication in
the condition with exposure and did in the condition without exposure. One
participant received no antidepressant medication in the exposure condition and
did in the condition without exposure.
For a description of the included study population see (Table 1). Ten participants started
with exposure to biodynamic lighting (condition A) and eight participants
started with the normal daylight condition (condition B).
5.1.
Severity of neuropsychiatric symptoms
As shown in (Table 2), significance was found in only one neuropsychiatric symptom. In the
symptom disinhibited behavior a significant decrease was revealed between
exposure and no exposure to biodynamic lighting (P=0.01). The data were not normally
equated. Therefore, the Wilcoxon signed rank test is used to compare the data [25].
The mean total score in the exposure condition is 8,1 (SD=6,4)
and in no exposure condition 9,6 (SD=6,0) (p=.289).
Visual inspection of the variables shows that none of the scores were normally
equated. The non-parametric Wilcoxon signed rank test was used to analyze the
data. At group level a comparison is made in total score with and without exposure
to biodynamic lighting. (Table 3) shows the number of participants and the level of severity of symptoms.
No significance
was found (P=0.187).
The total scores of severity of symptoms at individual level in both
conditions is shown in (Figure 3). The first eight participants started in condition B
(no exposure). In five participants the total score of severity decreased in condition
A (exposure) and in three participants the score increased in condition A. Ten participants
started in condition A (exposure) and in five participants the total score of
severity of symptoms increased in condition B (no exposure), decreased in three
participants and stayed equal in two participants.
The total score of (formal) caregiver
distress was also compared and is shown in (Table 4). There was a
decrease in scores on emotional impact on caregivers reported by caregivers in
11 participants in condition A. In one participant the emotional impact scores
reported by the caregiver was equal in both conditions. In 6 participants the
caregivers reported higher emotional impact scores in condition A compared to
condition B.
In condition A the mean total score
of caregiver distress is 8,89 (SD 7,9) and in condition B 11,00 (SD 6,18). A Wilcoxon
signed rank test is performed and no significance was found (p=.087).
Four participants completed two A and two B
conditions in an ABAB-design. Visual analysis of all participants in figure 4 show that biodynamic lighting has a positive
impact.
sev = severity of symptoms,
emo = emotional impact on caregiver
In all participants there is
a positive effect of scores on severity and emotional impact of the formal
caregiver compared to the previous condition. This suggests that biodynamic
lighting can have a positive effect on severity of symptoms and emotional
impact on caregivers when exposed to this lighting for a prolonged period. The
effect is reversible which indicates the positive effect is caused by the
exposure to biodynamic lighting. In participant 1 and 4 the effect however is
not that strong. Both participants were psychically deteriorating and suffering
from alcohol dementia. They were both not able to return to their homes and
were admitted in a nursing home.
6. Discussion
The present study set out to investigate the effects of a biodynamic
lighting intervention on neuropsychiatric symptoms in people with dementia admitted
in a psychiatric hospital during January 2016-January 2017. It was hypothesized
that exposure to biodynamic lighting during the whole day and evening
(7:00-23:00) with an average of 3-6 hours of exposure time would have a more
positive impact on the measures of severity of neuropsychiatric symptoms at
clients and scores of emotional impact on formal caregivers than the normal
lighting conditions in the common room of the hospital. Eighteen participants
primarily diagnosed with dementia with a mean age of 76 years were included in
this study. The effect of exposure to biodynamic lighting has been measured on
different levels (symptom, individual and group). Information and selection
bias were minimalized by questioning mostly the same formal caregiver per
participant by one and the same investigator. The internal
validity was ensured by collecting all data of the NPI-Q and the data of the
electronic patient files and registrated in SPSS.19. Co-researchers independently
controlled all the data and analyses. By placing three VitaalLichtLampen (VLL)
in the common area of the ward the internal validity was also ensured.
The present results showed that a 21-day exposure to biodynamic lighting
decreased the total score of severity in seven (delusions, hallucinations,
agitation/aggression, euphory/elation, disinhibited behavior,
irritability/lability and nighttime behavior) of the 12 symptoms. Only at the
symptom disinhibited behavior a significant difference was revealed (P=0.01).
This finding is consistent with recent research of Wahnschaffe et al. [22] who found
that dynamic lighting in a nursing home significantly reduced scores on the
Cohen Mansfield Agitation Index (CMAI). The CMAI includes several symptoms of
disinhibited behavior. Another study of Brodaty et al. [31] which
followed the prevalence and course of neuropsychiatric symptoms on the NPI-Q in
dementia over 3 years, found that overall levels of neuropsychiatric symptoms
increased over 3 years, in particular delusions, hallucinations, agitation,
anxiety, apathy, disinhibition, irritability and aberrant motor behavior
significantly increased. It is a very important finding that actually several
of these symptoms (delusions, hallucinations, agitation, disinhibited behavior
and irritability) even decreased in our study. Medication was monitored and
there was no medication prescribed influencing this behavior. Biodynamic
lighting also stimulates the circadian rhythm and hereby might have a positive
impact on disinhibited behavior because people sleep better, are less tired and
can regulate their behavior better.
Ten participants out 18 reported a decreasing of the
total score of severity of symptoms based on the exposure to biodynamic
lighting. Although, we did not reach significance on a group level, same trend
was found on an individual level. Other factors on the ward also influence
neuropsychiatric symptoms in participants and might have contributed in not
reaching significance, like a new admittance, the decease of a patient and
severe disrupting behavior like suicidal gestures or a patient suffering from a
psychosis.
In three participants who started in the exposure condition, the total
score of severity of symptoms increased compared with the no exposure condition.
This is the opposite result of our hypothesis. Possible reasons for this
findings could be that according to Zuidema [7] neuropsychiatric symptoms
increase because of the progressive state of dementia. On the
other hand, we found also participants who ended in the exposure condition the
total score of severity of symptoms decreased. It could be that because of the
exposure with VLL people become more active and notice their limitations in
daily life more. This assumption could also be seen in our results because of
the largest difference was found in symptoms of delusions, disinhibited
behavior and nighttime behavior. Another possible explanation for the increase
of severity of symptoms during the exposure condition at start of the study
could be the emotional impact and consequences of an admittance in a hospital. The
Dutch Alzheimer society states on their website [34] several
problems with an admittance: denial of their problems, resistance to leaving
their home environment, anxiety of losing the control over their life, a
negative perception of an admittance.
Four participants completed two full conditions as in
an ABAB-phase design. In all conditions there was a positive effect on scores
of severity of symptoms and emotional impact on caregivers compared to the
previous condition. This effect was reversible in three of the four
participants. In the exposure condition the neuropsychiatric symptoms and the
emotional impact on the formal caregivers decreased, then it increases during
the no exposure condition, it decreases again in the exposure condition. This
suggest a positive impact of biodynamic lighting when participants are exposed
for a prolonged period. The participant who shows no reversible effect was
suffering from increasing somatic complaints and was admitted in a nursing
home.
The present study also has some limitations. The exposure to dynamic
lighting reduces neuropsychiatric symptoms indicating short-term effects from
higher daily light exposure. This study should be replicated using a larger
sample size to increase the power of the study and using a longer treatment
duration to determine if long-term exposure could significantly reduce
neuropsychiatric symptoms in people with dementia, and therefore reduce formal
caregiver distress. Further investigation is also needed before results can be
extrapolated to at home situations. The results may also be influenced by
circumstances within the psychiatric hospital. Therefore, a home situation
could be suitable for further research. Furthermore, formal caregivers may have
known the purpose of the intervention and answered accordingly, however this is
unlikely because they were unfamiliar with the questionnaire and their
responses did not always favor the intervention condition. The choice of using
proxy-data instead of self-report data stemmed from the fact that all
participants were diagnosed with dementia.
Another limitation is there was no baseline measurement. Several
variables could have influenced the symptoms during the treatment duration. To
minimize these influences, the conditions should be repeated several times
within the subjects to be able to make conclusions about implications [27].
The positive effect of light is also found in
previous research. Riemersma- Van Der Lek et al. [12] found an increase of sleep duration with exposure at
a maximum of 1100 Lux. In dimmed or red light Nowak and Davis [35] found that people with
dementia calmed down. It is not
exactly clear what amount of lux the participants received in this study. There
were three VLL in the common ward producing a maximum of 5625 lux. The color
temperature also varied. In the morning bright-bluish light was produced an in
the evening warm red light (2700-6500 Kelvin). Participants were at least 180-360
minutes a day exposed to biodynamic lighting, because of their daily
activities. Shirani and Louis [36] concluded
positive effects in a study on sleep, depression and dementia with exposure to
5000 lux one hour per day for several weeks.
Medication use and doses intake
were monitored during the study. The present study showed
that biodynamic lighting exposure for three weeks in a geriatric ward of a
psychiatric hospital significantly decreases disinhibited behavior. This
finding is consistent with the study of Wahnschaffe et al. [22] and implicates dynamic lighting is a
promising intervention in influencing disinhibited behavior in people with
dementia. According to the review study of Sink, Holden and
Yaffe [37] primary treatment of neuropsychiatric symptoms
consists of non-pharmacological interventions, because the effect of medication
use is not clear at start and because of the side effects.
7. Conclusions
The aim of this study was
to investigate a non-pharmacological intervention that can reduce the neuropsychiatric
symptoms in people with dementia. The clinical relevance of the exposure to dynamic
lighting as non-pharmacological intervention is confirmed in this study and has
implications for future research. Future research on the impact of biodynamic
lighting is needed in a more longitudinal study with a larger sample size. Dynamic lighting might be suitable
for home use and hereby reduce the informal caregiver distress that is one of
the main reasons for transition of patients with dementia to more controlled
environments.
8. Acknowledgments
8.1. Funding
“No funding or sponsorship
was received for this study or publication of this article.”
8.2. Authorship
“All named authors meet the
International Committee of Medical Journal Editors (ICMJE) criteria for
authorship for this article, take responsibility for the integrity of the work
as a whole, and have given their approval for this version to be published.”.
8.3. Disclosures
“Ellen van Lieshout-van Dal,
Liselore Snaphaan, Nicole Arkink, and Inge Bongers declare that they have no
conflict of interest.”
8.4. Compliance with Ethics Guidelines
“All procedures performed in
studies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and with the
1964 Helsinki declaration and its later amendments or comparible ethical standards.
Informed consent was obtained from all individual participants included in the
study.”
8.5. Data Availablility
The datasets generated
during and/or analyzed during the current study are not publicly available due
to confidentiality concerns but are available from the corresponding author on
reasonable request.
8.6. Thanking The Participants
We would like to thank all
of our participants that have participated in our study.

Figure 1:
Picture of the biodynamic lighting lamp (VLL, type Brenda) used in this study.

Figure 2: Flow chart study
protocol. Note: subjects could also
receive condition B before A.

Figure 3: Total score of severity of symptoms per participant
in condition A (blue) and B (grey).




Figure 4: Results of four participants that completed an ABAB-condition.
Description of study population
|
n=18)
|
Age
|
76,4 (11.7)
|
Sex
|
Male
Female
|
9 (50%)
9 (50%)
|
Dementia Type
|
Alzheimer’s Disease
Frontotemporal dementia
Dementia due to substance abuse Dementia NOS
|
6 (33%)
1 (5.5%)
1 (5.5%)
10 (55%)
|
Medication
|
Start
|
End
|
|
Typical antipsychotics
Atypical antipsychotics
Sedatives/ Benzodiazepines
Pain medication
Antidepressants
Other medication (e.g. vitamin D)
|
14 (67%)
3 (16.5%)
9 (50%)
7 (38.5%)
4 (22%)
13 (71.5%)
|
8 (44%)
6 (33%)
9 (50%)
6 (33%)
5 (27.5%)
13 (71.5%)
|
SD or Percentages are shown in brackets
|
Table 1: Description of study population.
Neuropsychiatric symptoms
|
Condition A
|
Condition B
|
sign.
|
Participants (n)
|
|
|
n=18
|
n=18
|
(p)
|
Condition A compared to B
|
|
mean (sd)
|
mean (sd)
|
|
|
|
|
|
|
|
|
Increased
|
Decresed
|
Equal
|
1.Delusions
|
1,00 (1,00)
|
1,44 (1,29)
|
0,11
|
2
|
8
|
8
|
2.Hallucinations
|
0,56 (1,04)
|
0,67 (1,19)
|
0,49
|
1
|
4
|
13
|
3.Agitation/aggression
|
1,11 (1,08)
|
1,33 (0,98)
|
0,36
|
5
|
6
|
7
|
4.Depression/dysphoria
|
1,17 (0,92)
|
0,78 (0,81)
|
0,24
|
8
|
3
|
7
|
5.Anxiety
|
1,11 (1,23)
|
0,72 (1,23)
|
0,25
|
7
|
2
|
9
|
6.Euphoria/elation
|
0,28 (0,75)
|
0,39 (0,70)
|
0,48
|
2
|
3
|
13
|
7.Apathy/indifference
|
0,50 (0,79)
|
0,50 (0,92)
|
1,00
|
3
|
2
|
13
|
8.Disinhibited behavior
|
0,33 (0,77)
|
1,22 (1,26)
|
0,01*
|
1
|
11
|
6
|
9.Irritability/lability
|
0,83 (1,10)
|
1,22 (1,17)
|
0,23
|
2
|
8
|
8
|
10.Aberrant motor
|
0,39 (0,85)
|
0,11 (0,32)
|
0,16
|
4
|
1
|
13
|
11.Nighttime behavior
|
0,72 (1,13)
|
1,17 (0,99)
|
0,21
|
4
|
9
|
5
|
12.Appetite/eating
|
0,17 (0,51)
|
0,17 (0,71)
|
1,00
|
1
|
1
|
16
|
*Indicates a significant difference at severity of symptoms between condition A (exposure to biodynamic light ) and condition B (no exposure)
|
Table 2: The scores and comparison on severity of present symptoms in condition A (exposure) and condition B (no exposure).
n
|
total severity condition B < total severity condition A
|
6
|
total severity condition B > total severity condition A
|
10
|
total severity condition B = total severity condition A
|
2
|
Table 3: Total severity of symptom scores at group level.
n
|
total emotional impact condition B > total emotional impact condition A
|
11
|
total emotional impact condition B < total emotional impact condition A
|
6
|
total emotional impact condition B = total emotional impact condition A
|
1
|
Table 4: Total emotional impact on caregiver scores at group level.
Citation: van Lieshout-van Dal, Snaphaan L, Arkink N, Bongers I (2018) Exposing People with Dementia to Biodynamic Light. J Psychiatry Cogn Behav: JPCB-150. DOI: 10.29011/2574-7762. 000050