1. The effect of bright light exposure in elderly (extended proposal) Supervisor: Dr. Jacquelline Ho

2. Group members (Group 35) Chen Hiu Hung02515760T Hui Man Chi 02505986T Kwan Tsui Ying 02514227T Lee Tsz Wing 02513347T Li Kwan Fong 02513520T Tsang Cheuk Yee Cherry 02514946T Yeung Lai Kam 02513323T

3. Introduction For elderly person, sleep disturbance is a common problem (Foley, et al 1995; Swift, 1993)

4. Source: Swift, C.G. & Shapiro, C.M. (1993). Sleep and sleep problems in elderly people. BMJ, 306: 1468-1471

5. Introduction Loss of sleeping is prone to accidents, and QoL (Foley, et al 1995; Cambell, 1995) Interventions for such problem include: pharmacological use, psychotherapy, behavioral therapies, sleep hygiene education (Rogers, 1997; Chiu, 2003) and bright light exposure (Campbell, 1995; Dawson & Campbell, 1991; Yoon et al, 2002; Phipps-Nelson et al, 2003)

6. Introduction (con’t) However, due to physiology changes, –Medications  alter liver & kidney functions –More time in bed  better sleeping quality (Dawson & Campbell,1991; Montgomery & Dennis, 2004) There is a need for nurses to develop various interventions to promote sleep (Chan et al, 1997)

7. There were studies shown that light exposure could alter circadian system as well as sleeping time (Campbell SS, 1995; Campbell et al, 1999; Dawson & Campbell,1991; Phipps-Nelson et al, 2003; Yoon et al, 2002) reduce sleepiness (Phipps-Nelson et al, 2003) effective in improving sleep in people with dementia, severe Alzheimer’s disease (Ancoli- Israel et al, 1997; Bliwise, 1993; Campbell et al, 1999) contractindicated to people with mania (Ancoli- Israel, 2004)

8. Aim To explore if there are any effects of bright light exposure on sleep in elderly people

9. Objectives To study the changes in the sleep efficiency, latency and awaking time in the elderly people after bright light exposure. To study the sleep satisfaction level in the elderly people after bright light exposure. To study the duration of bright light effect of sleep in elderly people

10. Research Questions Are there any changes in the 1.sleep latency 2.sleep efficiency 3.awaking time 4.sleep satisfaction level in the elderly people after bright light exposure? 5. How long does the effectiveness of the bright light effect last? light effect last?

11. Literature review Sleep definition A normal state of altered consciousness (Black & Jacobs,1997) Decrease perception and reaction to environment (Blais et.al,1998) Minimal physical activity, consciousness level, change in body’s physiological processes

12. Literature review Sleep function Restores normal level of activity and normal balance among parts of nervous system Enhance the muscle tone and protein synthesis (Blais et.al,1998) Maintain mental activity such as learning, reasoning (Black & Jacobs,1997)

13. Literature review Sleep cycle Each cycle about 70 minutes; 4-6 cycles within 7-8 hours (Blais et.al,1998) [Figure 1. Borbely,A. (1986). Secrets of sleep. New York: Basic books.]

14. Literature review Sleep cycle (con’t) Non-rapid eye movement (NREM) 4 stages: stage 1-3 last about 30 mins; stage 4 lasts about 30 mins (Blais et.al,1998) Stage 1 and 2 are light sleep; stage 3 and 4 are slow-wave sleep (Black & Jacobs,1997) Physiological characteristic: lack of eye movement, low and fragmented cognitive activity (Black & Jacobs,1997)

15. Literature review Sleep cycle (con’t) Rapid eye movement (REM) REM lasts about 10 mins, increase time of REM in later sleep period (Black & Jacobs,1997) Low voltage, random fast waves, deep sleep (Black & Jacobs,1997) Characteristic: rapid eye movements, erratic respirations, low muscle tone (Black & Jacobs,1997)

16. Literature review Sleep problem in elderly Little or no NREM stage 4 (Shapiro & Swift,1993), decrease REM, more time in stage 1, sleep latency increases (Black & Jacobs,1997) Inadequate depth of sleep awaken more often during night, not enough sleep, awaking too early, needing naps (Shapiro & Swift,1993)

17. Literature review Sleep problem in elderly (con’t) Circadian rhythm advances (Ancoli-Israel 2004) Impairement of melatonin production (Cardinali &Pevet, 1998) Decrease melatonin rhythm amplitude (Reiter & Robinson, 1995; Schwartz 1997) Sleep disturbance leads to poor memory, difficult concentration (Ancoli-Israel 2004)

18. Literature review Melatonin Secreted by human pineal gland and retina Secreted by human pineal gland and retina (Cardinali & Pevet,1998) Convey information concerning daily cycle of light and darknss to body physiology. It used for the organization of circadian rhythms Convey information concerning daily cycle of light and darknss to body physiology. It used for the organization of circadian rhythms (Cardinali & Pevet,1998;Empson, 2002;Schwartz,1997) Induce circadian phase shift and influence sleep-wake cycle (Cardinali & Pevet,1998; ) Induce circadian phase shift and influence sleep-wake cycle (Cardinali & Pevet,1998; Schwartz,1997)

19. Literature review Circadian rhythm Internal clocks that control biological rhythms (Hobson,1989) Internally generated (Hobson,1989 ), period close to 24 hr (Duffy et al,1996) Circadian rhythm can be affected by environmental factors such as light and darkness (Blais et.al,1998) Change in circadian rhythm may cause chronic disruption of sleep (Blazer et al. 1995)

20. Literature review Light Is an important modulator of circadian rhythm (Kessler et al,1997) Additional light in the evening can raise melatonin level & delay circadian cycle→ Increase night sleep amount (Cooke et al,1998; Reiter & Robinson,1995)

21. Literature review Relationship between light,melatonin rhythm and circadian Light →a person’s light-dark cycle →Melatonin secretion rhythm →circadian rhythm →sleep pattern of a person

22. Methodology Research design Sampling Selection criteria Study design Instruments and equipments

23. Research design Quasi-experimental study Study the change in the sleep efficiency and latency of elderly after bright light exposure Light intensity is the independent variable to be manipulated. Subjects can serve as their only control group.

24. Sampling Convenience sampling method Subjects will be recruited on the basis of availability Economical and efficient There are difficulties to spend time & resources to study all members of a population (Polit, Beck & Hungler, 2001).

25. Sampling Number of subjects (N=30) Similar researches done before with similar sampling size  E.g. a study was done in Norway on 2001 to study the prevalence and characteristics of sleep disturbances among an entire nursing home population by actigraphy. (N=29), ( Sleep Disturbances Among Nursing Home Residents, Actas de Fisiologia 7, 2001).

26. Sampling E.g. a study done in HK presenting findings on utilizing bright light to alter sleep-wake cycle in order to improve quality of sleep (N=38) (Ho et. al., 2002).

27. Sampling No control group Subjects will serve as their own control group instead Comparison is made before & after the bright light exposure, both qualitative & quantitative data.

28. Selection criteria (inclusion) Aged 65 or above Old age home resident with no sleep partner Conscious & able to answer question Able to move their limb freely & independently Have sleep problem and desire to improve

29. Experimental setting Room temperature Video tapes of 50’s TV programs will be broadcasted and research team to chat with the subjects, during the light application period. during the light application period.

30. Study Procedure Season for data collection: -August, 2004 -August, 2004 -Stable environmental temperature -Stable environmental temperature in HK(around 26 degree Celcious) in HK(around 26 degree Celcious) -Less variables, to test bright light -Less variables, to test bright light effect on sleep effect on sleep (Murphy & Campbell, 1996) (Murphy & Campbell, 1996)

31. Period of data collection: Pre-bright light exposure stage: Day 1 & 2 -150lux red dim light -150lux red dim light -Day1: baseline data; Day2: Experimental -Day1: baseline data; Day2: Experimental data. data. Bright light exposure stage: -Day 3 to Day 7 (2500 lux white bright light) -Day 3 to Day 7 (2500 lux white bright light) Post-bright light stage: -Day 8 to Day 14 (150 lux red dim light) -Day 8 to Day 14 (150 lux red dim light)

32. Light intensity applied 2500lux white bright light -2500lux can totally suppresses melatonin secretion (Dollins et al,1993) -It is the intensity level of the sunlight daytime intensity during the spring and summer. (Emsinger, 2001) 150 red dim light -room light intensity:150-300lux (Heil and Mathis, 2002); -little or no suppression in light with long wavelength, red light. (Brainard et. al., 1985 & Wright and Lack, 2001)

33. Time of light therapy 1800-2100hours -Phase-delaying of sleep -To help subjects with advanced sleep phase (Kripke, 1989) -Phase-delaying of sleep -To help subjects with advanced sleep phase (Kripke, 1989)

34. Table 1 The Experimental Design Day and stage Light exposure Data collected Day 1- Day 2 Pre-bright light exposure stage Red dim light Day1: Data served as adaptation Day 2: Data served as baseline Day 3-Day 7 Bright white light exposure stage Bright white light Data served as experimental data Day 8-Day 14 Post-bright light exposure stage Red dim light Data served as experimental data

35. Light On Period -1800-2100 hours -Bright white light, 2500 lux or Red dim light, 150lux Light Off period - 2100 hours to get up time(next day) - All experimental lights are switched off Usual Routine - Get up time – 1800hours of the day - No experimental light are applied - Subjects perform their usual routine. Data collection procedure

36. Schedule of the study Date4/8/2004 (Wed) 5/8 (Thu) 6/8 (Fr i) 7/8 (Sat) 8/8 (Sun) 9/8 (Mon) 10/8 (Tue) 11/8 (Wed) 12/8 (Thu) 13/8 (Fri) 14/8 (Sat) 15/8 (Sun) 16/8 (Mon) 17/8 (Tue) Day1234567891011121314 Pre-bright light exposure stage (Adaptation) Pre-bright light exposure stage (Baseline) Bright Light Exposure StagePost-Bright light exposure stage -Subjects will expose to red dim light from 1800 to 2100 -During the light exposure period, the subjects will be watching TV. -Subjects will expose to bright white light from 1800 to 2100 -During the light exposure period, the subjects will be watching TV. -Same as Day 1 & 2.

37. Study protocol Always began and ended on weekdays -due to mood changes caused by the subjects being taken out by relatives -due to mood changes caused by the subjects being taken out by relatives Maintain constant room temperature Keep subjects ’ concentration

38. Instruments 1. Preliminary screening assessment 2. Sleep log

39. Instruments 1.A preliminary screening assessment: -Questionnaire adopted from The Hong Kong polytechnic University sleep research team (Ho et al. 2002) -Content validity index (CVI): 0.92, Pearson r : 0.87 Pearson r : 0.87 Two parts in the questionnaire: 1.A screening assessment 2.A preliminary assessment

40. Instruments (con’t) 1. Screening assessment: To screen eligible subject - Demographic data: age, sex, height, weight, health status, physical and psychological illness age, sex, height, weight, health status, physical and psychological illness - Sleep history : What, when, how, how long does the sleep problem

41. Instrument (con’t) 2. Preliminary assessment : Understand the sleep history of the subjects I. Sleep habits II. life style (sleep related)

42. Appendix 1 The Hong Kong Polytechnic University Date: ________ The Hong Kong Polytechnic University Date: ________ Department of Nursing and Health Sciences Code: ________ Department of Nursing and Health Sciences Code: ________ Screening Assessment Part I Demographic Information Please put a  in the appropriate box. 1. Age: _____ 2. Sex: _____ 3. Body Height: _____ (cm / ft & in) 4. Body Weight: _____ (kg / lbs) 5. How do you describe your present health status?  Very good  Very good  Good  Good  Acceptable  Acceptable  Poor  Poor  Very poor  Very poor 6. Do you have any mental, medical or physical illness(es)? ________________________________________________________________ ________________________________________________________________ Are you taking any medication(s)? Please specify the medication(s) with dosage, frequency, date of commencement & any reaction(s) related to the medication(s). ________________________________________________________________ ________________________________________________________________ 8. How do you describe your sleep status at night?  Very good  Very good  Good  Good

43.  Acceptable  Poor  Poor  Very poor  Very poor 9. How do you feel upon arising?  Refreshed  Refreshed  Acceptable  Acceptable  Still tired  Still tired  Sleepy  Sleepy 10. Do you sleep alone?  Yes  Yes  No  No 11. Do you use any sleep aids? Please describe. ________________________________________________________________ ________________________________________________________________ Part II Sleep History 1. How long have you been suffering from sleep disturbance? ____ month(s) / year(s) ____ month(s) / year(s) 2. How many night(s) a week do you have sleep disturbance? ____ nights per week ____ nights per week 3. How do you describe the onset of your sleep disturbance?  Gradual  Gradual  Sudden  Sudden 4. How do you describe your course of sleep disturbance?  Recur periodically (eg per week or per month)  Recur periodically (eg per week or per month)  Recur in relation to season (eg especially in spring)  Recur in relation to season (eg especially in spring)  Persistent without remission periods  Persistent without remission periods  No fixed mode  No fixed mode 5. What will exacerbate your sleep disturbance?  Go to toilet frequently  Go to toilet frequently  Too Noisy  Too Noisy  Temperature: too cold or too hot  Temperature: too cold or too hot  Physical discomfort  Physical discomfort

44.  I don’t know  I don’t know  Others: ______________________  Others: ______________________ Was/Were there any event(s) related to the onset of the sleep disturbance (eg death of loved one, retirement, physical or mental problems, etc)? ________________________________________________________________ ________________________________________________________________ 7. Do you have any trouble in falling asleep at night?  Frequently  Frequently  Sometimes  Sometimes  Rarely  Rarely  Never  Never 8. Do you have frequent awakenings during the night?  Frequently  Frequently  Sometimes  Sometimes  Rarely  Rarely  Never  Never 9. Do you wake up too early in the morning?  Frequently  Frequently  Sometimes  Sometimes  Rarely  Rarely  Never  Never 10. Do you have any difficulty in staying awake during the day?  Frequently  Frequently  Sometimes  Sometimes  Rarely  Rarely  Never  Never 11. Do you have any symptoms (eg shortness of breath, nightmare, etc) related to your sleep disturbance? Please state the rate of occurrence per week. sleep disturbance? Please state the rate of occurrence per week. ________________________________________________________________ ________________________________________________________________ 12. In the last six months, have you been particularly nervous or anxious?  Yes  Yes  No  No 13. In the last six months, had you say been worrying most of the time (more than a week)? week)?  Yes  Yes  No  No 14. In the last six months, had you been less interested in most of the things (regardless of your preference) or unable to enjoy nearly every day? of your preference) or unable to enjoy nearly every day?  Yes  Yes  No  No 15. For the past couple of years, have you been bothered by depressed mood?  Frequently  Frequently  Sometimes  Sometimes  Rarely  Rarely  Never  Never

45. Instruments Preliminary assessment (con’t) I. Sleep habits:  Bed time  Sleep onset latency (SOL)  Wake after sleep onset (WASO)  Sleep offset time (SoffT)  Rising time and napping

46. Instruments Preliminary assessment (con’t) II. Life style (sleep related): -smoking -caffeinated food, drink -alcohol consumptions -dairy products consumptions -exercise, outdoor sunlight exposure -snack consumptions

47. Instruments (con’t) 2.A sleep log (Self-description of sleep) (Self-description of sleep)  Only the individual can judge his or her sleep is good or not. (Closs,1997)  Evaluate the subjective sleep condition throughout the study Advantage: sleep efficiency and subjective sleep descriptive data can be estimated. Disadvantage : less validity on sleep durations and sleep-wake activity (Reidk,& Daso,1999)

48. Instruments Sleep log (Ho et al. 2002) Subjective reporting of sleep wake parameter  Entries for bedtime,  Arising time,  Sleep latency,  Number and duration of awakenings,  Sleep durations  Naps (Lacks P. 1987) Self –reported satisfaction of sleep  A five-point subjective rating scale (very good to very poor)

49. Instruments Sleep log (con’t) Data obtained in the sleep log incorporates with the actigraphy, compensate each other Helps to evaluate the effect of this study.

50. The sleep log Appendix II The Hong Kong Polytechnic University Date: _____________ The Hong Kong Polytechnic University Date: _____________ School of Nursing Code: _____________ School of Nursing Code: _____________ Sleep Log Day ______________ Sleep Log Day ______________ Please put a  in the appropriate box. 1. What was your final awakening time? _________ 2. What was your final arising time? _________ 3. Did you go to bed in the morning (before 1200 hours)? Time Lying Asleep Time Lying Asleep  No. _________ ___________ min(s) __________ min(s)  No. _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s) 4. Did you doze in the morning (before 1200 hours)? Time Asleep Time Asleep  No. ____________ ____________ min(s)  No. ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s) 5. Did you go to bed in the afternoon (before 1800 hours)? Time Lying Asleep Time Lying Asleep  No. _________ ___________ min(s) __________ min(s)  No. _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s) 6. Did you doze in the afternoon (before 1800 hours)? Time Asleep Time Asleep  No. ____________ ____________ min(s)  No. ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s) 7. Did you go to bed in the evening (after 1800 hours)? Time Lying Asleep Time Lying Asleep  No. _________ ___________ min(s) __________ min(s)  No. _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s)  Yes. How often? _________ _________ ___________ min(s) __________ min(s) 8. Did you doze in the evening (after 1800 hours)? Time Asleep Time Asleep  No. ____________ ____________ min(s)  No. ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s)  Yes. How often? _________ ____________ ____________ min(s) 9. When did you turn off the light? _________ 10. When did you go to bed? _________ 11. How long did you take to fall asleep? _______ min(s) / hour(s) 12. Did you have any trouble in falling asleep?  No.  No.  Yes. Why? __________________________________________________________________________________  Yes. Why? __________________________________________________________________________________ 13. Did you awake during the night?

51.  No.  No.  Yes. How often? _________  Yes. How often? _________ What was/were the cause(s) of the awakening(s)? What was/were the cause(s) of the awakening(s)?  Go to toilet frequently  Temperature: too cold or too hot  Too noisy  Go to toilet frequently  Temperature: too cold or too hot  Too noisy  Physical discomfort  I don’t know  Physical discomfort  I don’t know  Others: _____________________________________________________________________________________  Others: _____________________________________________________________________________________ What did you do in the awakening(s)?  Get up to do something (eg _______________________________) till sleepy  Get up to do something (eg _______________________________) till sleepy  Go to toilet  Take sleeping pills  Still rest on bed  Go to toilet  Take sleeping pills  Still rest on bed  Others: ____________________________________________________________________________________  Others: ____________________________________________________________________________________ Awakening Time Duration Awakening Time Duration ______________ _______ min(s) ______________ _______ min(s) 14. How did you describe your sleep?  Very good  Good  Acceptable  Poor  Very poor  Very good  Good  Acceptable  Poor  Very poor 15. How did you feel upon arising?  Refreshed  Acceptable  Still tired  Sleepy  Refreshed  Acceptable  Still tired  Sleepy 16. Had you taken any medication(s)? Please describe. ______________________________________________________________________________________________ ______________________________________________________________________________________________ 17. Did you have any physical discomfort that affected your sleep? Please describe. ______________________________________________________________________________________________ ______________________________________________________________________________________________ 18. Did you consume any caffeinated food or drink?  No.  No.  Yes. The caffeinated food or drink was/were:  Chinese Tea  Coffee  Western Tea  Others: ___________  Yes. The caffeinated food or drink was/were:  Chinese Tea  Coffee  Western Tea  Others: ___________ I had consumed ____________________. The last time I consumed such food or drink was at _________. I had consumed ____________________. The last time I consumed such food or drink was at _________. 19. Did you smoke?  No.  No.  Yes. The last cigarette was smoked at _________.  Yes. The last cigarette was smoked at _________. 20. Did you drink alcohol?  No.  No.  Yes. I had drunk _________ cup(s) / tael. The last drink was drunk at _________.  Yes. I had drunk _________ cup(s) / tael. The last drink was drunk at _________. 21. Did you consume dairy product(s)?  No.  No.  Yes. The dairy product(s) was/were: ______________________________.  Yes. The dairy product(s) was/were: ______________________________. I had consumed __________________. The last time I consumed dairy product was at _________. I had consumed __________________. The last time I consumed dairy product was at _________. 22. Did you do execrise? Time Duration Place In the morning (before 1200 hours) _______ min(s) Indoor / Outdoor In the morning (before 1200 hours) _______ min(s) Indoor / Outdoor  No. In the afternoon (before 1800 hours) _______ min(s) Indoor / Outdoor  No. In the afternoon (before 1800 hours) _______ min(s) Indoor / Outdoor  Yes. In the evening (after 1800 hours) _______ min(s) Indoor / Outdoor  Yes. In the evening (after 1800 hours) _______ min(s) Indoor / Outdoor 23. Did you have outdoor sunlight exposure? Time Duration In the morning (before 1200 hours) _________ min(s) In the morning (before 1200 hours) _________ min(s)  No. In the afternoon (before 1800 hours) _________ min(s)  No. In the afternoon (before 1800 hours) _________ min(s)  Yes. In the evening (after 1800 hours) _________ min(s)  Yes. In the evening (after 1800 hours) _________ min(s) 24. When did you have your dinner? _________ 25. Had you eaten snack before bedtime?  No.  Yes. Please describe: ______________________________________________________________  No.  Yes. Please describe: ______________________________________________________________

52. Equipments Bright Light exposure stage: (white bright light) 1. Four bright light boxes. @ 250W Lamp ( Osram, made in Germany) 2. Illuminant meter Ensure 2500 lux to each subject face. Ensure 2500 lux to each subject face.  high light intensity can suppress melatonin secretion (Dollins A.B.& lynch H.J. et al, 1993)

53. Equipments (con’t) Pre and post bright light exposure stage: (red dim light) 1. Two light boxes each contain six red globes @15W in 1 meter away. -Ensure 150 lux to each subjects’ faces. -Ensure 150 lux to each subjects’ faces.  low light intensity no effect on melatonin secretion (Trinder J, & Armstron S.M.)  Red light wavelength no effect on melatonin secretion ( Wright H.R. & Lack L.C., 2001)

54. Equipments (con’t) Wrist Actigraph: For record a subject’s movement over a period of study (two weeks) (Wykpisz et al, 1998) -Total numbers of sleep minutes / Total sleep time -Actual bed time/ Time to sleep onset -Periods of wakefulness/ Wake after sleep onset -Subthreshold activity/ Sleep efficiency Wrist of non-dominant hand (Wykpisz et al, 1998)

55. Equipments (con’t) Advantage: -EEG and wrist actigraph estimates of total sleep time were highly correlated, coefficient: r =+0.98 (Kripke et al, 1980) More cost-effective More cost-effective Easier to use Easier to use Less invasive and less expensive Less invasive and less expensive More objective data compare to sleep log. More objective data compare to sleep log.

56. Equipments (con’t) Disadvantage: -Underestimate wake and overestimate sleep. For example:  immobile sleep, immoblile waking (Webster et al),  Overestimate of activity e.g.tremors, (Labyek &Bourguignon., 2002)

57. Ethical considerations Three major ethical principles: 1.Beneficence 2.Respect for human dignity and 3.Justice. (Polit, 2001)

58. Ethical Considerations (con’t) The bright light intensity chosen at the optimal level in preventing eye/retinal damage. Effective bright light intensity from 2000- 3000lux for several hours; 10000lux for 15mins-1 hour (Kripke, 1998, Lam, & Levitt, 1999). Two type of lesions must be considered for bright light therapy: acute and chronic cumulative damage, e.g. cornea and conjunctiva lesions. (Young R.W., 1994)

59. Ethical considerations (con’t) Subjects are able to drop out freely. Inform and consent. Approval from PolyU and the old-aged home engaged Data are confidential and used in this study only

60. Data analysis Demographic data will be presented in the form of frequency, mean, mode, range and standard deviation using descriptive statistic. For the sleep-related factors, for example, caffeine or medication intake, milk or snake before bed, dinner time  frequency count and percentage calculation will be conducted.

61. Data analysis Actigraphic data Sleep-wake parameters will be counted and calculated.  sleep onset, sleep latency (time between retiring and onset of sleep),  total sleep time,  number frequency of awakenings,  awaking time and  sleep efficiency (the percentage of time in bed /spend asleep

62. Data analysis Actigraphic data (con’t) mean of the sleep onset latency, mean of sleep efficiency standard deviation of sleep onset latency, and standard deviation of sleep efficiency are actigrapic transformed. are actigrapic transformed.

63. Data analysis Sleep log Subjective satisfaction of sleep and self- reported descriptive data will be obtained

64. Data analysis Sleep log (subjective reporting of sleep- wake parameter) Three subjective sleep variables  averaged sleep onset latency,  averaged sleep efficiency and  averaged night waking time will be log transformed will be log transformed

65. Data analysis Sleep log Subjective data: sleep satisfaction level Data derived from Question 14 and 15 in the sleep log;

66. Data analysis: Any changes in the sleep latency and self efficiency in the elderly people after bright light exposure?

67. Data measurement Data are presented in minutes (sleep latency) and percentage (sleep efficiency), It is a kind of ratio measurement which are the dependent variable from the bright light exposure.

68. The test used paired t-test (α<0.05) will be employed to analyze the followed sets of data. paired t-test (α<0.05) will be employed to analyze the followed sets of data.

69. The data for analysis Four sets of data after stage 1 and 2; Four sets of data after stage 1 and 2; -1st: is means of sleep latency and -2nd: means of sleep efficiency from self-reported data of the sleep logs before and after the experiment; before and after the experiment; -3rd: means of sleep latency and -4th: means sleep efficiency from actigraphic data before and after the experiment; before and after the experiment;

70. Data analysis: any changes in the awaking time in the elderly people after bright light exposure? Averaged number of awaking hours Advanced or delayed hours will be calculated

71. Data analysis: Any changes in the sleep satisfaction level in the elderly people after bright light exposure?

72. When comparing two sets of results, with signed rank test; wilcoxon test can be applied. (Gunn C., 2001) Medians of the subjective sleep satisfaction level before and after experiment will be estimated; p value will be obtained.

73. Data Analysis: Any change in the sleep efficiency, sleep latency, awaking time, sleep satisfaction after the stage 3 (the 7 days of post-bright light exposure)

74. Similar as that done for the data in stage 1 and 2; the duration of the effectiveness bright light effect will be illustrated.

75. Limitations 1.Decrease generalization 2.Convenience sampling  biased result (Portney & Watkins, 1993)  Individuals who desire to improve their sleep quality. 3. Environmental factors, for example, room temperature.

76. References Kripke D., Mullaney D.,Messin S., Wyborney V.(1980) Wrist-actigraphic measures of sleep and rhythms. Electroencephalogr Clin Neurophysiol. 44: 674-676 Webster J., Kprike D., Messin S., Mullaney D. and Wyborney G. (1982) An activity based sleep monitory system for ambulatory use. Sleep. 5:389-399 Brainard G.C., Lewy A.J., Meanker M., Fredrickson R.H., Miller L.S., Weleber R.G., Cassone V. and Hudson D.(1985) Effect of light wavelength on the suppression of nocturnal plasma melatonin in normal volunteers. Annual NY academic science. 453:376-378. Lacks P. (1987) Behavioral treatment for persistent insomnia. Pergamon press:New York. Closs S.J. (1988) Assessment of sleep in hospital patients: a review of methods. Journal of Advanced Nursing 13: 501-510 Kearnes, S. (1989). Insomnia in the Elderly. Nursing Times. 85:47, 32-33 Kripke, D.F.(1989) Bright white light alleviates the depression. Psychiatry Research, 10, 105-112 Montgomery P, Dennis J. Bright light therapy for sleep problems in adults aged 60+ (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd. Dawson D, Campbell SS. (1991) Timed exposure to bright light improves sleep and alertness during simulated night shifts. Sleep.14:511-516 Cole R.J., Kripke D.F., Gruen W., Mullany D.J. and Gillin J.C. (1992) Automactic sleep/wake identification from wrsit activity. Sleep. 15:461-469. Swift, C.G. & Shapiro, C.M. (1993). Sleep and sleep problems in elderly people. BMJ, 306:1468-1471

77. Dollins A.B., Lynch H.J., Wurtman R.J., Deng M.H.and Lieberman H.R. (1993) Effects of illumination on Human Noctural Serum Melatonin levels and performance. Journal of.Sleep Research. 8: 301-310 Shapiro C.M. & Swfit C.G. (1993). Sleep and sleep problems in elderly people. BMJ 306:1468-1471 Bliwise D.L. (1993) Sleep in normal aging and dementia. Sleep 16:40-81 Campbell S.S. (1995) Effects of timed bright-light exposure on shift-work adaptation in middle-aged subjects. Sleep.18:408-16 Shapiro C.M. & Swfit C.G. (1993). Sleep and sleep problems in elderly people. BMJ 306:1468-1471 Saden A., Sharkey K.M. and Carskadon M.A. (1994) Avtivity-based sleep-wake identification: An empirical test to methodological issues. Sleep. 17:201-207. Young R.W. (1994) The family of sunlight-related eye diseases. Optometry and visual science. 71:125-144. Blazer D.G., Brown S.L., Foley D.J., Monjan A.A. Simonsick E.M. & Wallace R.B. (1995). Sleep complaints among elderly persons: An epidemiologic study of ther communities. Sleep. 18(6):425-432. Murphy, Patricia J. & Campbell, Scott S. (1996). 13 (1). :2-16 Murphy, Patricia J. & Campbell, Scott S. (1996) Journal of Clinical Neurophysiology. 13 (1). :2-16 K.Meire-Ewert & M. Okawa (1996). Sleep-wake disorders. New York: Plenum Press. Pp61-66 K.Meire-Ewert & M. Okawa (1996). Sleep-wake disorders. New York: Plenum Press. Pp61-66

78. Trinder J., armstrong S.M., O’Brien C., Luke D.and martin M.T. (1996). Inhibition of melatonin secretion onset by low levels of illumination. Journal of Sleep Research. 5: 77-82 K.Meire-Ewert & M. Okawa (1996).. New York: Plenum Press. Pp61-66 K.Meire-Ewert & M. Okawa (1996). Sleep-wake disorders. New York: Plenum Press. Pp61-66 Ancoli-Israel S, Klauber MR, Jones DW, Kripke DF, Martin J, Mason W, Pat- Horenczyk R, Fell R. (1997) Variations in circadian rhythms of activity, sleep, and light exposure related to dementia in nursing-home patients. Sleep. 20:18-23 Black J.M.& Jacobs.E.M.(1997).Medical-surgical nursing: clinical management for continuity of care(5th ed). Philadelphia:W.B.Saunders company. Chan, Y.H., et al. (1997). An exploratory study to investigate how much nurses know about the usefulness of sleep promoting measures in managing patients with insomnia. Kowloon West Cluster Hospitals Quality Week Bulletin 1997: 9-10 Ancoli-Israel S., Klauber M.R., Jones D.W., Kripke D.F., Martin J., Mason W., Pat- Horenczyk R. and Fell R. (1997) Variations in circadian rhythms of activity, sleep and light exposure related to demnta in nursing home patients. Sleep. 20(1997b):18-23. Jean-Louis G., Zizi F., Von Gizycki H. and Hauri P.(1997) Actigraphic assessment of sleep in insomnia: applicaton of the actigraph data analysis.. 5(4/5):659-663. Jean-Louis G., Zizi F., Von Gizycki H. and Hauri P.(1997) Actigraphic assessment of sleep in insomnia: applicaton of the actigraph data analysis. Physiology and Behaviour. 5(4/5):659-663. Rogers, A.E. (1997). Nursing management of sleep disorders: Part 2. Behavioral interventions., 24:6, 672-675 Rogers, A.E. (1997). Nursing management of sleep disorders: Part 2. Behavioral interventions. ANNA Journal, 24:6, 672-675

79. Kripke, D. F. (1998). Uses of bright light in office practice: How to brighten up your patients. In J.S.Poceta & M. M. Mitler (Eds.) Sleep Disorders in Primary Care Medicine Humana Press: Totowa, N.J. pp. 53-74. Blais.K.,Erb.G.,Kozier.B. &Wilkinson.J.M.(1998).. Menlo park: Addison Wesley Longman. Blais.K.,Erb.G.,Kozier.B. &Wilkinson.J.M.(1998). Fundamentals of nursing concepts,porcess,and practice (5th ed). Menlo park: Addison Wesley Longman. Cardinali D.P. & Pevet P. (1998). Basic aspects of melatonin action. Sleep medicine Reviews.2(3):175-190 Wykpize E.M., Redeker N.S., Mason D.J.and Glica B.(1998) Using the actigraphy to measure Activity-rest in the acute care setting.In Nursing and computers: an anthology 1987~1996. Spinger: New York Campbell S.S., Murphy, P.J., vanden Heuvel, C.J., Roberts, M.L., Stauble, T.N. (1999) Etiology and treatment of intrinsic circadian rhythm sleep disorders. Sleep Medicine Reviews. 3:179-200. Reid K., Dawson D. (1999) Correlation between wrist activity monitor and electrophysiological measures of sleep in a simulated shiftwork environment ofr younger and older subjects. Sleep. 52(2): 157-159 Ancoli-Israel S., Kripe D.F., Parker L. and Cobarrubias M. (1989) Sleep apnea in female patients in a nursing home: increased risk of mortality. Chest. 96(5):1054- 1058. Lam, R. W. & Levitt, A. J. (1999).. Clinical and Academic Publishing: Vancouver Lam, R. W. & Levitt, A. J. (1999). Canadian Consensus Guidelines for the Treatment of Seasonal Affective Disorder. Clinical and Academic Publishing: Vancouver

80. Shochat T., Martin J., Marler M. and Ancoli-Israel S. (2000) Illumination levels in nursing home patients: Effects on sleep and activity rhythms. Journal of Sleep Research. 9(4):373-380 Terman M. & Terman J.S (2000).. pp1258-1274. W.B. Saunders Company: Philadelphia. Terman M. & Terman J.S (2000). Light Therapy in Kryger M.H., Roth. T & Dement W.C. (Ed.) Principles and Practice of Sleep Medicine. pp1258-1274. W.B. Saunders Company: Philadelphia. Bjorvatn B. & Fetveit A. (2001). Sleep Disturbances Among Nursing Home Residents. 7, 2001). Bjorvatn B. & Fetveit A. (2001). Sleep Disturbances Among Nursing Home Residents. Actas de Fisiologia 7, 2001). Gunn C. (2001) Using maths in health science. Churchill Livingstone: Edinburg. P.p.36-39. Polit D.F., Beck C.T. & Hungler B.P. (2001). Essential of Nursing Research: Methods, Appraisal, and Utilization. Lippincott: Philedlphia. Emsinger P.A.(2001) Yale U. Press:New Haven Emsinger P.A.(2001) Life under the Sun. Yale U. Press:New Haven Heil D. P. and Mathis S. R. (2002) Characterizing free-living light exposure using a wrist-worn light monitor. 33:357-363. Heil D. P. and Mathis S. R. (2002) Characterizing free-living light exposure using a wrist-worn light monitor. Applied ergonomics. 33:357-363. Wright H.R. and Lack L.C. (2001) Effect of light wavelength on suppression and phase delay of the melatonin rhythm 18(5):801-808. Wright H.R. and Lack L.C. (2001) Effect of light wavelength on suppression and phase delay of the melatonin rhythm. Chronobiology international. 18(5):801-808.

81. Wright H.R., Lack L.C. (2001) Effect of light wavelength on suppression and phase delay of the melatonin rhythm. Chronobiology International 18(15): 801-808 Partonen T. $ Magnusson A. (2001). Seasonal Affective Disorder: Practice and research. Oxford University Press: New York. Ho S.C., Wong K.S., Tang P. L. and Pang M.C.(2002)Nonpharmacologic sleep promotion: bright sleep exposure. Complementary therapies in nursing and midwifery.8:130-135 Labyek S.E. and Bourguignon C. (2002) Measurement Issues Related to Actigraphy Use in Older Women. Topics in geriatric rehabilitation. 18(1):68-79. Yoon I, Jeong D, Kwon K, et al. Bright light exposure at night and light attenuation in the morning improve adaptation of night shift workers. Sleep 2002;25:351-6 Phipps-Nelson J; Redman JR; Dijk DJ; Rajaratnam SMW. (2003) Daytime exposure to bright light, as compared to dim light, decreases sleepiness and improves psychomotor vigilance performance. Sleep. 26(6):695-700. Chiu, L.P.W. (2003). Approach to insomnia. Hong Kong Practitioner. 25:435-445 Ancoli-Israel.S. (2004). Sleep disorders in older adults:A primary care guide to assessing 4 common sleep problems in geriatric patients. Geriatrics 59(1):37-40.

82. THANK YOU THANK YOU Any questions? Any questions?

83. Why old-aged home residents? Extremely ragmented sleep in older adults living in nursing homes (Ancoli-Israel S. et. al., 1989). Institutionalized patients aged 60-100 year of aaged with mild, moderate or no dementia spent a median of 9 mins exposed to light above 1000 lux. ( Ancoli-Israel et. al., 1997) 17% of the investigated 77 nursing homes patients were never exposed to light over 1000 lux, and 26% were never exposed to light over 200 lux on any of the 3 days during the investigation ( Shochat et. al., 2000),

84. Why sleep log + actigraphy Advance electronic technology and computers are useful in providing objective measurement of activity-rest in the study. Sleep logs provide valuable "detailed" information about the timing and distribution of specific activities across the stages, for example, caffeine or medication intake, self- perception of sleep satisfaction level. The usage of subjective data in sleep logs provide the way to take back some of the control lost outside the actigraphic data.