Download The use of light therapy to lower agitation in people

CLINICAL
DEVELOPMENT
The use of light therapy to lower
agitation in people with dementia
Alexopoulos, G.S. et al (1988) Cornell
scale for depression in dementia.
Biological Psychiatry; 23: 271–284.
Allen, H. et al (2003) Bright light
therapy, diurnal rhythm and sleep in
dementia. International
Psychogeriatrics; 15: (Suppl 2), 97–98.
Ballard, C.G. et al (2002) Aromatherapy
as a safe and effective treatment for the
management of agitation in severe
dementia: the results of a double-blind,
placebo controlled trial. Journal of
Clinical Psychiatry; 63: 553–558.
Bliwise, D.L. (1993) Sleep in normal
aging and dementia. Sleep; 16: 40–81.
Byrne, E.J. et al (2003) A randomised
controlled trial of bright light therapy for
agitation and sleep disorders in
dementia. International
Psychogeriatrics; 15: (Suppl 2), 97.
Campbell, S.S. et al (1995) Light
treatment for sleep disorders: consensus
report. V. age-related disturbances.
Journal of Biological Rhythms;
10: 151–154.
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There has been debate about the use of some atypical
antipsychotic drugs in the management of agitated
behaviour in dementia care. This has left health care
professionals searching for alternative treatments.
Research conducted in recent years has aimed
to develop an awareness that non-pharmacological
treatments could enhance the management of patients
with such behaviours, with one of these therapies being
bright light therapy (BLT).
Nature of agitation
Agitated behaviours are particularly common in the
latter stages of a dementia-type illness. Agitation and
sleep disturbances can be troublesome for those with
dementia and their carers (Lyketsos et al, 1999).
Many patients living in residential care facilities become agitated. Agitation is not a diagnostic term, rather
it is used to describe a group of symptoms (CohenMansfield et al, 1989), which include aggression, wandering, calling out, screaming and verbal abuse.
These behaviours pose a challenge for nursing staff.
There has been a gradual introduction of non-pharmacological therapies, such as aromatherapy, therapeutic
touch and behaviour modification (Douglas et al, 2004;
Ballard et al, 2002).
While antipsychotics have been shown to moderately
improve symptoms of agitation and psychological distress (Sultzer, 2003), there is an increasing concern
among health care professionals about their propensity
for adverse side-effects.
Sleep disturbance
Campbell et al (1995) estimate that half the population
aged over 65 years have chronically disrupted sleep
(sleep maintenance insomnia), and this is especially a
concern for people with dementia. In 1993, Bliwise
found that out of 47 residents with Alzheimer’s disease
in a special care unit, 24 per cent had moderately
disturbed sleep. Patients with dementia can often lose
their circadian organisation and experience increased
daytime napping, early morning waking and frequent
nocturnal interruptions. These are characteristics of
circadian disorganisation (Martin et al, 2000).
This phenomenon has been closely linked with behavioural disturbance, (McCurry et al, 2000). Pollak and Perlick (1991) say that behavioural restlessness during the
night can be a major factor in a carer’s decision to have
a relative institutionalised.
Previous research with BLT suggests that light levels
are an important modulator of circadian rhythms (Van
Someren et al, 1997).
Why is light important?
Many patients in nursing and residential homes are
exposed to limited daylight. Some staff seem reluctant
to take patients out of the building, even to sit outside.
Often only those patients visited by relatives enjoy the
luxury of being outdoors in natural light.
Light helps to regulate the body clock (Van Someren,
2000). It seemed feasible that light therapy might be
Table 1. aspects of light therapy
Positive aspects
Negative aspects
Low cost
Time consuming
Non-pharmacological
Resource issues
Few side-effects
May only be beneficial
in winter months
Reduced reliance on
sleeping tablets
Difficulty keeping
residents engaged
Easily integrated
into daily routine
Exclusion for sight
problems
Practical
Very bright light
SPL
References
AUTHORS Debbie Sutherland, BA, RMN, is research
sister; Yvonne Woodward, BSc, is research assistant;
Jane Byrne, is senior lecturer/honorary consultant
psychiatrist; Harry Allen, is consultant psychiatrist,
Alistair Burns, is professor of old age psychiatry; all at
Wythenshawe Hospital, Manchester.
ABSTRACT Sutherland, D. et al (2004) The use of
light therapy to lower agitation in people with
dementia. Nursing Times; 100: 44, 32–34.
Agitation and sleep disturbance are problematic for
people with dementia and their carers, and have been
linked to disrupted circadian rhythms caused by a lack
of exposure to light. Bright light therapy (BLT) offers a
powerful and cost-effective alternative to pharmacological options, and can be easily incorporated into care
routines. This article describes practical issues faced
when implementing light therapy in a nursing home
setting, and attempts to address existing perceptions
about its effectiveness.
NT 9 November 2004 Vol 100 No 45 www.nursingtimes.net
keywords n Dementia n Light therapy n Older people
References
Box 1. Case study
Joan Rider (not her real name) was given a diagnosis
of Alzheimer’s disease in 2001. She had presented to
the mental health team five years previously
complaining of memory difficulties. Her pre-illness
history showed Ms Rider to be sociable, playing an
active role in local government.
On assessment she showed a severe degree of
cognitive impairment, defined by the mini-mental
state exam (Folstein et al, 1975). Low mood was also
detected using the Cornell scale (Alexopoulos et al,
1988). The main assessment tool used was the CohenMansfield agitation inventory (Cohen-Mansfield et al,
1989), which measures level of agitation.
Ms Rider was unable to communicate verbally, was
restless and agitated and did not sleep restfully most
nights. She had also become socially isolated on the
ward. It was hoped bright light therapy would
decrease her agitation and increase restful sleep, and
that a change of environment and routine would lift
her mood. It was suggested that Ms Rider have her
most effective on shorter days in the winter months
(Byrne et al, 2003). Studies have shown that limited sunlight exposure may cause circadian dysrythmias, thus
inducing agitation (Martin et al, 2000; Satlin, 1992).
Agitation in some older residents increases as the sun
sets. This has been termed as the ‘sundown syndrome’
(Van Someren, 2000). Evans (1987) reported that 12.3
per cent of older institutionalised patients were more
restless and verbally agitated in late afternoon. The
prevention and alleviation of agitated behaviours is still
very much under investigation. For example, Bliwise
(1993) found seasonal variation in agitated behaviour,
with increased agitation occurring in the winter months.
Byrne et al (2003) and Allen et al (2003) found significant reduction in agitated behaviours during the winter
months in comparison with those patients receiving light
treatment during the summer months. This data suggests that light treatment may be a promising alternative to current practice (Table 1, p32).
Delivering the therapy
Between 2000 and 2002, 48 patients living in two
residential care homes took part in a study of BLT. Of
these, 22 patients received BLT, while 26 were randomised
for placebo light (Byrne et al, 2003).
A therapy room was established in each care home.
Each room was pleasant and quiet, which was important
to encourage compliance and to maintain a therapeutic
environment. Four chairs were placed around a table,
upon which four light boxes were situated. Patients were
seated in upright armchairs which were comfortable and
practical, and a notice was placed on the door to prevent
any potential disruptions from outside.
NT 9 November 2004 Vol 100 No 45 www.nursingtimes.net
breakfast in the light treatment room to allow BLT to
be incorporated into her normal daily routine.
During the initial sessions, Ms Rider appeared to
indicate reluctance to look into the light box, looking
away regularly, with facial grimacing. In the second
week of treatment, changes started to be observed
in Ms Rider’s behaviour. She appeared less agitated
and the facial grimacing completely stopped. She
started to try and move from her chair, something
she had not done for many years. Staff commented
that she had been trying to communicate with them
verbally, which was a dramatic change.
During the last week of treatment, night staff
commented that Ms Rider had been sleeping much
better and were amazed at the changes. Ms Rider’s
agitation scores decreased dramatically during
treatment: by 15 points in the first four weeks and a
further 15 points by week 8.
This objective data confirms a reduction seen in
agitated behaviour.
The distance from the light box and the angle of the
eyes determined the degree of light received by each
individual. For example, patients involved in this study
received 10,000 lux (1 metre = 10,000 lux). This can be
measured by using a light monitor.
Patients received the light treatment for two hours
each morning, which was optimal for most patients in
terms of their pre-treatment circadian rhythms.
Overcoming administration difficulties
For some patients it was difficult to engage their full
attention on the light box. For example, those patients
who were prone to wandering appeared to find it difficult
to sit for long periods of time. This may present a
challenging task for nurses. However, there are practical
solutions which can be implemented (Table 2, p34).
Cohen-Mansfield, J. et al (1989)
A description of agitation in a nursing
home. Journal of Gerontology;
44: M77–M84.
Douglas, S. et al (2004) Nonpharmacological interventions in
dementia. Advanced Psychiatry
Treatment; 10: 3, 171–177.
Evans, L.K. (1987) Sundown syndrome
in institutionalised elderly. Journal of
the American Geriatrics Society;
35, 553–563.
Folstein, M.F. et al (1975) Mini-mental
state: a practical method for grading the
cognitive state for clinician. Journal of
Psychiatric Research; 12: 189–198.
Hudson, P. (2003) The experience of
research participation for family
caregivers of palliative care cancer
patients. International Journal of
Palliative Nursing; 9: 120–123.
Lyketsos, C.G. et al (1999) A
randomised, controlled trial of bright
light therapy for agitated behaviours in
dementia patients residing in long term
care. International Journal of Geriatric
Psychiatry; 14: 520–525.
Martin, J. et al (2000) Circadian rhythms
of agitation in institutionalised patients
with Alzheimer’s disease. Chronobiology
International; 17, 405–418.
Was light therapy well received?
Nursing staff
Initially many of the nursing staff did not feel convinced
that bright light therapy could reduce agitated behaviour
in patients who have a long-standing history of
behavioural disturbances.
The researchers fully understood the lack of enthusiasm initially displayed by the staff as it is not immediately obvious how much such a simple intervention could
help reduce agitated behaviours. If a nurse is considering
implementing the therapy, it is important to anticipate
such negative reactions.
However, as the treatment progressed less agitation
was seen in the patients, particularly during the second
week of treatment. As many of the patients had a
high degree of cognitive impairment, it was not always
This article has been double-blind
peer-reviewed.
For related articles on this subject
and links to relevant websites see
www.nursingtimes.net
33
DEVELOPMENT
References
McCurry, S.M. et al (2000) Treatment of
sleep disturbances in Alzheimer’s
disease. Sleep Medical Review;
4: 603–628.
Pollak, C.P., Perlick, D. (1991) Sleep
problems and institutionalization of the
elderly. Journal of Geriatric Psychiatry
and Neurology; 4: 204–210.
Satlin, A. et al (1992) Bright light
treatment of behavioural and sleep
disturbances in patients with Alzheimer’s
disease. Americal Journal of Psychiatry;
149: 8, 1028–1032.
Sultzer, D.L. (2003) Psychosis and
antipsychotic medications in Alzheimer’s
disease: clinical management and
research perspectives. Dementia and
Geriatric Cognitive Disorders;
17: 1–2, 78–90.
Van Someren, E.J.W. (2000) Circadian
and sleep disturbances in the elderly.
Experimental Gerontology; 35,
1229–1237.
Van Someren, E.J.W. et al (1997)
Indirect bright light improves circadian
rest-activity rhythm disturbances in
demented patients. Biological
Psychiatry; 41, 955–963.
Campbell, S.S. et al (1995) Light
treatment for sleep disorders: consensus
report. V. Age-related disturbances.
Journal of Biological Rhythms;
10: 151–154.
34
easy to assess their experience of the light treatment.
Although care must be taken with regard to inferring
too much from behaviour, it appeared that the patients
started to approach the researcher more readily during
the treatment phase.
Some patients began to show highly positive nonverbal communication, for example having their arms
outstretched and smiling as the time for their light treatment approached.
The nursing staff also began to comment on the positive effects they had observed, and night staff regularly
reported that patients were sleeping for longer periods
with unbroken sleep.
Light treatment was continued at the weekend and
nursing staff became more actively involved in administering the therapy. Sitting with four agitated patients for
two hours, encouraging them to remain seated and look
into a light is not an easy task. But as the study progressed, the nurses’ overall perceptions appeared to
change and they became more enthusiastic about the
potential of BLT to reduce agitated behaviour (Box 1, p33).
During the treatment periods, the researcher sat with
the patients for two hours each week day in the treatment rooms. The researcher found that her own sleep
became heightened and her appetite increased. The researcher also felt very relaxed while close to the light
boxes although this is only a subjective observation and
not independently rateable.
Relatives
Previous studies have demonstrated that a majority of
family caregivers perceive there to be direct benefits
associated with involvement in research (Hudson, 2003).
Hudson also suggests that some relatives found the
assistance given them by the researcher to be a major
benefit. They felt that they were able to voice their
concerns and appreciated the opportunity for discussion
and feedback.
Relatives of the patients receiving the light treatment
viewed it in a positive way, and were hopeful of beneficial effects. Some patients were already prescribed a
range of medications and were possibly experiencing
side-effects. This alternative treatment was therefore
highly welcomed.
Families of patients who were involved in the light
therapy study expressed that they were pleased with the
results of the treatment and reported observing positive
changes in their relatives.
Conclusion
Living with dementia is never easy and when those
who are affected are suffering with agitation and sleep
disorders this can make the situation even more
distressing. Bright light treatment can be a way forward
to help these patients and can easily be integrated into
any daily routine, for example having breakfast in front
of the light box.
Most patients indicated that the light treatment was a
pleasurable experience. With participation and support
from nursing staff, BLT proved to be a cost-effective and
relaxing therapy. Nurse involvement with the treatment
on the wards can also allow a further development of
the nurse-patient relationship.
As previously discussed, assisting the patient to focus
on the light box can be challenging for the nurse.
However, if the practical and simple solutions are followed then this non-pharmacological treatment may be
easily implemented. In conclusion bright light treatment
can help to reduce agitation, particularly during the winter months (Allen et al, 2003). n
Table 2. Practical difficulties that may arise during light therapy administration
Situation
Possible solutions
The patient has difficulty
remaining seated
l Engage the patient in conversation (a diversional technique that also
builds rapport)
l Tactile stimulation where appropriate (for example holding the patient’s
hand for reassurance and comfort)
The patient becomes
distracted and does not focus
on the light box
l Having breakfast in front of the light encourages retained eye contact
for some patients (showing how BLT can be easily incorporated into a
patient’s daily routine)
The patient becomes
verbally and/or physically
abusive
l Verbal reassurance techniques are often effective in reducing these
behaviours
l If patients do not respond to reassurance and agitation continues to
increase, the session should be ended (it is important to recognise and
respond to non-verbal cues indicating the patient wishes to leave the room)
The patient refuses to enter
the light treatment room
l Initially, patients benefited from their named nurse escorting them to the
treatment room. This appeared to increase patient confidence and provide
reassurance during initial changes to their routine
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