The effect of bright light The effect of bright light exposure in elderlyexposure in elderly

(extended proposal)(extended proposal)

Supervisor: Dr. Jacquelline HoSupervisor: Dr. Jacquelline Ho

Group members (Group 35)Group members (Group 35)

Chen Hiu HungChen Hiu Hung 02515760T 02515760T

Hui Man Chi Hui Man Chi 02505986T 02505986T

Kwan Tsui Ying Kwan Tsui Ying 02514227T02514227T

Lee Tsz Wing Lee Tsz Wing 02513347T02513347T

Li Kwan Fong Li Kwan Fong 02513520T02513520T

Tsang Cheuk Yee Cherry Tsang Cheuk Yee Cherry 02514946T 02514946T

Yeung Lai Kam Yeung Lai Kam 02513323T 02513323T

IntroductionIntroduction

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

79 11 1072 25 374 20 673 18 973 22 5

64 21 1571 18 11

67 17 1667 17 16

54 29 1761 21 18

45 32 2356 24 20

46 25 29

MFMFMFMFMFMFMF

13-

1920

-29

30-

3940

-49

50-

5960

-69

70-

79

Age

Percentage of people in different age groupswho reported trouble with sleeping

Never or seldom Sometimes Often or all the time

Source:

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

IntroductionIntroduction

Loss of sleeping is prone to accidents, and Loss of sleeping is prone to accidents, and QoL QoL (Foley, et al 1995; Cambell, 1995)(Foley, et al 1995; Cambell, 1995)

Interventions for such problem include: phInterventions for such problem include: pharmacological use, psychotherapy, behaviarmacological use, psychotherapy, behavioral therapies, sleep hygiene education oral therapies, sleep hygiene education (Ro(Ro

gers, 1997; Chiu, 2003)gers, 1997; Chiu, 2003) and bright light exposure and bright light exposure (C(Campbell, 1995; Dawson & Campbell, 1991; Yoon et al, 2002; Phippampbell, 1995; Dawson & Campbell, 1991; Yoon et al, 2002; Phipps-Nelson et al, 2003)s-Nelson et al, 2003)

IntroductionIntroduction (con’t) (con’t)However, due to physiology changes,However, due to physiology changes,– Medications Medications alter liver & kidney functions alter liver & kidney functions– More time in bed More time in bed better sleeping qualitybetter sleeping quality

(Dawson & Campbell,1991;(Dawson & Campbell,1991; Montgomery & Dennis, 2004)Montgomery & Dennis, 2004)

There is a need for nurses to develop There is a need for nurses to develop various interventions to promote sleep various interventions to promote sleep (Chan et al, 1997)(Chan et al, 1997)

There were studies shown that light exposThere were studies shown that light exposure could alter circadian system as well as ure could alter circadian system as well as sleeping timesleeping time (Campbell SS, 1995; Campbell et al, 1(Campbell SS, 1995; Campbell et al, 1999; Dawson & Campbell,1991; Phipps-Nelson et al, 200999; Dawson & Campbell,1991; Phipps-Nelson et al, 2003; Yoon et al, 2002)3; Yoon et al, 2002)

reduce sleepinessreduce sleepiness (Phipps-Nelson et al, 2003) (Phipps-Nelson et al, 2003)

effective in improving sleep in people with demeneffective in improving sleep in people with dementia, severe Alzheimer’s diseasetia, severe Alzheimer’s disease (Ancoli-Israel et al, (Ancoli-Israel et al, 1997; Bliwise, 1993; Campbell et al, 1999)1997; Bliwise, 1993; Campbell et al, 1999)

contractindicated to people with maniacontractindicated to people with mania (Ancoli-Isra (Ancoli-Israel, 2004) el, 2004)

AimAim

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

ObjectivesObjectives

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

Research QuestionsResearch QuestionsAre there any changes in the Are there any changes in the 1.1. sleep latencysleep latency2.2. sleep efficiency sleep efficiency 3.3. awaking time awaking time 4.4. sleep satisfaction level sleep satisfaction level

in the elderly people after bright light exposure?in the elderly people after bright light exposure?5.5. How long does the effectiveness of the bright How long does the effectiveness of the bright light effect last?light effect last?  

Literature reviewLiterature reviewSleep definitionSleep definition

A normal state of altered consciousness A normal state of altered consciousness (Bl(Black & Jacobs,1997)ack & Jacobs,1997)

Decrease perception and reaction to envirDecrease perception and reaction to environment onment (Blais et.al,1998)(Blais et.al,1998)

Minimal physical activity, consciousness leMinimal physical activity, consciousness level, change in body’s physiological procesvel, change in body’s physiological processesses

Literature review Literature review Sleep functionSleep function

Restores normal level of activity and normRestores normal level of activity and normal balance among parts of nervous systemal balance among parts of nervous system

Enhance the muscle tone and protein syntEnhance the muscle tone and protein synthesis hesis (Blais et.al,1998)(Blais et.al,1998)

Maintain mental activity such as learning, rMaintain mental activity such as learning, reasoning easoning (Black & Jacobs,1997)(Black & Jacobs,1997)

Literature reviewLiterature reviewSleep cycleSleep cycle

Each cycle about 70 minutes; 4-6 cycles wEach cycle about 70 minutes; 4-6 cycles within 7-8 hours ithin 7-8 hours (Blais et.al,1998)(Blais et.al,1998)

[Figure 1. Borbely,A. (1986). Secrets of sleep. New York: Basic books.][Figure 1. Borbely,A. (1986). Secrets of sleep. New York: Basic books.]

Literature review Literature review Sleep cycle (con’t)Sleep cycle (con’t)

Non-rapid eye movement (NREM)Non-rapid eye movement (NREM)

4 stages: stage 1-3 last about 30 mins; sta4 stages: stage 1-3 last about 30 mins; stage 4 lasts about 30 mins ge 4 lasts about 30 mins (Blais et.al,1998)(Blais et.al,1998)

Stage 1 and 2 are light sleep; stage 3 and Stage 1 and 2 are light sleep; stage 3 and 4 are slow-wave sleep 4 are slow-wave sleep (Black & Jacobs,1997)(Black & Jacobs,1997)

Physiological characteristic: lack of eye mPhysiological characteristic: lack of eye movement, low and fragmented cognitive acovement, low and fragmented cognitive activity tivity (Black & Jacobs,1997)(Black & Jacobs,1997)

Literature reviewLiterature reviewSleep cycle (con’t)Sleep cycle (con’t)

Rapid eye movement (REM)Rapid eye movement (REM)

REM lasts about 10 mins, increase time of REM lasts about 10 mins, increase time of REM in later sleep period REM in later sleep period (Black & Jacobs,199(Black & Jacobs,1997)7)

Low voltage, random fast waves, deep sleLow voltage, random fast waves, deep sleep ep (Black & Jacobs,1997)(Black & Jacobs,1997)

Characteristic: rapid eye movements, erratCharacteristic: rapid eye movements, erratic respirations, low muscle tone ic respirations, low muscle tone (Black & Jaco(Black & Jacobs,1997)bs,1997)

Literature reviewLiterature reviewSleep problem in elderlySleep problem in elderly

Little or no NREM stage 4 Little or no NREM stage 4 (Shapiro & Swift,1993),(Shapiro & Swift,1993), decrease REM, more time in stage 1, sleep decrease REM, more time in stage 1, sleep latency increases latency increases (Black & Jacobs,1997)(Black & Jacobs,1997)

Inadequate depth of sleep awaken more often Inadequate depth of sleep awaken more often during night, not enough sleep, awaking too during night, not enough sleep, awaking too early, needing naps early, needing naps (Shapiro & Swift,1993)(Shapiro & Swift,1993)

Literature reviewLiterature reviewSleep problem in elderlySleep problem in elderly

(con’t)(con’t)

Circadian rhythm advances Circadian rhythm advances (Ancoli-Israel 2004)(Ancoli-Israel 2004)

Impairement of melatonin production Impairement of melatonin production (Cardinali &(Cardinali &Pevet, 1998)Pevet, 1998)

DecreaseDecrease melatonin rhythm amplitude melatonin rhythm amplitude (Reit(Reiter & Robinson, 1995; Schwartz 1997)er & Robinson, 1995; Schwartz 1997)

Sleep disturbance leads to poor memory, difficuSleep disturbance leads to poor memory, difficult concentration lt concentration (Ancoli-Israel 2004)(Ancoli-Israel 2004)

Literature reviewLiterature reviewMelatoninMelatonin

Secreted by human pineal gland and retina Secreted by human pineal gland and retina (Cardinali & Pevet,1998)

Convey information concerning daily cycle of lighConvey information concerning daily cycle of light and darknss to body physiology. It used for the t and darknss to body physiology. It used for the organization of circadian rhythms organization of circadian rhythms (Cardinali & Pevet,1998;Empson, 2002;Schwartz,1997)

Induce circadian phase shift and influence sleeInduce circadian phase shift and influence sleep-wake cycle p-wake cycle (Cardinali & Pevet,1998; (Cardinali & Pevet,1998; Schwartz,1997))

Literature reviewLiterature review Circadian rhythmCircadian rhythm

Internal clocks that control biological rhythms Internal clocks that control biological rhythms (Ho(Hobson,1989)bson,1989)

Internally generatedInternally generated (Hobson,1989 (Hobson,1989)), period close t, period close to 24 hr o 24 hr (Duffy et al,1996)(Duffy et al,1996)

Circadian rhythm can be affected by environmenCircadian rhythm can be affected by environmental factors such as light and darkness tal factors such as light and darkness (Blais et.al,1(Blais et.al,1998)998)

Change in circadian rhythm may cause chronic dChange in circadian rhythm may cause chronic disruption of sleep isruption of sleep (Blazer et al. 1995)(Blazer et al. 1995)

Literature reviewLiterature reviewLightLight

Is an important modulator of circadian Is an important modulator of circadian rhythm rhythm (Kessler et al,1997)(Kessler et al,1997)

Additional light in the evening can raise Additional light in the evening can raise melatonin level & delay circadian cycle→ melatonin level & delay circadian cycle→ Increase night sleep amount Increase night sleep amount (Cooke et al,1998; (Cooke et al,1998; Reiter & Robinson,1995)Reiter & Robinson,1995)

Literature reviewLiterature reviewRelationship between light ,melatonin Relationship between light ,melatonin

rhythm and circadianrhythm and circadian

Light →a person’s light-dark cycle Light →a person’s light-dark cycle →Melatonin secretion rhythm →circadian →Melatonin secretion rhythm →circadian rhythm →sleep pattern of a personrhythm →sleep pattern of a person

MethodologyMethodology

Research designResearch designSamplingSamplingSelection criteriaSelection criteriaStudy designStudy designInstruments and equipmentsInstruments and equipments

Research designResearch design

Quasi-experimental studyQuasi-experimental study

Study the change in the sleep efficiency Study the change in the sleep efficiency and latency of elderly after bright light and latency of elderly after bright light exposureexposure

Light intensity is the independent variable Light intensity is the independent variable to be manipulated. Subjects can serve as to be manipulated. Subjects can serve as their only control group.their only control group.

SamplingSamplingConvenience sampling methodConvenience sampling methodSubjects will be recruited on the basis of aSubjects will be recruited on the basis of availabilityvailabilityEconomical and efficientEconomical and efficientThere are difficulties to spend time & resoThere are difficulties to spend time & resources to study all members of a population urces to study all members of a population (Polit, Beck & Hungler, 2001).(Polit, Beck & Hungler, 2001).

SamplingSamplingNumber of subjects (N=30)Number of subjects (N=30)Similar researches done before with similaSimilar researches done before with similar sampling sizer sampling size

E.g. a study was done in Norway on 2001 E.g. a study was done in Norway on 2001 to study the prevalence and characteristics to study the prevalence and characteristics of sleep disturbances among an entire nurof sleep disturbances among an entire nursing home population by actigraphy. (N=2sing home population by actigraphy. (N=29), 9),

((Sleep Disturbances Among Nursing Home Residents, Actas de Fisiologia 7, 2001).Sleep Disturbances Among Nursing Home Residents, Actas de Fisiologia 7, 2001).

SamplingSampling

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

SamplingSampling

No control groupNo control group

Subjects will serve as their own control Subjects will serve as their own control group insteadgroup instead

Comparison is made before & after the Comparison is made before & after the bright light exposure, both qualitative & bright light exposure, both qualitative & quantitative data.quantitative data.

Selection criteria (inclusion)Selection criteria (inclusion)

Aged 65 or aboveAged 65 or above

Old age home resident with no sleep Old age home resident with no sleep partnerpartner

Conscious & able to answer questionConscious & able to answer question

Able to move their limb freely & Able to move their limb freely & independentlyindependently

Have sleep problem and desire to improveHave sleep problem and desire to improve

Experimental settingExperimental setting

Room temperature Room temperature

Video tapes of 50’s TV programs will be Video tapes of 50’s TV programs will be broadcasted and research team to chat broadcasted and research team to chat with the subjects,with the subjects,

during the light application period.during the light application period.

Study ProcedureStudy Procedure

Season Season for data collection: 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 sleepeffect on sleep

(Murphy & Campbell, 1996)(Murphy & Campbell, 1996)

PeriodPeriod of data collection: of data collection: Pre-bright light exposure stage: Day 1 & 2Pre-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: 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: Post-bright light stage: -Day 8 to Day 14 (150 lux red dim light)-Day 8 to Day 14 (150 lux red dim light)

Light intensity appliedLight intensity applied2500lux white bright light2500lux white bright light

- 2500lux can totally suppresses melatonin secretio2500lux can totally suppresses melatonin secretion n (Dollins et al,1993)(Dollins et al,1993)

- It is the intensity level of the sunlight daytime intenIt is the intensity level of the sunlight daytime intensity during the spring and summer. sity during the spring and summer. (Emsinger, 2001)(Emsinger, 2001)

150 red dim light150 red dim light- room light intensity:150-300luxroom light intensity:150-300lux (Heil and Mathis, 200(Heil and Mathis, 200

2); 2); - little or no suppression in light with long wavelengtlittle or no suppression in light with long wavelengt

h, red light.h, red light. (Brainard et. al., 1985 & Wright and Lack, 20(Brainard et. al., 1985 & Wright and Lack, 2001)01)

Time of light therapyTime of light therapy

1800-2100hours1800-2100hours

-Phase-delaying of sleep-Phase-delaying of sleep-To help subjects with advanced sleep -To help subjects with advanced sleep phasephase(Kripke, 1989)(Kripke, 1989)

Table 1 The Experimental DesignTable 1 The Experimental Design

Day and stageDay and stage Light exposureLight exposure Data collectedData collected

Day 1- Day 2Day 1- Day 2

Pre-bright Pre-bright light exposure light exposure stage stage

Red dim light Red dim light Day1: Data served Day1: Data served as adaptationas adaptation

Day 2: Data served Day 2: Data served as baseline as baseline

Day 3-Day 7Day 3-Day 7

Bright white Bright white light exposure light exposure stage stage

Bright white Bright white light light

Data served asData served as

experimental data experimental data

Day 8-Day 14Day 8-Day 14

Post-bright Post-bright light exposure light exposure stage stage

Red dim light Red dim light Data served as Data served as experimental dataexperimental data

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 procedureData collection procedure

Schedule of the studySchedule of the studyDate 4/8/2004

(Wed)5/8(Thu)

6/8(Fri)

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)

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14

  Pre-bright light exposure stage (Adaptation)

Pre-bright light exposure stage (Baseline)

Bright Light Exposure Stage Post-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.

 

Study protocolStudy protocol

Always began and ended on Always began and ended on weekdays weekdays

-due to mood changes caused by the -due to mood changes caused by the subjects being taken out by relativessubjects being taken out by relatives

Maintain constant room temperatureMaintain constant room temperature

Keep subjects’ concentrationKeep subjects’ concentration

InstrumentsInstruments

1. Preliminary screening assessment1. Preliminary screening assessment

2. Sleep log2. Sleep log

InstrumentsInstruments1.1. A preliminary screening assessment:A preliminary screening assessment:

- Questionnaire adopted from The Hong Kong Questionnaire adopted from The Hong Kong polytechnic University sleep research team polytechnic University sleep research team (Ho et al. (Ho et al. 2002)2002)

- Content validity index (CVI): 0.92,Content validity index (CVI): 0.92, Pearson r : 0.87Pearson r : 0.87

Two parts in the questionnaire:Two parts in the questionnaire:1.1. A screening assessmentA screening assessment2.2. A preliminary assessmentA preliminary assessment

Instruments (con’t)Instruments (con’t)

1. 1. Screening assessment: Screening assessment: To screen eligible To screen eligible subjectsubject

- Demographic data:- Demographic data:

age, sex , height , weight , health status, age, sex , height , weight , health status, physical and psychological illnessphysical and psychological illness

- Sleep history : - Sleep history : What, when, how, how long does the What, when, how, how long does the sleep problem sleep problem

Instrument (con’t)Instrument (con’t)

2. 2. Preliminary assessmentPreliminary assessment : : Understand the sleep history of the subjectsUnderstand the sleep history of the subjects

I. Sleep habits I. Sleep habits

II. life style (sleep relatedII. life style (sleep related))

Appendix 1Appendix 1 The Hong Kong Polytechnic University The Hong Kong Polytechnic University Date: ________ Date: ________ Department of Nursing and Health Sciences Department of Nursing and Health Sciences Code: ________Code: ________ Screening AssessmentScreening AssessmentPart I Demographic InformationPart I Demographic InformationPlease put a Please put a in the appropriate box. in the appropriate box.1. Age: _____ 1. Age: _____ 2. Sex: _____2. Sex: _____3. Body Height: _____ (cm / ft & in)3. Body Height: _____ (cm / ft & in)4. Body Weight: _____ (kg / lbs)4. Body Weight: _____ (kg / lbs)5. How do you describe your present health status?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)?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 commencemAre you taking any medication(s)? Please specify the medication(s) with dosage, frequency, date of commencement & any reaction(s) related to the medication(s).ent & any reaction(s) related to the medication(s). ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________8. How do you describe your sleep status at night?8. How do you describe your sleep status at night? Very good Very good Good Good

Acceptable Acceptable Poor Poor Very poor Very poor 9. How do you feel upon arising?9. How do you feel upon arising? Refreshed Refreshed Acceptable Acceptable Still tired Still tired Sleepy Sleepy 10. Do you sleep alone? 10. Do you sleep alone? Yes Yes No No 11. Do you use any sleep aids? Please describe.11. Do you use any sleep aids? Please describe. ________________________________________________________________ ________________________________________________________________ Part II Sleep HistoryPart II Sleep History1. How long have you been suffering from sleep disturbance?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?2. How many night(s) a week do you have sleep disturbance? ____ nights per week____ nights per week3. How do you describe the onset of your sleep disturbance? 3. How do you describe the onset of your sleep disturbance? GradualGradual Sudden Sudden 4. How do you describe your course of sleep disturbance? 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?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

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)?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?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?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?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?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 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?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 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 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?15. For the past couple of years, have you been bothered by depressed mood? Frequently Frequently Sometimes Sometimes Rarely Rarely Never Never

InstrumentInstrumentssPreliminary assessment (con’t)Preliminary assessment (con’t)

I. I. Sleep habitsSleep habits: : Bed timeBed time Sleep onset latency (SOL)Sleep onset latency (SOL) Wake after sleep onset (WASO)Wake after sleep onset (WASO) Sleep offset time (SoffT)Sleep offset time (SoffT) Rising time and nappingRising time and napping

InstrumentsInstrumentsPreliminary assessment (con’t)Preliminary assessment (con’t)

II. II. Life styleLife style (sleep related): (sleep related):

- smoking smoking

- caffeinated food, drinkcaffeinated food, drink

- alcohol consumptions alcohol consumptions

- dairy products consumptions dairy products consumptions

- exercise, outdoor sunlight exposureexercise, outdoor sunlight exposure

- snack consumptionssnack consumptions

Instruments (con’t)Instruments (con’t)2.2. A sleep log A sleep log (Self-description of sleep)(Self-description of sleep)

Only the individual can judge his or her sleep is goOnly the individual can judge his or her sleep is good or not. od or not. ((Closs,1997)Closs,1997)

Evaluate the subjective sleep condition throughout Evaluate the subjective sleep condition throughout the studythe study

Advantage: sleep efficiency and subjective Advantage: sleep efficiency and subjective sleep descriptive data can be sleep descriptive data can be estimated. estimated.

Disadvantage : less validity on sleep Disadvantage : less validity on sleep durations and sleep-wake durations and sleep-wake activit activity y (Reidk,& Daso,1999)(Reidk,& Daso,1999)

Instruments Instruments Sleep logSleep log (Ho et al. 2002)(Ho et al. 2002)

Subjective reporting of sleep wake Subjective reporting of sleep wake parameterparameter

Entries for bedtime,Entries for bedtime, Arising time, Arising time, Sleep latency, Sleep latency, Number and duration of awakenings , Number and duration of awakenings , Sleep durationsSleep durations Naps (Lacks P. 1987)Naps (Lacks P. 1987)

Self –reported satisfaction of sleepSelf –reported satisfaction of sleep A five-point subjective rating scale (very good to very A five-point subjective rating scale (very good to very

poor)poor)

InstrumentsInstrumentsSleep log (con’t)Sleep log (con’t)

Data obtained in the sleep log incorporateData obtained in the sleep log incorporates with the actigraphy, compensate each ots with the actigraphy, compensate each other her

Helps to evaluate the effect of this study. Helps to evaluate the effect of this study.

The sleep logThe sleep logAppendix IIAppendix II

The Hong Kong Polytechnic University The Hong Kong Polytechnic University Date: _____________ Date: _____________ School of Nursing School of Nursing Code: _____________ Code: _____________ Sleep Log Sleep Log Day ______________Day ______________Please put a Please put a in the appropriate box. in the appropriate box.1. What was your final awakening time? _________ 1. What was your final awakening time? _________ 2. What was your final arising time? _________ 2. What was your final arising time? _________ 3. Did you go to bed in the morning (before 1200 hours)?3. Did you go to bed in the morning (before 1200 hours)? Time Lying AsleepTime 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)?4. Did you doze in the morning (before 1200 hours)? Time AsleepTime 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)?5. Did you go to bed in the afternoon (before 1800 hours)? Time Lying AsleepTime 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)?6. Did you doze in the afternoon (before 1800 hours)? Time AsleepTime 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)?7. Did you go to bed in the evening (after 1800 hours)? Time Lying AsleepTime 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)?8. Did you doze in the evening (after 1800 hours)? Time AsleepTime 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? _________9. When did you turn off the light? _________10. When did you go to bed? _________10. When did you go to bed? _________11. How long did you take to fall asleep? _______ min(s) / hour(s)11. How long did you take to fall asleep? _______ min(s) / hour(s)12. Did you have any trouble in falling asleep?12. Did you have any trouble in falling asleep? No.No. Yes. Why? __________________________________________________________________________________Yes. Why? __________________________________________________________________________________13. Did you awake during the night?13. Did you awake during the night?

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 frequentlyGo to toilet frequently Temperature: too cold or too hot Temperature: too cold or too hot Too noisy Too noisy Physical discomfortPhysical discomfort I don’t know I don’t know Others: _____________________________________________________________________________________Others: _____________________________________________________________________________________ What did you do in the awakening(s)?What did you do in the awakening(s)? Get up to do something (eg _______________________________) till sleepyGet up to do something (eg _______________________________) till sleepy Go to toiletGo to toilet Take sleeping pills Take sleeping pills Still rest on bed Still rest on bed Others: ____________________________________________________________________________________Others: ____________________________________________________________________________________ Awakening TimeAwakening Time Duration Duration ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) ______________ _______ min(s) 14. How did you describe your sleep?14. How did you describe your sleep? Very good Very good Good Good Acceptable Acceptable Poor Poor Very poor Very poor15. How did you feel upon arising?15. How did you feel upon arising? Refreshed Refreshed Acceptable Acceptable Still tired Still tired Sleepy Sleepy 16. Had you taken any medication(s)? Please describe.16. Had you taken any medication(s)? Please describe. ____________________________________________________________________________________________________________________________________________________________________________________________17. Did you have any physical discomfort that affected your sleep? Please describe.17. Did you have any physical discomfort that affected your sleep? Please describe. ____________________________________________________________________________________________________________________________________________________________________________________________18. Did you consume any caffeinated food or drink?18. Did you consume any caffeinated food or drink? No.No. Yes. The caffeinated food or drink was/were: Yes. The caffeinated food or drink was/were: Chinese Tea Chinese Tea Coffee Coffee Western Tea Western Tea Others: ___________ 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?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?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)?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? 22. Did you do execrise? Time Duration Place Time Duration Place In the morning (before 1200 hours) _______ min(s) Indoor / OutdoorIn 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? 23. Did you have outdoor sunlight exposure? Time Duration 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? _________24. When did you have your dinner? _________25. Had you eaten snack before bedtime?25. Had you eaten snack before bedtime? No.No. Yes. Please describe: ______________________________________________________________ Yes. Please describe: ______________________________________________________________

EquipmentsEquipmentsBright Light exposure stage: (white brigBright Light exposure stage: (white bright light) ht light)

1. Four bright light boxes. @ 250W Lamp ( Osram, 1. Four bright light boxes. @ 250W Lamp ( Osram, made in Germany)made in Germany)

2. Illuminant meter2. Illuminant meter Ensure 2500 lux to each subject face.Ensure 2500 lux to each subject face.

high light intensity can suppress melatonin secrehigh light intensity can suppress melatonin secretion tion (Dollins A.B.& lynch H.J. et al, 1993)(Dollins A.B.& lynch H.J. et al, 1993)

Equipments (con’t)Equipments (con’t)Pre and post bright light exposure stage: (red Pre and post bright light exposure stage: (red dim light)dim light)

1. Two light boxes each contain six red globes @1. Two light boxes each contain six red globes @15W in 1 meter away. 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 secretiolow light intensity no effect on melatonin secretion n (Trinder J, & Armstron S.M.)(Trinder J, & Armstron S.M.)

Red light wavelength no effect on melatonin secrRed light wavelength no effect on melatonin secretion etion ( Wright H.R. & Lack L.C., 2001)( Wright H.R. & Lack L.C., 2001)

Equipments (con’t)Equipments (con’t)Wrist Actigraph:Wrist Actigraph: For record a subject’s movement over a period oFor record a subject’s movement over a period of study (two weeks) f study (two weeks) (Wykpisz et al, 1998)(Wykpisz et al, 1998)

- Total numbers of sleep minutes / Total sleep timTotal numbers of sleep minutes / Total sleep timee

- Actual bed time/ Time to sleep onset Actual bed time/ Time to sleep onset - Periods of wakefulness/ Wake after sleep onsetPeriods of wakefulness/ Wake after sleep onset- Subthreshold activity/ Sleep efficiencySubthreshold activity/ Sleep efficiency

Wrist of non-dominant hand Wrist of non-dominant hand (Wykpisz et al, 1998)(Wykpisz et al, 1998)

Equipments (con’t)Equipments (con’t)Advantage:Advantage:

- EEG and wrist actigraph estimates of total EEG and wrist actigraph estimates of total sleep time were highly correlated , coefficisleep time were highly correlated , coefficient: r =+0.98 ent: r =+0.98 (Kripke et al, 1980)(Kripke et al, 1980)

More cost-effectiveMore cost-effective Easier to useEasier to use Less invasive and less expensiveLess invasive and less expensive More objective data compare to sleep lMore objective data compare to sleep l

og.og.

Equipments (con’t)Equipments (con’t)

Disadvantage: Disadvantage:

- Underestimate wake and overestimate sleUnderestimate wake and overestimate sleep . For example:ep . For example:

immobile sleep, immoblile waking immobile sleep, immoblile waking (Webster (Webster

et al)et al), , Overestimate of activity e.g.tremors,Overestimate of activity e.g.tremors,(Labye(Labye

k &Bourguignon., 2002)k &Bourguignon., 2002)

Ethical considerationsEthical considerations

Three major ethical principles: Three major ethical principles:

1.1. BeneficenceBeneficence

2.2. Respect for human dignity andRespect for human dignity and

3.3. Justice. Justice. (Polit, 2001)(Polit, 2001)

Ethical Considerations (con’t)Ethical Considerations (con’t)The bright light intensity chosen at the optimal The bright light intensity chosen at the optimal level in preventing eye/retinal damage.level in preventing eye/retinal damage.

Effective bright light intensity from 2000-3000lEffective bright light intensity from 2000-3000lux for several hours; 10000lux for 15mins-1 houx for several hours; 10000lux for 15mins-1 hour ur (Kripke, 1998, Lam, & Levitt, 1999).(Kripke, 1998, Lam, & Levitt, 1999).

Two type of lesions must be considered for briTwo type of lesions must be considered for bright light therapy: acute and chronic cumulative ght light therapy: acute and chronic cumulative damage, e.g. cornea and conjunctiva lesions. damage, e.g. cornea and conjunctiva lesions. (Young R.W., 1994)(Young R.W., 1994)

Ethical considerations (con’t)Ethical considerations (con’t)

Subjects are able to drop out freely.Subjects are able to drop out freely.

Inform and consent.Inform and consent.

Approval from PolyU and the old-aged hoApproval from PolyU and the old-aged home engagedme engaged

Data are confidential and used in this studData are confidential and used in this study onlyy only

Data analysisData analysisDemographic data will be presented in the Demographic data will be presented in the form of frequency, mean, mode, range and form of frequency, mean, mode, range and standard deviation using descriptive standard deviation using descriptive statistic.statistic.For the sleep-related factors, for example, For the sleep-related factors, for example, caffeine or medication intake, milk or caffeine or medication intake, milk or snake before bed, dinner timesnake before bed, dinner time

frequency count and percentage frequency count and percentage calculation will be conducted. calculation will be conducted.

Data analysisData analysisActigraphic dataActigraphic data

Sleep-wake parameters will be counted and Sleep-wake parameters will be counted and calculated.calculated.

sleep onset, sleep latency (time between sleep onset, sleep latency (time between retiring and onset of sleep), retiring and onset of sleep),

total sleep time, total sleep time, number frequency of awakenings, number frequency of awakenings, awaking time andawaking time andsleep efficiency (the percentage of time in sleep efficiency (the percentage of time in

bed /spend asleepbed /spend asleep

Data analysisData analysisActigraphic data (con’t)Actigraphic data (con’t)

mean of the sleep onset latency, mean of the sleep onset latency,

mean of sleep efficiencymean of sleep efficiency

standard deviation of sleep onset latency, standard deviation of sleep onset latency, andand

standard deviation of sleep efficiency standard deviation of sleep efficiency

are actigrapic transformed.are actigrapic transformed.

Data analysis Data analysis Sleep logSleep log

Subjective satisfaction of sleep and self-Subjective satisfaction of sleep and self-reported descriptive data will be obtainedreported descriptive data will be obtained

Data analysisData analysisSleep log (Sleep log (subjective reporting of sleep-subjective reporting of sleep-

wake parameter)wake parameter)

Three subjective sleep variables Three subjective sleep variables averaged sleep onset latency,averaged sleep onset latency,averaged sleep efficiency andaveraged sleep efficiency andaveraged night waking time averaged night waking time

will be log transformed will be log transformed

Data analysisData analysisSleep logSleep log

Subjective data: sleep satisfaction levelSubjective data: sleep satisfaction level

Data derived from Question 14 and 15 in Data derived from Question 14 and 15 in the sleep log; the sleep log;

Data analysis: Any changes in Data analysis: Any changes in the sleep latency and self the sleep latency and self

efficiency in the elderly people efficiency in the elderly people after bright light exposure?after bright light exposure?

Data measurementData measurement

Data are presented in minutes (sleep Data are presented in minutes (sleep latency) and percentage (sleep efficiency), latency) and percentage (sleep efficiency),

It is a kind of ratio measurement which are It is a kind of ratio measurement which are the dependent variable from the bright the dependent variable from the bright light exposure. light exposure.

The test usedThe test used

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

The data for analysisThe 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 and1st: is means of sleep latency and- 2nd: means of sleep efficiency from self-reported 2nd: means of sleep efficiency from self-reported

data of the sleep logsdata of the sleep logs

before and after the experiment; before and after the experiment; - 3rd: means of sleep latency and 3rd: means of sleep latency and - 4th: means sleep efficiency from actigraphic dat4th: means sleep efficiency from actigraphic dat

a a

before and after the experiment; before and after the experiment;

Data analysis: any changes in Data analysis: any changes in the awaking time in the elderly the awaking time in the elderly

people after bright light people after bright light exposure?exposure?

Averaged number of awaking hours Averaged number of awaking hours Advanced or delayed hours will be Advanced or delayed hours will be

calculatedcalculated

Data analysis: Any changes in Data analysis: Any changes in the sleep satisfaction level in the the sleep satisfaction level in the elderly people after bright light elderly people after bright light

exposure?exposure?

When comparing two sets of results, with sWhen comparing two sets of results, with signed rank test; wilcoxon test can be appliigned rank test; wilcoxon test can be applied. (Gunn C., 2001) ed. (Gunn C., 2001)

Medians of the subjective sleep satisfactioMedians of the subjective sleep satisfaction level before and after experiment will be n level before and after experiment will be estimated; estimated;

p value will be obtained. p value will be obtained.

Data Analysis: Any change in the Data Analysis: Any change in the sleep efficiency, sleep latency, sleep efficiency, sleep latency,

awaking time, sleep satisfaction awaking time, sleep satisfaction after the stage 3 (the 7 days of after the stage 3 (the 7 days of

post-bright light exposure)post-bright light exposure)

Similar as that done for the data in stage 1 Similar as that done for the data in stage 1 and 2; and 2;

the duration of the effectiveness bright the duration of the effectiveness bright light effect will be illustrated. light effect will be illustrated.

LimitationsLimitations

1.1. Decrease generalizationDecrease generalization

2.2. Convenience sampling Convenience sampling biased result biased result (Portney & Watkins, 1993)(Portney & Watkins, 1993)

Individuals who desire to improve their slIndividuals who desire to improve their sleep quality.eep quality.

3. Environmental factors, for example, room 3. Environmental factors, for example, room temperature.temperature.

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THANK YOUTHANK YOU

Any questions?Any questions?

Why old-aged home residents?Why old-aged home residents?Extremely ragmented sleep in older adults living in nursinExtremely ragmented sleep in older adults living in nursing homes g homes (Ancoli-Israel S. et. al., 1989).(Ancoli-Israel S. et. al., 1989).

Institutionalized patients aged 60-100 year of aaged with Institutionalized patients aged 60-100 year of aaged with mild, moderate or no dementia spent a median of 9 mins mild, moderate or no dementia spent a median of 9 mins exposed to light above 1000 lux. (exposed to light above 1000 lux. (Ancoli-Israel et. al., 1997)Ancoli-Israel et. al., 1997) 17% of the investigated 77 nursing homes patients were 17% of the investigated 77 nursing homes patients were never exposed to light over 1000 lux, and 26% were nevnever exposed to light over 1000 lux, and 26% were never exposed to light over 200 lux on any of the 3 days durier exposed to light over 200 lux on any of the 3 days during the investigation (ng the investigation (Shochat et. al., 2000),Shochat et. al., 2000),

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