Effects on subjective and objective alertness and sleep in response to evening light exposure in older subjects

The bright and dark side of blue-enriched light on sleep and activity in older adults

Low indoor light in urban housing can disrupt health and wellbeing, especially in older adults who experience reduced light sensitivity and sleep/circadian disruptions with natural aging. While controlled studies suggest that enhancing indoor lighting may alleviate the negative effects of reduced light sensitivity, evidence for this to be effective in the real world is lacking. This study investigates the effects of two light conditions on actigraphic rest-activity rhythms and subjective sleep in healthy older adults (≥ 60 years) living at home. Two photon-matched lights were compared; a control white light (4000 K) and a blue-enriched white light (17000 K) at two different intensities (300-450 lx and 1100-1200 lx respectively). Participants (n = 36, 25 female) completed an 11-week randomized, cross-over study, comprising 1 week of baseline, 3 weeks of self-administered light exposure (2 h in the morning and 2 h in the evening), and 2 weeks of washout for each light condition. Participants completed sleep diaries, wore a wrist actigraph and a light sensor necklace, and collected urine to measure 6-sulphatoxymelatonin. Longer duration of morning blue-enriched light significantly improved rest-activity rhythm stability and decreased sleep fragmentation. More time spent above 2500 lx increased actigraphy amplitude, daytime activity, and advanced bedtime. Evening light exposure, however, increased sleep latency and lowered sleep efficiency. Our findings show morning blue-enriched light is beneficial whereas evening light should be avoided. Optimal timing of self-administered light interventions thus may offer a promising strategy to improve sleep and rest-activity rhythms in older adults in real-world settings.

Time-Dependent Effects of Altered Prebedtime Light Exposure in Enclosed Spaces on Sleep Performance Associated with Human States

Purpose

Exposure to artificial light influences human performance, which is essential for maintaining healthy work and sleep. However, existing research has not explored the intrinsic links between sleep performance and human states over time under prebedtime light exposure interventions (LEIs).

Methods

To investigate the time-dependent effects of altered prebedtime light exposure, four LEI groupings (#L1 - #L4) and a Time factor (D8, D9, and D10) were chosen for sleep experiments in enclosed spaces. Forty-eight young adults recruited were available for data analysis. Subjective alertness (SA), negative affect (NA), subjective sleep, and objective sleep were measured via the Karolinska Sleepiness Scale, Positive and Negative Affect Schedule, Next-day Self-assessment Sleep Quality, and joint assessment of wrist actigraphy and sleep diaries, respectively. Statistical analysis was used for the effects of light exposure on the human states (corresponding to the SA and NA) and sleep performance, while the process model helped construct the associations between the two.

Results

The statistical effects revealed that the Time had a significant main effect on subjective sleep and changes in prebedtime alertness; the LEI had a significant main effect only on sleep onset latency (SOL). After undergoing altered prebedtime light exposure, the mean SA increased at prebedtime of D9 (p = 0.022) and D10 (p = 0.044); No significant effect on the NA was observed; Mean subjective sleep had a significant increase from D8 to D10. Moreover, five actigraphy-estimated sleep parameters were interrelated. In light of this, a chained pathway relationship was identified. The SOL played a mediating predictor between prebedtime state and objective sleep, which was linked to the awakening state through subjective sleep.

Conclusion

Our study suggests that time-dependent effects of altered prebedtime light exposure on sleep performance are associated with human states at prebedtime and awakening, with implications for its prediction of sleep health.

Effects of calibrated blue-yellow changes in light on the human circadian clock

Evening exposure to short-wavelength light can affect the circadian clock, sleep and alertness. Intrinsically photosensitive retinal ganglion cells expressing melanopsin are thought to be the primary drivers of these effects. Whether colour-sensitive cones also contribute is unclear. Here, using calibrated silent-substitution changes in light colour along the blue-yellow axis, we investigated whether mechanisms of colour vision affect the human circadian system and sleep. In a 32.5-h repeated within-subjects protocol, 16 healthy participants were exposed to three different light scenarios for 1 h starting 30 min after habitual bedtime: baseline control condition (93.5 photopic lux), intermittently flickering (1 Hz, 30 s on-off) yellow-bright light (123.5 photopic lux) and intermittently flickering blue-dim light (67.0 photopic lux), all calibrated to have equal melanopsin excitation. We did not find conclusive evidence for differences between the three lighting conditions regarding circadian melatonin phase delays, melatonin suppression, subjective sleepiness, psychomotor vigilance or sleep.The Stage 1 protocol for this Registered Report was accepted in principle on 9 September 2020. The protocol, as accepted by the journal, can be found at https://doi.org/10.6084/m9.figshare.13050215.v1 .

Effectiveness of caffeine and blue-enriched light on cognitive performance and electroencephalography correlates of alertness in a spaceflight robotics simulation

Human cognitive impairment associated with sleep loss, circadian misalignment and work overload is a major concern in any high stress occupation but has potentially catastrophic consequences during spaceflight human robotic interactions. Two safe, wake-promoting countermeasures, caffeine and blue-enriched white light have been studied on Earth and are available on the International Space Station. We therefore conducted a randomized, placebo-controlled, cross-over trial examining the impact of regularly timed low-dose caffeine (0.3 mg per kg per h) and moderate illuminance blue-enriched white light (~90 lux, ~88 melEDI lux, 6300 K) as countermeasures, separately and combined, in a multi-night simulation of sleep-wake shifts experienced during spaceflight among 16 participants (7 F, ages 26-55). We find that chronic administration of low-dose caffeine improves subjective and objective correlates of alertness and performance during an overnight work schedule involving chronic sleep loss and circadian misalignment, although we also find that caffeine disrupts subsequent sleep. We further find that 90 lux of blue-enriched light moderately reduces electroencephalogram (EEG) power in the theta and delta regions, which are associated with sleepiness. These findings support the use of low-dose caffeine and potentially blue-enriched white light to enhance alertness and performance among astronauts and shiftworking populations.

Light therapy in insomnia disorder: A systematic review and meta-analysis

In the management of insomnia, physicians and patients are seeking alternative therapeutics to sleeping pills, in addition to sleep hygiene and cognitive behavioural therapy. Bright light therapy (LT) has proven its efficacy in circadian and mood disorders. We conducted a systematic literature review and meta-analysis according to Cochrane and PRISMA guidelines and using the databases Medline, Cochrane, and Web of Science, with a special focus on light therapy and insomnia. Twenty-two studies with a total of 685 participants were included, five of which with a high level of proof. Meta-analysis was performed with 13 of them: light therapy for insomnia compared with control conditions significantly improved wake after sleep onset (WASO: SMD = -0.61 [-1.11, -0.11]; p = 0.017; weighted difference of 11.2 min ±11.5 based on actigraphy, and SMD = -1.09 [-1.43, -0.74] (p < 0.001) weighted difference of -36.4 min ±15.05) based on sleep diary, but no other sleep measures such as sleep latency, total sleep time (TST), or sleep efficiency. Qualitative analysis of the review showed some improvement mainly in subjective measures. Morning light exposure advanced sleep-wake rhythms and evening exposure led to a delay. No worsening was observed in objective nor subjective measures, except for TST in one study with evening exposure. A light dose-response may exist but the studies' heterogeneity and publication bias limit the interpretation. To conclude, light therapy shows some effectiveness for sleep maintenance in insomnia disorders, but further research is needed to refine the light parameters to be chosen according to the type of insomnia, in the hope of developing personalised therapeutics.

Seasonal Variation in the Responsiveness of the Melanopsin System to Evening Light: Why We Should Report Season When Collecting Data in Human Sleep and Circadian Studies

It is well known that variations in light exposure during the day affect light sensitivity in the evening. More daylight reduces sensitivity, and less daylight increases it. On average days, we spend less time outdoors in winter and receive far less light than in summer. Therefore, it could be relevant when collecting research data on the non-image forming (NIF) effects of light on circadian rhythms and sleep. In fact, studies conducted only in winter may result in more pronounced NIF effects than in summer. Here, we systematically collected information on the extent to which studies on the NIF effects of evening light include information on season and/or light history. We found that more studies were conducted in winter than in summer and that reporting when a study was conducted or measuring individual light history is not currently a standard in sleep and circadian research. In addition, we sought to evaluate seasonal variations in a previously published dataset of 72 participants investigating circadian and sleep effects of evening light exposure in a laboratory protocol where daytime light history was not controlled. In this study, we selectively modulated melanopic irradiance at four different light levels (<90 lx). Here, we aimed to retrospectively evaluate seasonal variations in the responsiveness of the melanopsin system by combining all data sets in an exploratory manner. Our analyses suggest that light sensitivity is indeed reduced in summer compared to winter. Thus, to increase the reproducibility of NIF effects on sleep and circadian measures, we recommend an assessment of the light history and encourage standardization of reporting guidelines on the seasonal distribution of measurements.

Night-to-night associations between light exposure and sleep health

Previous research has demonstrated that exposure to light preceding and during sleep is associated with poor sleep, but most research to date has utilized either experimental or cross-sectional designs. The current study expands upon prior studies by using a microlongitudinal design that examines the night-to-night associations between light and sleep health in a diverse sample of adults (pre-registered at osf.io/k5zgv). US adults aged 18-87 years from two parent studies (N = 124) wore an actiwatch for up to 10 nights. Light variables estimated from actigraphy include both average exposure and time above light threshold of 10 (TALT10 ) and 40 (TALT40 ) lux both during sleep and for the 1-hr preceding sleep. Actigraphy-based sleep variables included sleep offset, duration, percentage and fragmentation index. Higher average light exposure during sleep was associated with a later sleep-offset time, lower sleep percentage and higher fragmentation index (all p < 0.01). More minutes of TALT10 during sleep was associated with later sleep timing, lower sleep percentage and higher fragmentation index (all p < 0.01), and greater TALT40 during sleep was associated with lower sleep percentage. Light exposure was not related to sleep duration. In summary, greater light exposure during sleep was related to poorer sleep continuity and later wake time. The lack of association between light and sleep duration may be the result of compensating for sleep disruption by delaying wake time. Multi-level interventions to consistently reduce light levels during sleep should be considered.

Evening light environments can be designed to consolidate and increase the duration of REM-sleep

Evening exposure to short-wavelength light has disruptive effects on circadian rhythms and sleep. These effects can be mitigated by blocking short-wavelength (blue) frequencies, which has led to the development of evening blue-depleted light environments (BDLEs). We have previously reported that residing 5 days in an evening BDLE, compared with residing in a normal indoor light environment of similar photopic lux, advances circadian rhythms and increases the duration of rapid eye movement (REM) sleep in a randomized cross-over trial with twelve healthy participants. The current study extends these findings by testing whether residing in the evening BDLE affects the consolidation and microstructure of REM sleep in the same sample. Evening BDLE significantly reduces the fragmentation of REM sleep (p = 0.0003), and REM sleep microarousals in (p = 0.0493) without significantly changing REM density or the latency to first REM sleep episode. Moreover, the increased accumulation of REM sleep is not at the expense of NREM stage 3 sleep. BDLE further has a unique effect on REM sleep fragmentation (p = 0.0479) over and above that of circadian rhythms phase-shift, indicating a non-circadian effect of BDLE. If these effects can be replicated in clinical populations, this may have a therapeutic potential in disorders characterized by fragmented REM sleep.

Treatment of Circadian Rhythm Sleep-Wake Disorders

Circadian rhythm sleep-wake disorders (CRSWDs) are a distinct class of sleep disorders caused by alterations to the circadian time-keeping system, its entrainment mechanisms, or a mismatch between the endogenous circadian rhythm and the external environment. The main clinical manifestations are insomnia and excessive daytime sleepiness that often lead to clinically meaningful distress or cause mental, physical, social, occupational, educational, or other functional impairment. CRSWDs are easily mistaken for insomnia or early waking up, resulting in inappropriate treatment. CRSWDs can be roughly divided into two categories, namely, intrinsic CRSWDs, in which sleep disturbances are caused by alterations to the endogenous circadian rhythm system due to chronic changes in the regulation or capture mechanism of the biological clock, and extrinsic circadian rhythm sleep-wake disorders, in which sleep disorders, such as jet lag or shift-work disorder, result from environmental changes that cause a mismatch between sleep-wakefulness times and internal circadian rhythms. Sleep diaries, actigraphy, and determination of day and night phase markers (dim light melatonin onset and core body temperature minimum) have all become routine diagnostic methods for CRSWDs. Common treatments for CRSWD currently include sleep health education, time therapy, light therapy, melatonin, and hypnotic drug therapy. Here, we review the progress in the epidemiology, etiology, diagnostic evaluation, diagnostic criteria, and treatment of intrinsic CRSWD, with emphasis on the latter, in the hope of bolstering the clinical diagnosis and treatment of CRSWDs.

Effects of morning and evening exposures to blue light of varying illuminance on ocular growth rates and ocular rhythms in chicks

Recent evidence indicates that moderate levels of blue light are sufficient to suppress the nighttime rise in serum melatonin in humans, suggesting that luminous screens may be deleterious to sleep cycles and to other functions. Little is known however, about the effects of exposures to blue light on ocular physiology. We tested the effects of transient blue light exposures of various illuminances on ocular growth rates and ocular rhythms in chicks. 10-day old chicks were exposed to narrow band blue light (460 nm) of specific illuminance for 4 h in the evening (ZT8-ZT12) or the morning (ZT0-ZT4) for 9 days; for the remainder of the day they were in white light (588 lux). For the evening, four illuminances were tested: 0.15 lux (n = 15), 200 lux (radiometrically matched to white controls; n = 16), 600 lux (photometrically matched to white controls; n = 15) or 1000 lux (n = 8). The 600 lux condition was also tested using a 2-h duration (n = 8). The 200 and 600 lux conditions were extended to 14 and 21 days (n = 8 each). For morning exposures, 200 lux (n = 9), 600 lux (n = 9) and 1000 lux (n = 8) were tested. Controls remained in white light (n = 23). Ocular dimensions were measured by A-scan ultrasonography on days 1 and 9 to assess growth rates. On day 8 or 9, measurements were made at 6-h intervals over 24 h starting at noon to assess rhythm parameters. Evening exposure to blue light stimulated ocular growth rates relative to controls for all except the bright condition (0.15 lux, 200 lux, 600 lux vs bright and white respectively: 845 μm, 838 μm, 898 μm vs 733 μm and 766 μm; p < 0.05 for all comparisons). 2 h exposures to 600 lux were similarly effective (915 μm vs 766 μm; p < 0.05). Morning exposures only resulted in growth stimulation for the 200 lux condition (200 lux vs white: 884 μm vs 766 μm; p < 0.05). Furthermore, for this group only, growth of the anterior chamber had a significant contribution to the overall effect (vs white: p < 0.05), and choroids showed significant thickening. For evening exposures to 200 and 600 lux, the growth stimulatory effect lasted for 14 days (p = 0.01); by 21 days only the 600 lux group still differed (p < 0.0001). Evening exposures caused circadian disruptions in the choroidal thickness rhythms, and morning exposures disrupted both axial and choroidal rhythms. Exposure to 4 h of blue light at lower illuminances (less than 1000 lux) at transition times of lights-on and lights-off stimulates ocular growth rates and affects ocular rhythms in chicks, suggesting that such exposures may be deleterious to emmetropization in children.

Effects of nocturnal light exposure on circadian rhythm and energy metabolism in healthy adults: A randomized crossover trial

Exposure to continuous light at night, including night-shift work or a nocturnal lifestyle, is emerging as a novel deleterious factor for weight gain and obesity. Here, we examined whether a single bout of bright light (BL) exposure at night affects energy metabolism via changes in circadian rhythm and nocturnal melatonin production. Ten healthy young men were randomized to a two-way crossover experimental design protocol: control (< 50 lux) and BL (approximately 10000 lux) conditions, with at least seven days of interval. The participants were exposed to each condition for 3 h (21:00-24:00) before sleep (0 lux, 00:00-07:00) in a room-type metabolic chamber. On each experimental night (21:00-07:00), energy expenditure, respiratory quotient (RQ), and substrate oxidation were measured to determine the energy metabolism. BL exposure prior to bedtime altered biological rhythms, disrupted the nocturnal decline in body temperature, and suppressed the melatonin level before sleeping, resulting in an increase in sleep latency. Indirect calorimetry data revealed that BL exposure significantly decreased the fat oxidation and increased the RQ, an indicator of the carbohydrate-to-fat oxidation ratio, throughout the whole period (light exposure and sleep). We revealed that acute BL exposure prior to bedtime exacerbated circadian rhythms and substrate oxidations, suggesting that chronic BL exposure at night may lead to obesity risk due to disturbances in circadian rhythms and macronutrient metabolism.

A longitudinal study of morning, evening, and night light intensities and nocturnal sleep quality in a working population

We aimed to investigate whether higher light intensity in the morning is associated with better nocturnal sleep quality and whether higher light intensities in the evening or night have the opposite effect. Light intensity was recorded for 7 consecutive days across the year among 317 indoor and outdoor daytime workers in Denmark (55-56° N) equipped with a personal light recorder. Participants reported sleep quality after each nocturnal sleep. Sleep quality was measured using three parameters; disturbed sleep index, awakening index, and sleep onset latency. Associations between increasing light intensities and sleep quality were analyzed using mixed effects models with participant identity as a random effect. Overall, neither white nor blue light intensities during morning, evening, or night were associated with sleep quality, awakening, or sleep onset latency of the subsequent nocturnal sleep. However, secondary analyses suggested that artificial light during the morning and day contrary to solar light may increase vulnerability to evening light exposure. Altogether, we were not able to confirm that higher morning light intensity significantly improves self-reported sleep quality or that higher evening or night light intensities impair self-reported sleep quality at exposure levels encountered during daily life in a working population in Denmark. This suggests that light intensities alone are not important for sleep quality to a degree that it is distinguishable from other important parameters in daily life settings.

Sleep in Normal Aging, Homeostatic and Circadian Regulation and Vulnerability to Sleep Deprivation

In the context of geriatric research, a growing body of evidence links normal age-related changes in sleep with many adverse health outcomes, especially a decline in cognition in older adults. The most important sleep alterations that continue to worsen after 60 years involve sleep timing, (especially early wake time, phase advance), sleep maintenance (continuity of sleep interrupted by numerous awakenings) and reduced amount of sigma activity (during non-rapid eye movement (NREM) sleep) associated with modifications of sleep spindle characteristics (density, amplitude, frequency) and spindle-Slow Wave coupling. After 60 years, there is a very clear gender-dependent deterioration in sleep. Even if there are degradations of sleep after 60 years, daytime wake level and especially daytime sleepiness is not modified with age. On the other hand, under sleep deprivation condition, older adults show smaller cognitive impairments than younger adults, suggesting an age-related lower vulnerability to extended wakefulness. These sleep and cognitive age-related modifications would be due to a reduced homeostatic drive and consequently a reduced sleep need, an attenuation of circadian drive (reduction of sleep forbidden zone in late afternoon and wake forbidden zone in early morning), a modification of the interaction of the circadian and homeostatic processes and/or an alteration of subcortical structures involved in generation of circadian and homeostatic drive, or connections to the cerebral cortex with age. The modifications and interactions of these two processes with age are still uncertain, and still require further investigation. The understanding of the respective contribution of circadian and homeostatic processes in the regulation of neurobehavioral function with aging present a challenge for improving health, management of cognitive decline and potential early chronobiological or sleep-wake interventions.

Age-related neuroendocrine and alerting responses to light

Aging is associated with sleep and circadian alterations, which can negatively affect quality of life and longevity. Importantly, the age-related reduction in light sensitivity, particularly in the short-wavelength range, may underlie sleep and circadian alterations in older people. While evidence suggests that non-image-forming (NIF) light responses may diminish in older individuals, most laboratory studies have low sample sizes, use non-ecological light settings (e.g., monochromatic light), and typically focus on melatonin suppression by light. Here, we investigated whether NIF light effects on endogenous melatonin levels and sleep frontal slow-wave activity (primary outcomes), and subjective sleepiness and sustained attention (secondary outcomes) attenuate with aging. We conducted a stringently controlled within-subject study with 3 laboratory protocols separated by ~ 1 week in 31 young (18-30 years; 15 women) and 16 older individuals (55-80 years; eight women). Each protocol included 2 h of evening exposure to commercially available blue-enriched polychromatic light (6500 K) or non-blue-enriched light (3000 K or 2500 K) at low levels (~ 40 lx, habitual in evening indoor settings). Aging significantly affected the influence of light on endogenous melatonin levels, subjective sleepiness, sustained attention, and frontal slow-wave activity (interaction: P < 0.001, P = 0.004, P = 0.007, P = 0.001, respectively). In young individuals, light exposure at 6500 K significantly attenuated the increase in endogenous melatonin levels, improved subjective sleepiness and sustained attention performance, and decreased frontal slow-wave activity in the beginning of sleep. Conversely, older individuals did not exhibit signficant differential light sensitivity effects. Our findings provide evidence for an association of aging and reduced light sensitivity, with ramifications to sleep, cognition, and circadian health in older people.

Individual differences in light sensitivity affect sleep and circadian rhythms

Artificial lighting is omnipresent in contemporary society with disruptive consequences for human sleep and circadian rhythms because of overexposure to light, particularly in the evening/night hours. Recent evidence shows large individual variations in circadian photosensitivity, such as melatonin suppression, due to artificial light exposure. Despite the emerging body of research indicating that the effects of light on sleep and circadian rhythms vary dramatically across individuals, recommendations for appropriate light exposure in real-life settings rarely consider such individual effects. This review addresses recently identified links among individual traits, for example, age, sex, chronotype, genetic haplotypes, and the effects of evening/night light on sleep and circadian hallmarks, based on human laboratory and field studies. Target biological mechanisms for individual differences in light sensitivity include differences occurring within the retina and downstream, such as the central circadian clock. This review also highlights that there are wide gaps of uncertainty, despite the growing awareness that individual differences shape the effects of evening/night light on sleep and circadian physiology. These include (1) why do certain individual traits differentially affect the influence of light on sleep and circadian rhythms; (2) what is the translational value of individual differences in light sensitivity in populations typically exposed to light at night, such as night shift workers; and (3) what is the magnitude of individual differences in light sensitivity in population-based studies? Collectively, the current findings provide strong support for considering individual differences when defining optimal lighting specifications, thus allowing for personalized lighting solutions that promote quality of life and health.

Associations between objectively measured physical activity, sedentary behaviour and time in bed among 75+ community-dwelling Danish older adults

BACKGROUND

Older adults are recommended to sleep 7-8 h/day. Time in bed (TIB) differs from sleep duration and includes also the time of lying in bed without sleeping. Long TIB (≥9 h) are associated with self-reported sedentary behavior, but the association between objectively measured physical activity, sedentary behavior and TIB is unknown.

METHODS

This study was based on cross-sectional analysis of the Healthy Ageing Network of Competence (HANC Study). Physical activity and sedentary behaviour were measured by a tri-axial accelerometer (ActiGraph) placed on the dominant wrist for 7 days. Sedentary behavior was classified as < 2303 counts per minute (cpm) in vector magnitude and physical activity intensities were categorized, as 2303-4999 and ≥ 5000 cpm in vector magnitude. TIB was recorded in self-reported diaries. Participants were categorized as UTIB (usually having TIB 7-9 h/night: ≥80% of measurement days), STIB (sometimes having TIB 7-9 h/night: 20-79% of measurement days), and RTIB (rarely having TIB 7-9 h/night: < 20% of measurement days). Multinominal regression models were used to calculate the relative risk ratios (RRR) of being RTIB and STIB by daily levels of physical activity and SB, with UTIB as the reference group. The models were adjusted for age, sex, average daily nap length and physical function.

RESULTS

Three hundred and fourty-one older adults (median age 81 (IQR 5), 62% women) were included with median TIB of 8 h 21 min (1 h 10 min)/day, physical activity level of 2054 (864) CPM with 64 (15) % of waking hours in sedentary behavior. Those with average CPM within the highest tertile had a lower RRR (0.33 (0.15-0.71), p = 0.005) for being RTIB compared to those within the lowest tertile of average CPM. Accumulating physical activity in intensities 2303-4999 and ≥ 5000 cpm/day did not affect the RRR of being RTIB. RRR of being RTIB among highly sedentary participants (≥10 h/day of sedentary behavior) more than tripled compared to those who were less sedentary (3.21 (1.50-6.88), p = 0.003).

CONCLUSIONS

For older adults, being physically active and less sedentary was associated with being in bed for 7-9 h/night for most nights (≥80%). Future longitudinal studies are warranted to explore the causal relationship sbetween physical activity and sleep duration.

The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU

BACKGROUND

Fatigue-related errors that occur during patient care impose a tremendous socioeconomic impact on the health care system. Blue-enriched light has been shown to promote alertness and attention. The present study tested whether blue-enriched light can help to reduce medical errors in a university hospital adult ICU.

METHODS

In this interventional study, a blue-enriched white light emitting diode was used to enhance traditional fluorescent light at the nurse workstation and common areas in the ICU. Medical errors were identified retrospectively using an established two-step surveillance process. Suspected incidents of potential errors detected on nurse chart review were subsequently reviewed by two physicians blinded to lighting conditions, who made final classifications. Error rates were compared between the preintervention fluorescent and postintervention blue-enriched lighting conditions using Poisson regression.

RESULTS

The study included a total of 1,073 ICU admissions, 522 under traditional and 551 under interventional lighting (age range 17-97 years, mean age ± standard deviation 58.5 ± 15.8). No difference was found in overall medical error rate (harmful and non-harmful) pre- vs. postintervention, 45.5 vs. 42.7 per 1,000 patient-days (rate ratio: 0.94, 95% confidence interval = 0.71-1.23, p = 0.64).

CONCLUSION

Interventional lighting did not have an effect on overall medical error rate. The study was likely underpowered to detect the 25% error reduction predicted. Future studies are required that are powered to assess more modest effects for lighting to reduce the risk of fatigue-related medical errors and errors of differing severity.

Objective and Subjective Characteristics of Vigilance under Different Narrow-Bandwidth Light Conditions: Do Shorter Wavelengths Have an Alertness-Enhancing Effect?

The aim of this study was to explore the effects of 20 min of narrow-bandwidth light exposure of different wavelengths (455, 508, and 629 nm, with irradiance of 14 µW/cm2) on various neuropsychological and neurophysiological parameters of vigilance in healthy volunteers and to provide further evidence of the behavioral (subjective sleepiness, reaction time) and electrophysiological (P300 and spectral characteristics) responses to light. The results show that the short-wavelength light condition (455 nm) was found to be most effective in terms of its alerting effect for the following variables: subjective sleepiness, latency of P300 response, and absolute EEG power in higher beta (24-34 Hz) and gamma (35-50 Hz) range at each of the 19 recording electrodes. However, no differences in current power density were observed at the level of cortical EEG sources estimated by exact low-resolution electromagnetic tomography. Our results are in line with other research that shows significant alerting effects of blue (short-wavelength) light in comparison to lights of longer wavelengths. Our results confirm earlier findings that exposure to short-wavelength light during the day may enhance cognitive performance in task-specific scenarios.

The Role of Daylight for Humans: Gaps in Current Knowledge

Daylight stems solely from direct, scattered and reflected sunlight, and undergoes dynamic changes in irradiance and spectral power composition due to latitude, time of day, time of year and the nature of the physical environment (reflections, buildings and vegetation). Humans and their ancestors evolved under these natural day/night cycles over millions of years. Electric light, a relatively recent invention, interacts and competes with the natural light-dark cycle to impact human biology. What are the consequences of living in industrialised urban areas with much less daylight and more use of electric light, throughout the day (and at night), on general health and quality of life? In this workshop report, we have classified key gaps of knowledge in daylight research into three main groups: (I) uncertainty as to daylight quantity and quality needed for "optimal" physiological and psychological functioning, (II) lack of consensus on practical measurement and assessment methods and tools for monitoring real (day) light exposure across multiple time scales, and (III) insufficient integration and exchange of daylight knowledge bases from different disciplines. Crucial short and long-term objectives to fill these gaps are proposed.

Advanced Circadian Timing and Sleep Fragmentation Differentially Impact on Memory Complaint Subtype in Subjective Cognitive Decline

BACKGROUND

Increased sleep fragmentation and advanced circadian timing are hallmark phenotypes associated with increased age-related cognitive decline. Subjective cognitive decline (SCD) is considered a prodromal stage of neurodegeneration and dementia; however, little is known about how sleep and circadian timing impact on memory complaints in SCD.

OBJECTIVE

To determine how sleep and circadian timing impact on memory complaint subtypes in older adults with SCD.

METHODS

Twenty-five older adults with SCD (mean age = 69.97, SD = 5.33) completed the Memory Functioning Questionnaire to characterize their memory complaints. They also underwent neuropsychological assessment, and completed 1 week of at-home monitoring of sleep with actigraphy and sleep diaries. This was followed by a two-night laboratory visit with overnight polysomnography and a dim light melatonin onset assessment to measure circadian timing.

RESULTS

Advanced circadian timing was associated with greater memory complaints, specifically poorer memory of past events (r = -0.688, p = 0.002), greater perceived decline over time (r = -0.568, p = 0.022), and increased reliance on mnemonic tools (r = -0.657, p = 0.004). Increased sleep fragmentation was associated with reduced self-reported memory decline (r = 0.529, p = 0.014), and reduced concern about everyday forgetfulness (r = 0.435, p = 0.038).

CONCLUSION

Advanced circadian timing was associated with a number of subjective memory complaints and symptoms. By contrast, sleep fragmentation was linked to lowered perceptions of cognitive decline, and less concern about memory failures. As circadian disruption is apparent in both MCI and Alzheimer's disease, and plays a key role in cognitive function, our findings further support a circadian intervention as a potential therapeutic tool for cognitive decline.

Circadian Rhythm Sleep-Wake Phase Disorders

This article reviews delayed and advanced sleep-wake phase disorders. Diagnostic procedures include a clinical interview to verify the misalignment of the major nocturnal sleep episode relative to the desired and social-normed timing of sleep, a 3-month or greater duration of the sleep-wake disturbance, and at least a week of sleep diary data consistent with the sleep timing complaint. Treatment options include gradual, daily shifting of the sleep schedule (chronotherapy); shifting circadian phase with properly timed light exposure (phototherapy); or melatonin administration. Future directions are discussed to conclude the article.

Linking Light Exposure and Subsequent Sleep: A Field Polysomnography Study in Humans

Study objectives

To determine the effect of light exposure on subsequent sleep characteristics under ambulatory field conditions.

Methods

Twenty healthy participants were fitted with ambulatory polysomnography (PSG) and wrist-actigraphs to assess light exposure, rest–activity, sleep quality, timing, and architecture. Laboratory salivary dim-light melatonin onset was analyzed to determine endogenous circadian phase.

Results

Later circadian clock phase was associated with lower intensity (R² = 0.34, χ²(1) = 7.19, p < .01), later light exposure (quadratic, controlling for daylength, R² = 0.47, χ²(3) = 32.38, p < .0001), and to later sleep timing (R² = 0.71, χ²(1) = 20.39, p < .0001). Those with later first exposure to more than 10 lux of light had more awakenings during subsequent sleep (controlled for daylength, R² = 0.36, χ²(2) = 8.66, p < .05). Those with later light exposure subsequently had a shorter latency to first rapid eye movement (REM) sleep episode (R² = 0.21, χ²(1) = 5.77, p < .05). Those with less light exposure subsequently had a higher percentage of REM sleep (R² = 0.43, χ²(2) = 13.90, p < .001) in a clock phase modulated manner. Slow-wave sleep accumulation was observed to be larger after preceding exposure to high maximal intensity and early first light exposure (p < .05).

Conclusions

The quality and architecture of sleep is associated with preceding light exposure. We propose that light exposure timing and intensity do not only modulate circadian-driven aspects of sleep but also homeostatic sleep pressure. These novel ambulatory PSG findings are the first to highlight the direct relationship between light and subsequent sleep, combining knowledge of homeostatic and circadian regulation of sleep by light. Upon confirmation by interventional studies, this hypothesis could change current understanding of sleep regulation and its relationship to prior light exposure.

Clinical trial details

This study was not a clinical trial. The study was ethically approved and nationally registered (NL48468.042.14).

Light modulates oscillatory alpha activity in the occipital cortex of totally visually blind individuals with intact non-image-forming photoreception

The discovery of intrinsically photosensitive retinal ganglion cells (ipRGCs) marked a major shift in our understanding of how light information is processed by the mammalian brain. These ipRGCs influence multiple functions not directly related to image formation such as circadian resetting and entrainment, pupil constriction, enhancement of alertness, as well as the modulation of cognition. More recently, it was demonstrated that ipRGCs may also contribute to basic visual functions. The impact of ipRGCs on visual function, independently of image forming photoreceptors, remains difficult to isolate, however, particularly in humans. We previously showed that exposure to intense monochromatic blue light (465 nm) induced non-conscious light perception in a forced choice task in three rare totally visually blind individuals without detectable rod and cone function, but who retained non-image-forming responses to light, very likely via ipRGCs. The neural foundation of such light perception in the absence of conscious vision is unknown, however. In this study, we characterized the brain activity of these three participants using electroencephalography (EEG), and demonstrate that unconsciously perceived light triggers an early and reliable transient desynchronization (i.e. decreased power) of the alpha EEG rhythm (8–14 Hz) over the occipital cortex. These results provide compelling insight into how ipRGC may contribute to transient changes in ongoing brain activity. They suggest that occipital alpha rhythm synchrony, which is typically linked to the visual system, is modulated by ipRGCs photoreception; a process that may contribute to the non-conscious light perception in those blind individuals.

Plasticity in the Sensitivity to Light in Aging: Decreased Non-visual Impact of Light on Cognitive Brain Activity in Older Individuals but No Impact of Lens Replacement

Beyond its essential visual role, light, and particularly blue light, has numerous non-visual effects, including stimulating cognitive functions and alertness. Non-visual effects of light may decrease with aging and contribute to cognitive and sleepiness complaints in aging. However, both the brain and the eye profoundly change in aging. Whether the stimulating effects light on cognitive brain functions varies in aging and how ocular changes may be involved is not established. We compared the impact of blue and orange lights on non-visual cognitive brain activity in younger (23.6 ± 2.5 years), and older individuals with their natural lenses (NL; 66.7 ± 5.1 years) or with intraocular lens (IOL) replacement following cataract surgery (69.6 ± 4.9 years). Analyses reveal that blue light modulates executive brain responses in both young and older individuals. Light effects were, however, stronger in young individuals including in the hippocampus and frontal and cingular cortices. Light effects did not significantly differ between older-IOL and older-NL while regression analyses indicated that differential brain engagement was not underlying age-related differences in light effects. These findings show that, although its impact decreases, light can stimulate cognitive brain activity in aging. Since lens replacement did not affect light impact, the brain seems to adapt to the progressive decrease in retinal light exposure in aging.

Sleep and mood changes in advanced age after blue-blocking (yellow) intra ocular lens (IOLs) implantation during cataract surgical treatment: a randomized controlled trial

OBJECTIVES

Both advanced age and depression are characterized by changes in sleep patterns. Light exposure is one of the main synchronizers of circadian cycles and influences sleep by inhibiting melatonin secretion, which is mostly sensitive to light of low wavelengths (blue). Blue-blocking (yellow) intraocular lenses (IOLs) have supplanted the usual UV-blocking (clear) IOLs during cataract surgery to prevent age-related macular degeneration, however, the impact of yellow IOLs on sleep and mood is unclear. The purpose of this study was to compare the effects of yellow and clear IOLs on sleep and mood in aged patients undergoing bilateral cataract surgery.

METHODS

A randomized controlled superiority study was conducted within three ophthalmic surgical wards in France. A total of 204 subjects (mean age 76.2 ± 7.5 years) were randomized into yellow or clear IOLs groups. Patients completed a sleep diary, the pictorial sleepiness scale and the Beck Depression Inventory (BDI) one week before and eight weeks after the last surgical procedure.

RESULTS

According to an Intent To Treat (ITT) analysis, no significant difference was found between yellow and clear IOLs groups regarding sleep time, sleep latency, total sleep duration, quality of sleep and BDI scores. The rate of patients whose BDI score increased at the cutoff score of ≥5 after surgery was significantly higher in the yellow IOL group (n = 11, 13.1%) compared with the clear IOL group (n = 4; 4.7%); p = 0.02.

CONCLUSIONS

Using yellow IOLs for cataract surgery doesn't significantly impact sleep but may induce mood changes in aging.

Improved cognitive morning performance in healthy older adults following blue-enriched light exposure on the previous evening

OBJECTIVES

Exposure to light can have acute alerting and circadian phase-shifting effects. This study investigated the effects of evening exposure to blue-enriched polychromatic white (BEL) vs. polychromatic white light (WL) on sleep inertia dissipation the following morning in older adults.

METHODS

Ten healthy older adults (average age = 63.3 yrs; 6F) participated in a 13-day study comprising three baseline days, an initial circadian phase assessment, four days with 2-h evening light exposures, a post light exposure circadian phase assessment and three recovery days. Participants were randomized to either BEL or WL of the same irradiance for the four evening light exposures. On the next mornings at 2, 12, 22 and 32 min after each wake time, the participants completed a 90-s digit-symbol substitution test (DSST) to assess working memory, and objective alertness was assessed using a wake EEG recording. DSST and power density from the wake EEG recordings were compared between the two groups.

RESULTS

DSST performance improved with time awake (p < 0.0001) and across study days in both light exposure groups (p < 0.0001). There was no main effect of group, although we observed a significant day x group interaction (p = 0.0004), whereby participants exposed to BEL performed significantly better on the first two mornings after light exposures than participants in WL (post-hoc, p < 0.05). On those days, the BEL group showed higher EEG activity in some of the frequency bins in the sigma and beta range (p < 0.05) on the wake EEG.

CONCLUSION

Exposure to blue-enriched white light in the evening significantly improved DSST performance the following morning when compared to polychromatic white light. This was associated with a higher level of objective alertness on the wake EEG, but not with changes in sleep or circadian timing.

Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline

A systematic literature review and meta-analyses (where appropriate) were performed and the GRADE approach was used to update the previous American Academy of Sleep Medicine Practice Parameters on the treatment of intrinsic circadian rhythm sleep-wake disorders. Available data allowed for positive endorsement (at a second-tier degree of confidence) of strategically timed melatonin (for the treatment of DSWPD, blind adults with N24SWD, and children/ adolescents with ISWRD and comorbid neurological disorders), and light therapy with or without accompanying behavioral interventions (adults with ASWPD, children/adolescents with DSWPD, and elderly with dementia). Recommendations against the use of melatonin and discrete sleep-promoting medications are provided for demented elderly patients, at a second- and first-tier degree of confidence, respectively. No recommendations were provided for remaining treatments/ populations, due to either insufficient or absent data. Areas where further research is needed are discussed.

Effect of home-based light treatment on persons with dementia and their caregivers

Sleep disorders are problematic for persons with dementia and their family caregivers. This randomized controlled trial with crossover evaluated the effects of an innovative blue-white light therapy on 17 pairs of home-dwelling persons with dementia and their caregivers. Subjects with dementia received blue-white light and control ('red-yellow' light) for six weeks separated by a four-week washout. Neither actigraphic nor most self-reported sleep measures significantly differed for subjects with dementia. For caregivers, both sleep and role strain improved. No evidence of retinal light toxicity was observed. Six weeks of modest doses of blue-white light appear to improve sleep in caregivers but not in persons with dementia. Greater or prolonged circadian stimulation may be needed to determine if light is an effective treatment for persons with dementia.

Pulsing blue light through closed eyelids: effects on acute melatonin suppression and phase shifting of dim light melatonin onset

Circadian rhythm disturbances parallel the increased prevalence of sleep disorders in older adults. Light therapies that specifically target regulation of the circadian system in principle could be used to treat sleep disorders in this population. Current recommendations for light treatment require the patients to sit in front of a bright light box for at least 1 hour daily, perhaps limiting their willingness to comply. Light applied through closed eyelids during sleep might not only be efficacious for changing circadian phase but also lead to better compliance because patients would receive light treatment while sleeping. Reported here are the results of two studies investigating the impact of a train of 480 nm (blue) light pulses presented to the retina through closed eyelids on melatonin suppression (laboratory study) and on delaying circadian phase (field study). Both studies employed a sleep mask that provided narrowband blue light pulses of 2-second duration every 30 seconds from arrays of light-emitting diodes. The results of the laboratory study demonstrated that the blue light pulses significantly suppressed melatonin by an amount similar to that previously shown in the same protocol at half the frequency (ie, one 2-second pulse every minute for 1 hour). The results of the field study demonstrated that blue light pulses given early in the sleep episode significantly delayed circadian phase in older adults; these results are the first to demonstrate the efficacy and practicality of light treatment by a sleep mask aimed at adjusting circadian phase in a home setting.

Light and chronobiology: implications for health and disease

Environmental light synchronizes the primary mammalian biological clock in the suprachiasmatic nuclei, as well as many peripheral clocks in tissues and cells, to the solar 24-hour day. Light is the strongest synchronizing agent (zeitgeber) for the circadian system, and therefore keeps most biological and psychological rhythms internally synchronized, which is important for optimum function. Circadian sleep-wake disruptions and chronic circadian misalignment, as often observed in psychiatric and neurodegenerative illness, can be treated with light therapy. The beneficial effect on circadian synchronization, sleep quality, mood, and cognitive performance depends on timing, intensity, and spectral composition of light exposure. Tailoring and optimizing indoor lighting conditions may be an approach to improve wellbeing, alertness, and cognitive performance and, in the long term, producing health benefits.

Acute exposure to evening blue-enriched light impacts on human sleep

Light in the short wavelength range (blue light: 446-483 nm) elicits direct effects on human melatonin secretion, alertness and cognitive performance via non-image-forming photoreceptors. However, the impact of blue-enriched polychromatic light on human sleep architecture and sleep electroencephalographic activity remains fairly unknown. In this study we investigated sleep structure and sleep electroencephalographic characteristics of 30 healthy young participants (16 men, 14 women; age range 20-31 years) following 2 h of evening light exposure to polychromatic light at 6500 K, 2500 K and 3000 K. Sleep structure across the first three non-rapid eye movement non-rapid eye movement - rapid eye movement sleep cycles did not differ significantly with respect to the light conditions. All-night non-rapid eye movement sleep electroencephalographic power density indicated that exposure to light at 6500 K resulted in a tendency for less frontal non-rapid eye movement electroencephalographic power density, compared to light at 2500 K and 3000 K. The dynamics of non-rapid eye movement electroencephalographic slow wave activity (2.0-4.0 Hz), a functional index of homeostatic sleep pressure, were such that slow wave activity was reduced significantly during the first sleep cycle after light at 6500 K compared to light at 2500 K and 3000 K, particularly in the frontal derivation. Our data suggest that exposure to blue-enriched polychromatic light at relatively low room light levels impacts upon homeostatic sleep regulation, as indexed by reduction in frontal slow wave activity during the first non-rapid eye movement episode.

Out of the lab and into the bathroom: evening short-term exposure to conventional light suppresses melatonin and increases alertness perception

Life in 24-h society relies on the use of artificial light at night that might disrupt synchronization of the endogenous circadian timing system to the solar day. This could have a negative impact on sleep-wake patterns and psychiatric symptoms. The aim of the study was to investigate the influence of evening light emitted by domestic and work place lamps in a naturalistic setting on melatonin levels and alertness in humans. Healthy subjects (6 male, 3 female, 22-33 years) were exposed to constant dim light (<10 lx) for six evenings from 7:00 p.m. to midnight. On evenings 2 through 6, 1 h before habitual bedtime, they were also exposed to light emitted by 5 different conventional lamps for 30 min. Exposure to yellow light did not alter the increase of melatonin in saliva compared to dim light baseline during (38 ± 27 pg/mL vs. 39 ± 23 pg/mL) and after light exposure (39 ± 22 pg/mL vs. 44 ± 26 pg/mL). In contrast, lighting conditions including blue components reduced melatonin increase significantly both during (office daylight white: 25 ± 16 pg/mL, bathroom daylight white: 24 ± 10 pg/mL, Planon warm white: 26 ± 14 pg/mL, hall daylight white: 22 ± 14 pg/mL) and after light exposure (office daylight white: 25 ± 15 pg/mL, bathroom daylight white: 23 ± 9 pg/mL, Planon warm white: 24 ± 13 pg/mL, hall daylight white: 22 ± 26 pg/mL). Subjective alertness was significantly increased after exposure to three of the lighting conditions which included blue spectral components in their spectra. Evening exposure to conventional lamps in an everyday setting influences melatonin excretion and alertness perception within 30 min.