11 minute read
Night and Day Care
NIGHT AND DAY CARE
Summarising the recent online event, Innovators in Residential Healthcare, Dr Shelley James looks at the mounting academic and case study evidence of the beneficial use of 'circadian' lighting in care homes
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We are all too familiar with the uphill battle faced by the social care sector with rising demand, a funding crisis and crumbling infrastructure, pressures compounded by the pandemic and low staff morale. Pioneering healthcare professionals are battling the odds to invest in dynamic lighting solutions that actively support the sleep-wake cycle of their residents and staff.
They are seeing first hand what a powerful difference that can make. These innovative care home managers point to a 32 per cent reduction in falls, eight per cent reduction in anti-anxiety medication use, in addition to improved staff health and engagement.
The personal rewards are remarkable enough, but their commitment to health and wellbeing turns out to be good for the bottom line too: reduced energy bills, premium pricing and improved occupancy rates as families actively choose these providers because of the positive results they see.
The science backs up the anecdotal evidence with a growing number of studies pointing to the short and longer-term effects of circadian approaches to lighting. At the same time, leading academics are keen to highlight the complexities involved and warn against drawing simplistic conclusions: it is almost impossible to separate changes to the lighting from other aspects of the environment including staff attitudes, multiple underlying medical conditions, and wide variations in visual and biological response in an ageing population.
Prof Russell Foster, currently advising the House of Lords on these issues, is clear that the time is right for closer collaboration between healthcare providers, scientists and the professionals who design, build and deliver lighting solutions. Helen Loomes, now president of the SLL, concurs: 'We must keep the conversation and collaboration moving forward. The Society of Light and Lighting is delighted to facilitate this.'
Most of us will know a friend or family member who lives in residential care. We will certainly know someone who has been affected by dementia, which, according to the Alzheimer’s Society UK, is currently the leading cause of death in the UK.1
Sleep and disruption to the circadian rhythm are critical symptoms of dementia, contributing to the night-time wandering and confusion that are associated with increased risk of falls, depression and memory loss. Hard-pressed residential care teams often resort to medication to manage these distressing symptoms. According to Journal International Psychogeriatrics, at least one in three nursing home residents are taking at least one type of psychotropic medication at any one time.2 While drugs can deal with the most obvious symptoms of insomnia and agitation, they do not tackle the underlying cause: most residential care homes simply do not offer the contrast between bright, active days and dark, quiet nights that the ageing body clock needs to stay on track.
High staff turnover and burn-out rates suggest that the care home environment does not serve the staff either, particularly those who work nights: according to Skills for Care in 2021, turnover among care staff in the UK in 2021 stood at 29 per cent,3 double the national average of 15 per cent.4
Stable teams with good morale are particularly important in this sector where clients and their families are extremely vulnerable and acutely sensitive to change. A growing body of scientific evidence suggests that changes to the lighting have the potential to improve the health and wellbeing of people living with dementia as well as the dedicated teams who care for them. In this context, it makes sense to invest in an environment that actively supports the sleep and wider mental health of resident and staff alike.
And yet this is surprisingly rare as these small businesses operating from buildings that are often in desperate need of basic repairs struggle to raise the capital budgets needed to upgrade the lighting. There are also logistical problems.
A living area at Woodside Care Village run by WCS Care, which has invested in dynamic lighting with good results
WCS
Jo Cheshire, marketing director at WCS Care, highlighted the problem of retrofitting new lighting while maintaining the daily routine in a busy residential home. She is nevertheless clear about the scale of the opportunity: there are nearly half a million registered bed spaces in the UK alone which need a retrofit solution.5
Cheshire is working with lighting designer John Bullock and the academic team at Oxford University to refine a model and specification that makes it possible and feasible for the UK care sector to adopt this approach. She points to the potential ripple effects if the approach was adopted across the industry, linking into reduced hospital admissions and reduced costs. But for Cheshire, resident health and wellbeing is always central to everything they do.
Considering how to gain that industry momentum, she points to her experience of innovating with acoustic monitoring: a system that allows night teams to be aware of unusual movement or sounds in a resident's room without needing to physically go in and switch the lights on. ‘We were the first in the UK to introduce acoustics,' she says. 'We were able to provide evidence that this had a very big impact on the reduction of falls at night and during the day for residents.’
The approach was spotted by the UK regulator, the CQC, which featured it in its annual report. Slowly, it began to be noticed by the Department of Health and Social Care and others. That technology is now being funded through the NHS Transformation Directorate. Cheshire and the team at WCS Care would like to see a similar direction of travel for circadian lighting. If that funding is made available, the approach will become a more mainstream component, not only for new builds but for retrofit to older buildings too. Cheshire is clear that potential customers choose WCS because of the technology.
Michelle Borreson who runs two rural residential facilities for Gundersen Health in the USA also took a retrofit approach. She had spotted this technology at a trade fair and decided to apply for a small grant from her head office to install the technology herself. With a limited budget, all the products were ‘off the shelf’ with no special controls. Borreson is clear about the impact:
'After installation in 2017, we saw a 32 per cent reduction in falls – from 9.12 falls per resident day to 6.17. We also saw a reduction in anti-anxiety medication use from 1.99 to 1.84 per 1000 resident days. We saw some reduction in our antipsychotic use also on our dementia unit, from 1 to 0.92 per 1000 resident days. These results are mirrored in a second property.'
Anti-depressant use also fell: from 5.47 per 1000 resident days to 5.3. These results are all the more impressive as the decreases took place during the pandemic, when residents couldn't see their families for long periods of time.
Borreson points to a reduction in electricity costs too. In the first year, one facility reported $3000 savings per year, while the second noted a $4000 reduction. She concludes: ‘We’re seeing less hypnotic use. And our residents are getting better sleep for sure.'
A third example, a state-run care home in Denmark, demonstrates how these benefits extend to staff too. Manager Kirsten SorensenGosvig explained that they made a strategic decision to install the lighting upgrade over the weekend that marks the shift between summer and wintertime in order to maximise the effect for staff. She noted that her teams who work the evening shift were able to fall asleep more quickly after coming home from work. While they used to need around two hours to wind down, after the lighting installation they were able to switch off after just one hour.
Her staff reported quieter nights and fewer conflicts between the residents during the evening, and felt healthier and happier themselves. Prior to the new lighting, patients stepping out into the corridors at night would see bright lights and assume it was morning, wanting to get dressed and asking for breakfast. The care teams were surprised to note that within days of the new lighting installation, when the residents came out in the corridors, they turned around and went back to bed.
The new dynamic lighting was so successful that the nurses all wanted to work nights in the buildings with the upgrade. So they set up a rotation system to settle the argument. Sorensen-Gosvig described how her teams were clear about the difference in their wellbeing in the mornings after night shifts spent under the standard and upgraded lighting. One anecdote brings the value of the transformation into sharp relief. After three years, the lighting broke down following a lightning strike. The employees were very upset at the loss of the 'circadian' lights which, in their view had become a ‘right’ and a standard part of a safe and effective working environment.
While these experiences can be classified as anecdotal, the scientific research points to similar effects, as the following speakers testified.
Prof Shadab Rahman of Brigham Women’s Hospital at Harvard has carried out pioneering work on the impact of dynamic lighting on falls. In the USA, one in four older adults fall each year, at least in the US at a cost of around $50bn each year. Those falls lead to three million emergency room visits a year.6 These numbers are rising, with an increase of around 30 per cent in the past decade alone. So it's a major concern in the ageing population.
There are multiple risk factors that are associated with falls. So typically, an intervention to reduce falls needs to be multifaceted. Various options have been tried and tested, including patient education, changes in lifestyle and changes in the environment. The last factor includes changes in the lighting environment so that people can see better.
Bedroom area at WCV: marketing director Jo Cheshire is working with lighting designer John Bullock and Oxford University to refine a model and specification that makes a retrofit solution feasible for the UK care sector
WCS
However, these interventions are often broad and complex, and meet many barriers when it comes to implementation long term. Rahman and his team were therefore keen to explore the potential of a passive intervention and installed a dynamic lighting schedule in a recent large-scale study across a number of different sites. They tracked a 43 per cent reduction in the risk of falls following the lighting intervention.7
Alongside the impact on falls, Rahman invited Northwestern Laboratories in association with the Department of Energy in the US to carry out an independent assessment of the energy saving that resulted from this lighting intervention. This conversion from standard fluorescent to LEDs led to a 60-70 per cent reduction in energy usage. Rahman points out that this delivers a win-win for clinical and facilities teams: a reduction in the rate of falls and major energy savings.
Rahman carried out another small-scale study in a domestic setting to investigate the potential for very simple ‘off-the-shelf’ dynamic lighting solutions to improve sleep for patients with mild traumatic brain injury. The trial used a bright ‘cool’ overhead light for daytime and a low-level table lamp with blue-depleted lighting for the evening. His team saw a marked reduction in the Insomnia Severity Score during the dynamic lighting intervention, and saw the scores deteriorate over time when the intervention was removed.8
Rahman is keen to consider the care providers too. In another study, he focused on medical errors. These errors are costly to patients and care providers alike and linked to around 200,000 deaths and more than a million injuries every year in the USA alone.
Lack of sleep is well established as a major risk factor for medical errors. So in this study, Rahman and his team simply upgraded the lighting in the nursing stations to deliver far higher levels of blue-enriched white light with the aim of maximising alertness and productivity (from 61 to 208 EDI). They tracked the impact on medical errors over a 12-month period: six months baseline plus six months post-intervention. When Rahman’s team analysed the difference in error rates before and after the lighting upgrade, they found a six per cent reduction in medical errors, which did not reach statistical significance. But they did find a 10 per cent reduction in potential errors and a 13 per cent reduction in harmful errors. More importantly, there was a 33 per cent fall in high-severity harmful errors.9
Scientists and care providers alike are keen to stress the need to keep an open mind and to focus on solutions that are simple, affordable and sustainable. But they all agree that the right light at the right time has the potential to offer a ray of hope for those living with dementia as well as those who love and care for them.
Prof Rahman quotes a Persian saying: 'When you shut out the sun from coming through the window, the doctor comes in the door.'
