300

Chapter 18
Light Therapy in Smart
Healthcare Facilities
for Older Adults:
An Overview

Joost van Hoof Bjrn Schrader

Fontys University of Applied Sciences, The Lucerne University of Applied Sciences and
Netherlands & ISSO, The Netherlands Arts, Switzerland

Marille P. J. Aarts Eveline J. M. Wouters

Eindhoven University of Technology, The Fontys University of Applied Sciences, The
Netherlands Netherlands

Adriana C. Westerlaken Harold T. G. Weffers

TNO, The Netherlands Eindhoven University of Technology, The
Netherlands
Myriam B. C. Aries
Eindhoven University of Technology, The Netherlands

ABSTRACT
Light therapy is applied as treatment for a variety of problems related to health and ageing, including
dementia. Light therapy is administered via light boxes, light showers, and ambient bright light using
ceiling-mounted luminaires. Long-term care facilities are currently installing dynamic lighting systems
with the aim to improve the well-being of residents with dementia and to decrease behavioural symptoms.
The aim of this chapter is to provide an overview of the application of ceiling-mounted dynamic lighting
systems as a part of intelligent home automation systems found in healthcare facilities. Examples of such
systems are provided and their implementation in practice is discussed. The available, though limited,
knowledge has not yet been converted into widespread implementable lighting solutions, and the solu-
tions available are often technologically unsophisticated and poorly evaluated from the perspective of
end-users. New validated approaches to the design and application of ambient bright light are needed.

DOI: 10.4018/978-1-4666-7284-0.ch018

Copyright 2015, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.

Light Therapy in Smart Healthcare Facilities for Older Adults
1. INTRODUCTION
Light therapy is increasingly administered and
studied as a non-pharmacological treatment for a
variety of health-related problems including de-
mentia. It is applied in a variety of ways, ranging
from being exposed to daylight, to being exposed
to light emitted from electric sources both at the
own home and in institutional healthcare facili-
ties (Aarts et al., 2014; Aries et al., 2013; Ellis
et al., 2013; van Hoof et al., 2013). The systems
used for light therapy include light boxes, light
showers, and ambient bright light. Ambient
bright light is one of the ways to administer light
therapy by using electric lighting. It encompasses
the increase of the general illuminance levels in
buildings using special luminaires, light sources,
and control technology for the luminaire. It does
not include luminance or shading devices. Some
ambient bright light solutions expose occupants to
dynamic lighting scenarios that mimic the natural
daylight cycle. Light therapy covers an area in
medicine where medical sciences meet the realms
of physics, engineering and technology (van Hoof
et al., 2012). This article deals with therapy by
electric light sources only.
Light therapy is an emerging therapy within
the domain of dementia care. Dementia can be
caused by a number of progressive disorders that
affect memory, thinking, behavior, and the abil-
ity to perform everyday activities. Alzheimers
disease is the most common cause of dementia.
Recent research indicates that the quality of life
of people with dementia can be improved, and
that dementia could be slowed down by treat-
ments that reset the bodys biological clock (and
ones circadian rhythmicity), light therapy in
particular. This kind of research started with the
work by van Someren et al. (1997), who con-
ducted a study on the effects of ambient bright
light emitted from ceiling-mounted luminaires on
rest-activity patterns. In a randomised controlled
study by Riemersma-van der Lek et al. (2008),
brighter daytime lighting was applied to improve
the sleep of persons with dementia, and to slow
down cognitive decline. A full overview of effects
is given by van Hoof et al. (2010; 2013). At the
same time, the scientific basis for ambient bright
light, as seen from a medical perspective, is still
weak. Forbes et al. (2009) concluded that due to
the lack of randomised controlled studies, there
are no clear beneficial outcomes of light therapy
for older persons. Also, Shikder et al. (2012)
concluded that the implementation of therapeutic
aspects of lighting in buildings is still debatable
due to insufficient relevant investigations and
robustness of their findings. At the same time,
many light therapy studies are methodologically
flawed from an engineering perspective, too (van
Hoof et al., 2012).
Still, the rationale for applying light therapy in
dementia care is clear. Persons with dementia do
not venture outdoors as much as healthy younger
adults, due to mobility impairments. When insti-
tutionalised, going outside is no longer part of
ones daily routine and mostly depends on time
and effort of the family. Indoors, older persons are
exposed to light levels that are not sufficient for
proper vision, let alone yielding positive outcomes
to circadian rhythmicity and mood (Sinoo et al.,
2011; Aarts and Westerlaken, 2005; Aries et al.,
2013). Using light as a care instrument does not
only apply to people with dementia, it also applies
to ageing in general.
Although the evidence regarding the positive
impact of light on the well-being of especially older
people and persons with dementia or other neuro-
logical diseases are hopeful but not convincingly
and scientifically affirmed (Forbes et al., 2009;
Brown et al., 2013), these insights are already being
converted to implementable solutions. Applying
light as an instrument for treatment has tremendous
benefits. Ambient bright light is non-invasive,
it is relatively cheap in its implementation and
maintenance, and it has a high level of intuitive use
creating a low threshold for acceptance. However,
another complicating factor in the implementa-
tion of light therapy is that there is no conclusive
301

Light Therapy in Smart Healthcare Facilities for Older Adults
evidence on which lighting conditions are most
favourable to persons being exposed. The wider
community also lacks a clear definition of what
technicians and product developers call healthy
lighting, lighting that meets both human visual
and non-visual demands without causing visual
discomfort. It is also largely unknown how to
design and install such healthy lighting systems,
for instance, in relation to the emergence of new
energy-friendly light sources as light emitting
diodes (LED) (van Hoof et al., 2012). Therefore,
this work focuses on the application and design
of intelligent light therapies for older adults with
dementia.
2. TECHNOLOGY: DESIGN
AND IMPLEMENTATION
Dynamic ambient bright light systems are being
developed and implemented for the use in geriat-
ric care facilities (Figure 1). The Netherlands are
frontrunner in this field, both from the perspective
of research and implementation. The underlying
assumption of such dynamic lighting systems is
that human beings evolved in daylight conditions,
which are highly dynamic and variable, and that
the/a dynamic component further contributes
to the positive effects of the lighting systems.
Figure 2 shows the rationale behind a dynamic
lighting protocol and the way it has been shaped
in practice. As can be seen in the figure, both il-
Figure 1. Examples of dynamic lighting installed in Dutch nursing homes: Amadea by Derungs, Biosun
by Van Doorn, and Strato by Philips
302
luminance and colour temperature are controlled
through dedicated software, and both parameters
vary throughout the day. In most projects, only the
main luminaire in the living room is steered via a
dynamic protocol. Almost all luminaires contain
fluorescent light sources. In addition, the majority
of research was carried out with fluorescent light
sources although in the future new light source as
LED (Light Emitting Diode) or OLED (Organic
Light Emitting Diode) may be used.
The required illuminance levels of (dynamic)
light therapy lighting systems are much higher
than average, i.e., values of two to five times
higher than normal conditions in healthcare facili-
ties. Basically, all daylight mimicking systems
produce higher levels than currently achieved
with electric lighting (which is actually based
on visual performance). It is often said that il-
luminance should exceed 1000 lx, but the exact
threshold levels have not yet been determined in
a combination of laboratory and field studies. In
addition, the (correlated) colour temperature of the
light is much higher, too. The colour temperature
should exceed 5000 K, or even 6500 K, although
no exact threshold values can be given due to a
lack of research data. Values of fluorescent light
sources used in office environments range from
2700 to 4000 K. In practice, both illuminance
and colour temperature are controlled through
dedicated software. As there is no validated set
of algorithms which can be used in these lighting
systems, including evidence regarding the relative

Light Therapy in Smart Healthcare Facilities for Older Adults

Figure 2. Example of a protocol for dynamic lighting; the horizontal illuminance on the table level var-
ies between 0 and 1500 lx (left axis). The colour temperature of the light varies between 0 and 6500 K
(right axis). The so-called post lunch dip can be found in the first hour of the noon.

effects of static versus dynamic lighting protocols,
there is still room for innovation and research
(Figueiro, 2008; Barroso and den Brinker, 2013).
In fact, there is no conclusive data that dynamic
lighting protocols have better results than static
lighting systems. The dynamic lighting protocols
currently in use are also static compared to the
daylight since they only change over the day, but
not between days. Manufacturers and dealers of
dynamic lighting systems claim that the lighting
has a positive effect on the behaviour and the
sleep-wake rhythm of people with dementia. The
vast majority of scientific literature reports only
about the results of experiments using static light-
ing systems (Aarts et al., 2014). When searching
for the influence of dynamic lighting systems on
(older) persons with dementia, only one scientific
study was found (Spreeuwenberg et al., 2010).
This was a longitudinal quasi-experimental study
that lasted three months. The study was conducted
in two living rooms for geriatric patients with
dementia among 10 people in the control group
and 10 in the light intervention group. The results
show that the activity level in the intervention
group decreased significantly, during night-time,
as well as during daytime, compared to baseline.
The ratio between day and night time activities
remained the same. The research team concluded
that more research is necessary before the results
can be fully interpreted. The maximum correlated
colour temperature of the lighting of the system
was 4600 K. The maximum illuminance was
1200 lx.
In all the studies concerning light therapy,
the exposure to daylight is often an ill-described
aspect. We do, therefore, not fully understand
the effects of the interactions between daylight
and electric lighting. Daylight has a dynamic
character, which is mimicked by dynamic lighting
systems in a simplified manner. With new tech-

303

Light Therapy in Smart Healthcare Facilities for Older Adults
nologies, electric lighting can be supplemented
to the available daylight, which also has positive
effects on energy consumption. This requires that
new lighting solutions are to be integrated within
a framework of smart home control systems (in-
cluding sensor-based networks, ambient-assisted
living) and smart faade systems (measuring
incoming daylight and its spectral composition),
and, last but not least, a building that is optimised
for daylight use.
New lighting solutions should combine all
sources of daylight and novel lighting technologies
such as LED technology. It should be noted that
in the case of LED, the spectral composition of
the light determines its use. The intricate balance
between daylight and electric light sources calls
for smart sensors in the dwelling and dedicated
software to steer the lighting exposure of persons,
and buildings that are suitable for daylight use.
These sensors should also measure the presence
of occupants, and the type of activity they are
engaged in. The dip in lighting protocols (Figure
2) is related to the length of the lunch break. If
this break takes longer, perhaps the dip in the
protocol should be too. The protocol should ide-
ally follow the care regime. Apart from manual
controls, a sensor-based network can help achieve
accounting for the regime. This also creates a
more dynamic protocol that differs per day (real
dynamic lighting).
In addition, light therapy also calls for an
attractive design of the lighting equipment,
especially when it is applied in an all-day liv-
ing situation of people. General light therapy
equipment (i.e., for acne treatment) can still be
a light box. Indoor lighting conditions may be
perceived as unfavourable from the perspective of
personal preferences and taste, particularly with
higher colour temperature lighting or light with a
dedicated spectrum which accounts for the human
circadian photoreception sensitivity that peaks at
approximately 480 nm (following from the C()
curve (Pechacek et al., 2008)). Sometimes, in
order to improve the acceptance of such systems,
304
a smaller, more home-like luminaire is mounted
below the dynamic luminaire.
3. IMPLEMENTATION AND
FUTURE CHALLENGES
The effects of the dynamic electric lighting systems
are often unclear, although the additional costs of
these systems are significant. These issues are very
relevant as budgets in long-term care are under
extreme pressure due to political choices and
prioritisation. Although the evidence regarding
the positive impact of light on the well-being is
hopeful but not convincingly and scientifically af-
firmed, these insights are already being converted
to implementable solutions. Applying light therapy
as an instrument for care has obvious benefits. It is
non-invasive, non-pharmacological, it is cheap in
implementation and maintenance, and it has a high
level of intuitive use creating a low threshold for
acceptance. As mentioned before, two additional
incentives for the purchase of (dynamic) lighting
solutions are:
1. That persons with dementia do not venture
outdoors as much as healthy younger adults,
due to mobility impairments, and
2. Inside their homes they are exposed to light
levels which are insufficient.
Another complication factor is the lack of
standardisation and documentation dealing with
lighting for older people. These documents can
serve as an underlying basis when conducting
research and for product and service innovation.
There is, however, a growing interest within the
building community for the non-visual aspects
of light (Webb, 2006). The European standard
EN 12464-1 (2011) summarises recommenda-
tions of lighting of indoor work places. The
standard specifies horizontal illuminances for
health care facilities, such as waiting rooms,
corridors, examination rooms, and spaces for

Light Therapy in Smart Healthcare Facilities for Older Adults
diagnostics in hospitals. Nursing homes are not
included in this standard, as the standard deals
with work places (staff) and not any residential
areas (nursing homes). The standard does not
specifically include colour temperature for health
care facilities in general, too. At the same time,
we need to be critical. There is still a lot we do
not know. To date, we do not know if dynamic
systems have better outcomes than static lighting
systems, and how such systems (should) interact
with available daylight. We do know that vision
can be improved by raising general illuminance
levels and glare control; the non-visual benefits
cannot be quantified yet. Therefore, the economic
and well-being benefits of accounting for these
parameters are not yet clear.
As long as there are many uncertainties, maybe
we should suggest exposing our older citizens to
plenty of daylight, for instance, by taking them
out for a stroll. Instead of evidence-based practice,
we see the results of market-based research: with
care facilities buying new lighting technologies
because of their supposed health benefits. One
could argue that given the lack of negative side-
effects, investing in lighting equipment is a sound
option, and that science is always one step behind
practice. Still, geriatric care facilities are not a place
for reckless experimentation. The innovations in
the realm of sensors and ambient intelligence
in the home environment hold a promise that in
the future the nursing home can administer the
right amount of light to its residents, which al-
lows them to enjoy the highest degree of quality
of life, mainly though improving conditions for
proper vision. Significant innovations and system
improvements can be expected when dynamic
lighting systems are integrated with self-learning
sensors, motion detectors, sensors that recognise
certain (behavioural) rhythms, learning, guiding,
or probabilistic algorithms instead of the static
one-day dynamic electric light protocol.
REFERENCES
Aarts, M. P. J., Aries, M. B. C., & Straathof, J.,
& van Hoof. J. (2014). (in press). Dynamic light-
ing systems in psychogeriatric care facilities in
The Netherlands: A quantitative and qualitative
analysis of the subjective responses of stakeholders
and technology. Indoor and Built Environment.
doi:10.1177/1420326X14532387
Aarts, M. P. J., & Westerlaken, A. C. (2005).
Field study of visual and biological light condi-
tions of independently-living elderly people.
Gerontechnology, 4(3), 141152. doi:10.4017/
gt.2005.04.03.004.00
Aries, M. B. C., Aarts, M. P. J., & van Hoof, J.
(2014). (in press). Daylight and health: A review
of the evidence and consequences for the built
environment. Lighting Research & Technology.
doi:10.1177/1477153513509258
Barroso, A., & den Brinker, B. (2013). Boosting
circadian rhythms with lighting: A model driven
approach. Lighting Research & Technology, 45(2),
197216. doi:10.1177/1477153512453667
Brown, C. A., Berry, R., Tan, M. C., Khoshia, A.,
Turlapati, L., & Swedlove, F. (2013). A critique of
the evidence base for non-pharmacological sleep
interventions for persons with dementia. Dementia,
12(2), 210237. doi:10.1177/1471301211426909
PMID:24336770
CEN / Comit Europen de Normalisation. (2011).
EN 12464-1. Light and lighting - Lighting of work
places Part 1: Indoor work places. Brussels,
Belgium: Comit Europen de Normalisation.
Ellis, E. V., Gonzalez, E. W., & McEachron, D. L.
(2013). Chronobioengineering indoor lighting to
enhance facilities for ageing and Alzheimers dis-
order. Intelligent Buildings International, 5(sup1),
4860. doi:10.1080/17508975.2013.807764
305

Light Therapy in Smart Healthcare Facilities for Older Adults
Figueiro, M. G. (2008). A proposed 24 h
lighting scheme for older adults. Lighting
Research & Technology, 40(2), 153160.
doi:10.1177/1477153507087299
Forbes, D., Culum, I., Lischka, A. R., Morgan,
D. G., Peacock, S., Forbes, J., & Forbes, S.
(2009). Light therapy for managing cognitive,
sleep, behavioural, or psychiatric disturbances
in dementia. Cochrane Database of Systematic
Reviews, CD003946. PMID:19821317
Pechacek, C. S., Andersen, M., & Lockley, S.
W. (2008). Preliminary method for prospective
analysis of the circadian efficacy of (day)light
with applications to healthcare architecture.
LEUKOS, 5(1), 126. doi:10.1080/15502724.2
008.10747625
Riemersma-van der Lek, R. F., Swaab, D. F.,
Twisk, J., Hol, E. M., Hoogendijk, W. J. G., &
van Someren, E. J. W. (2008). Effect of bright
light and melatonin on cognitive and noncogni-
tive function in elderly residents of group care
facilities. A randomized controlled trial. Journal
of the American Medical Association, 299(22),
26422655. doi:10.1001/jama.299.22.2642
PMID:18544724
Shikder, S., Mourshed, M., & Price, A. (2012).
Therapeutic lighting design for the elderly: A
review. Perspectives in Public Health, 132(6),
282291. doi:10.1177/1757913911422288
PMID:23111083
Sinoo, M. M., van Hoof, J., & Kort, H. S. M.
(2011). Lighting conditions for older adults in
the nursing home. Assessment of environmental
illuminances and colour temperature. Building and
Environment, 46(10), 19171927. doi:10.1016/j.
buildenv.2011.03.013
306
Spreeuwenberg, M. D., Willems, C., Verheesen,
H., Schols, J., & de Witte, L. (2010). Dynamic
lighting as a tool to influence the day-night
rhythm of clients with psychogeriatric disorders:
A pilot study in a Dutch nursing home. Jour-
nal of the American Geriatrics Society, 58(5),
981982. doi:10.1111/j.1532-5415.2010.02825.x
PMID:20722824
van Hoof, J., Aarts, M. P. J., Rense, C. G., &
Schoutens, A. M. C. (2009). Ambient bright light
in dementia: Effects on behavior and circadian
rhythmicity. Building and Environment, 44(1),
146155. doi:10.1016/j.buildenv.2008.02.005
van Hoof, J., Kort, H. S. M., Duijnstee, M. S. H.,
Rutten, P. G. S., & Hensen, J. L. M. (2010). The
indoor environment and the integrated building
design of homes for older people with dementia.
Building and Environment, 45(5), 12441261.
doi:10.1016/j.buildenv.2009.11.008
van Hoof, J., Schoutens, A. M. C., & Aarts, M.
P. J. (2009). High colour temperature lighting
for institutionalised older people with dementia.
Building and Environment, 44(9), 19591969.
doi:10.1016/j.buildenv.2009.01.009
van Hoof, J., Westerlaken, A. C., Aarts, M. P. J.,
Wouters, E. J. M., Schoutens, A. M. C., Sinoo,
M. M., & Aries, M. B. C. (2012). Light therapy:
Methodological issues from an engineering per-
spective. Health Care and Technology, 20, 1123.
PMID:22297710
van Hoof, J., Wouters, E. J. M., Schrder, B.,
Weffers, H. T. G., Aarts, M. P. J., Aries, M. B.
C., & Westerlaken, A. C. (2013). Intelligent light
therapy for older adults: Ambient assisted living.
In A. Agah (Ed.), Medical Applications of Artifi-
cial Intelligence (pp. 341351). Boca Raton, FL:
CRC Press/Taylor & Francis Group. doi:10.1201/
b15618-22

Light Therapy in Smart Healthcare Facilities for Older Adults
van Someren, E. J. W., Kessler, A., Mirmiran, M.,
& Swaab, D. F. (1997). Indirect bright light im-
proves circadian rest-activity rhythm disturbances
in demented patients. Biological Psychiatry, 41(9),
955963. doi:10.1016/S0006-3223(97)89928-3
PMID:9110101
Webb, A. R. (2006). Considerations for light-
ing in the built environment: Non-visual effects
of light. Energy and Building, 38(7), 721727.
doi:10.1016/j.enbuild.2006.03.004
KEY TERMS AND DEFINITIONS
Ambient Bright Light: Lighting providing an
area with overall high illuminance levels exceed-
ing 1000 lx.
Colour Temperature: Property of a light
source, which corresponds to a temperature of
an ideal black-body radiator that radiates light of
comparable hue to that of the light source. It is
stated in kelvins [K].
Illuminance: The total luminous flux incident
on a surface, per unit area. It is stated in lux (lx)
or lm/m2.
Light Therapy: (Or phototherapy) Consists of
exposure to daylight or to specific wavelengths of
light. This light is administered for a prescribed
amount of time and/or at specific times of day.
Light: Electromagnetic radiation visible to
the human eye, having a wavelength in the range
of 400 to 700 nm.
Luminaire: Electrical device used to create
artificial light by use of an electric lamp. Also
known as a light fixture or light fitting.
307