Light Therapy

on the
Development of
Delirium
Bailey Blandford, Julie Dailey, Sofia Fetsis, Jorge Gonzalez,
Connie Lee, Morgan Perlman, Payton Pavlicek, Bri Salzetti,
Katherine White
Lab Group C
 Introduction
Delirium: acute brain failure that disturbs neurocognition

● Inattention, lack of environmental awareness

● May experience memory deficits, disorientation,
disturbance in language and perception, reduced LOC,
and/or hallucinations/delusions
● Altered arousal ranges from near-coma level
responsiveness to hypervigilance
● Rapid onset- typically arises over hours or a few days
● Fluctuates in severity
● Can last days to weeks to months
● Can lead to increased mortality in ICU
● Pathophysiology not fully understood

(Wilson et al., 2020)

 Circadian Rhythm: regulation of
physiological and behavioral functions over a
24-hour period

● Suprachiasmatic Nucleus = master

clock
● Retinal innervation of low light→ SCN
triggers pineal gland to release melatonin
● Early morning= cortisol peak
● Deep sleep= growth hormone peak
● Peripheral clocks- nearly every cell in
the body has its own internal clock that is
influenced by the SCN

(Ayyar & Sukumaran, 2021; Integris, 2019)

 Alterations in Circadian Rhythm → Poor sleep →
Delirium

Neurotransmitter Sensory Hormonal Metabolic Systemic

Imbalance sensitivity Imbalance changes Inflammation

● Sleep deprivation ● Can lead to

● Changes in cortisol ● Metabolism influenced
● Circadian rhythm increases sensitivity neuroinflammation
and melatonin by circadian rhythm
influences to sensory stimuli ● Alterations in
release ● Dysruptions→ changes
neurotransmitter release ● More susceptible to molecular clock
● Elevated cortisol in energy supply to
● Dysregulation→ altered noise, light, and
associated with brain→ neuronal
cognitive function environmental
delirium dysfunction
changes (Ayyar & Sukumaran, 2021)
Current Nursing Practice Concern
● Delirium is associated with worse outcomes
○ prolonged duration of stay in the ICU
○ longer duration of mechanical ventilation
○ long-term cognitive deficits

Modifiable Non-Modifiable

Environmental lighting * Old age

Isolation Illness severity

Restraints Past coma history

Use of benzodiazepines Trauma prior to admission

(Lee at al. 2021)

 Current Nursing Practice Concern
How does caring for delirious patients impact the nurse giving care?

The Unpredictable Nature

The deficit in updated
of Patients with Delirium,
knowledge, education, and
which Creates Safety
resources
Concerns

Provision of Care
Caring for Patients with
Achieved Using Various
Delirium, Impacts Heavily
Strategies
on the Nurses’ Workload
(Thomas et al., 2021)
 PICOT Question

In critical care patients (P) how does altering circadian rhythms

with daylight or bright light therapy (I) compared to no light
therapy (C) impact the development of delirium (O) during the
patient’s stay in the critical care unit (T)?
 Current Practice
Currently bright light therapy
(higher lux values such as 5000
lux for example) is being
explored for its effects on
Circadian Rhythms
Bright lights in the middle of the
day can help increase melatonin
production at night.
Light at night has a negative
effect on melatonin production
and lowering the lights at night
can help maintain a more normal
circadian rhythm.
Opening windows to let in
natural light reduces the risk of
delirium compared to
windowless rooms where there
was no natural light.
 Current Practice
Daytime light
Rooms with windows intensity was greater
helped patients differentiate than nighttime light
between day and night. intensity.

Using bright lights at night Nighttime conditions

confused patients about the were uniformly dim.
time of day.
 Current Practice

By increasing daytime light,

circadian rhymes become
more normalized/stabilized.

By increasing daytime
light it has also been
shown to improve normal
nocturnal melatonin levels.
Natural light helped reduce
the incidence of delirium in
mechanically ventilated
patients.

(Fan et al., 2017; Smonig et al., 2019)

 Current Practice
Natural light demonstrated
patients needed less antipsychotic Timed light exposure helps
medication compared to patients regulate melatonin levels and
who did not get exposed to improve circadian rhythms in ICU
natural light. patients.

Natural light also demonstrated There was a correlation between

patients had less hallucination above average light levels (higher
episodes compared to no natural lux values) before protected sleep
light use. time and improved sleep quality.

(Smonig et al., 2019; Gehlbach et al., 2018; Czempik et al., 2019)

Current Literature Findings
OVERALL our studies found that increased light
exposure during the day (BLT or windows w/ sunlight)
increases sleep via regulation of circadian rhythms and
melatonin production. Consequently, delirium and
agitation has found to reduce.

In studies where light therapy did not increase melatonin

production at a significant level to regulate circadian
rhythms, it was found that the lux of light was
insufficient.

Natural light does not always protect patients from the

development of delirium.

(Czempik et al., 2019; Engwall et al., 2015; Fan et al., 2017; Gehlbach et al., 2018; Gimenz et al., 2017; Lee et al., 2021;
Potharajaroen et al., 2018; Simons et al., 2016; Smonig et al., 2019 )
 Current Literature
Findings
In articles focusing directly on BLT it was
determined that the exact lux of light impacts the
development of delirium (200 vs 5000lx).

Regulation of circadian rhythms has an impact and

correlation to the development of delirium. As this
was mentioned in almost every article!

Natural light varies on lux depending on weather conditions and indoor/outdoor status. BLT
provides consistent lux. Therefore, most studies found that depending on the lux of light,
melatonin production increases, and circadian rhythms become synchronized. As a result
delirium and agitation is reduced.

(Czempik et al., 2019; Engwall et al., 2015; Fan et al., 2017; Gehlbach et al., 2018; Gimenz et al., 2017; Lee et al., 2021;
Potharajaroen et al., 2018; Simons et al., 2016; Smonig et al., 2019 )
 Strengths and Limitations
Strengths Limitations
Minimized extraneous Not all studies double-
variables and blinded and
confounding factors
randomized

Some patients received

Large study sizes with
medications that can
high severity scores and
change effects of
delirium incidence
intervention

Highly successful rate of Attrition rate reduced

data collection, and use of participants and room
tools with reliability and transfers could alter
validity results

(Czempik et al., 2019; Engwall et al., 2015; Fan et al., 2017; Gehlbach et al., 2018; Gimenz et al., 2017; Lee et al., 2021;
Potharajaroen et al., 2018; Simons et al., 2016; Smonig et al., 2019 )
 Nursing Based Practice Recommendations
● Research articles concluded that there is a distinguishable link between
management of circadian rhythms and development of delirium.
● Research findings indicate the following:
○ BLT should be applied for up to 2 hours during the day (with a minimum
of 30 minutes)
○ Best application of BLT during midday or early morning
○ BLT should be at least 5,000 to 10,000 lux for optimal results
○ Delirium incidence is significantly reduced in individuals undergoing
light therapy, which reduces LOS
○ Sunlight or normal window light varies from as low as 200 lux.
○ Distance light approximately 16+ inches away
● This noted, the following recommendation was produced

(Fan et al., 2017; Gehlbach et al., 2018; Gimenz et al., 2017; Potharajaroen et al., 2018)
Nursing Practice Recommendations

Nurses will implement timed bright light

exposure therapy in all ICU patients to
promote restoration of circadian rhythms,
thus protecting against the development of
delirium. This will be implemented through
the use of the Circadian Optics Lumos
therapy light (10,000 lux) between one to
two hours daily between the hours of 1000
and 1400.
 Application
For 1-2 hours a
day between
1000-1400, the
Upon nurses will set up
admission to the light on the
Then, work with ICU, patients tray table and
IT department to are assigned a angle it towards
implement a light light that will the patient to
therapy section in stay in their provide BLT
the EHR room

First, purchase Nurses will

Have a nurse assess & score
the Circadian CAM-ICU
educator using CAM-ICU
Optics Lumos scores will be
understand the prior to BLT. It’s
Lights measured again
program and important to
create 4, 1 hour determine if the by nurses after
long mandatory BLT is safe for the BLT at 1900
teaching session some patients
for nurses (e.g. eye issues,
epilepsy, etc.)
(Landgraf, 2022)
 Application

Trends regarding
baseline incidence Over time, an
of delirium in the Changes would
incidence rate of
ICU will be be made to the
delirium in the
compared at both 30 program based
ICU would be
and 90 days post - on feedback and
reduced from the
intervention by the effectiveness
current baseline
nurse educator

Nurse educator If successful, this Future goals

After discharge will return to could be to
method of BLT
from the ICU, the evaluate expand this
would be
lights will be effectiveness of program into
maintained for all
cleaned and intervention and other facilities or
patients in the ICU
sanitized for use to receive nurse to other floors
on another patient feedback where delirium is
prevalent
(Landgraf, 2022)
 Cost Analysis

Nurse Educator -
Lights - The average nurse educator in Arizona
Circadian Optics Lumos 2.0 Light gets paid an average of $52 an hour. For
Therapy Lamp is $65.99 per lamp. 8 hours (4 teaching and 4 for feedback)
42 lamps - $2,772 for nurse educator would cost $416 for
light teaching.

Electricity - Total -
15 watts *2 hours a day /1000 = .030 Lights: $2,772
kWh Electricity: ~ $7.14 /year
TEP average - $0.0157485/kWh Educator: $416
Total cost/year/lamp - ~$0.17
Total cost/year/42 lamps: ~$7.14 Total: $3,195.14

(Tucson Electric Power Company, n.d.), (Nurse Salary in Arizona: Hourly Rate, November 2023), (Amazon.com, n.d.)
 Risks and Benefits
Risks Benefits
Noninvasive
Increased ICP

May also help prevent/

manage depressive
symptoms
Adverse effects related to
impaired communication
Small risk to benefit ratio

Use with photosensitizing Cheap, portable,

medications lightweight, easily
manageable and
implementable

(Bhandary et al., 2021; Hoffman & Weber, 2021; Saeidi et al., 2021)
 Evaluation

1. Contact nurse informatics and IT managers, implement light

therapy section on EHR - 30-90 days.
2. Delirium incidence of last 90 days to set baseline
3. Nurses chart CAM-ICU 0700 and 1900 daily for 90 days.
4. At 30 and 90 days, data collected. Feedback from staff given to
nurse educator.

(Collinsworth et al., 2014)

 Goals

1 ICU nursing staff will have an 80% adherence rate for light
therapy administration within 90 days.

2 In the ICU, incidence of delirium will decrease by 20%

compared to baseline within 90 days.

Chi-square test shows statistically significant difference (p

3 < 0.05) in ICU delirium occurrences after 90 days of
intervention.

(Chong et al., 2013; McHugh, 2013).

 Summary
● Delirium is an increasing issue in the ICU population that compromises the health and safety of both
patients and nurses.
● The alteration of circadian rhythms and sleep disturbances is a major contributing factor to delirium.
● Delirium increases the length of stay and the risk of future cognitive deficits in patients.
● For nurses, delirious patients can pose a safety risk and increase overall workload.
● Studies have shown that increasing light exposure with bright light therapy has proven to reduce
delirium. This exposure is far higher than the current practice of opening windows during the day.
● Best practice for BLT includes a light >5,000 lux, for up to two hours daily, and in the early morning to
midday.
● This can be implemented into an ICU such as TMC through nurse-led BLT with Circadian Optic
Lumos lights as previously described
● It will cost approximately $3,000/year for purchasing the lights, running the electricity, and providing
education for nurses
● Although low risk, nurses should exercise caution in neuro patients or those with photosensitivity.
● Overall, this simple, noninvasive, cost-effective intervention done by nurses can significantly improve
the incidence of delirium in the ICU.
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