Dynamic lighting study demonstrates reduction in falls for seniors
By Megan Headley
Falls are the leading cause of injury-related death in the United States for adults ages 65 and older. The economic impact of falls is immense, with fatal falls estimated to cause almost $754 million in medical costs each year and nonfatal falls causing almost $50 billion annually. Reducing falls has huge potential to save lives and reduce healthcare costs. Now, researchers with Brigham and Women’s Hospital and the Midwest Lighting Institute (MLI) have evidence to indicate that a passive solution—one that requires no effort from facility staff—can make a major difference in senior residents’ health and safety.
The results of a two-year study conducted by investigators at Brigham and Women’s Hospital and MLI, published in the Journal of the American Medical Directors Association (JAMDA), found a 43% reduction in resident falls at long-term care facilities that installed a tunable LED lighting system compared to control facilities that maintained standard lighting.
As the study notes, “A passive intervention that requires little active effort by either the staff or residents is a promising addition to current preventive strategies to reduce falls.”
From observation to formal study
Prior to the research published in JAMDA, Rodney Heller, president of MLI and partner at Energy Performance Lighting (EPL), had seen a hint at how these improvements might play out. Gundersen’s Tweeten Care Center in Spring Grove, Minnesota, reached out to EPL after reading about how lighting may affect residents. EPL upgraded the facility’s lighting with a tunable lighting system. “It was a very early model,” Heller explains. “We changed the light from darkness at night to a rich blue first thing in the morning, ramped up the brightness during the day, then at 5 o’clock we changed it to a real warm color, and then brought it to no light at night.”
After 1,000 patient days, facility administrator Michelle Borreson shared her findings with Heller: 32% fewer resident falls, 10% less use of anti-anxiety and antipsychotic medications, and 40% fewer occurrences of sundowning. It was a notable enough observation that, with funding from the Wisconsin Department of Health’s Civil Monetary Penalty program, MLI designed an upgraded lighting system in another long-term care facility and saw similar results.
Around the same time, Heller connected with two professionals from the Division of Sleep and Circadian Disorders at Brigham and Women’s Medicine: neuroscientist Steven Lockley, PhD, and assistant professor of medicine Shadab Rahman, PhD, MPH. The researchers contracted MLI to design a dynamic lighting system that would be at the center of a formal study on how a tunable lighting schedule might impact the rate of falls in long-term care home residents.
The observational study examined two pairs of care homes operated by Brigham, across a total of four sites with 758 residents. Before the lighting upgrade, the care homes had used predominantly fluorescent lamps. EPL installed a solid-state tunable lighting system at one site from each care home pair, while the other site served as a control.
The lighting upgrades were made within common areas, including hallways and sitting rooms, as well as in residents’ bedrooms. In general, the lighting intensity and spectrum were changed to increase residents’ exposure to short-wavelength blue light during the day and decrease the exposure overnight. The changes in exposure during daytime hours happened gradually, with the lighting intensity reaching 60% from 6 a.m. to 10 a.m., peaking at 100% from 10 a.m. to 3 p.m., and then going back down to 60% from 3 p.m. to 6 p.m.
“We just followed the natural day,” Heller says. “While they were eating dinner, we switched everything over in the hallways and in their rooms, because the dining area stayed static. Then once they left the dining area, they went into this warmer, comfortable light that would let melatonin begin to flow.”
The evening setting featured a blue-depleted white light from 6 p.m. to 10 p.m. A lower-intensity, blue-depleted white light was used overnight. In bedrooms, the dynamic lighting consisted of a high-intensity, blue-enriched white light from 6 a.m. to 6 p.m., and a lower-intensity, blue-depleted white light overnight.
Some aspects of the lighting schedule were programmed automatically, but staff and residents also received simple instructions on how to use the lighting manually, if necessary. Heller also ensured that a remote network connection could resolve any hardware or software issues.
Why lighting makes a difference
A critical point in the study notes that the reduction in falls occurred largely overnight, when lighting levels were dim. Moreover, while the overall rate of falls was lower in the care homes with lighting upgrades, there was a trend toward more falls during the daytime. As the researchers note in the study, these findings suggest that the reduction in falls is not related to brighter lighting and better visual acuity. Instead, the researchers suggest, the improved lighting is more likely to provide better overnight sleep quality.
“There’s a whole host of literature about sleep deprivation, how that can negatively affect people, particularly the elderly,” points out Brian Liebel, director of standards and research for the Illuminating Engineering Society and a member of the MLI advisory council. “If they’re in a static environment and they don’t sleep well during the night, what do they do? They catnap during the day. Well, if they catnap during the day, they’re not going to sleep as well during the night.”
In other words, by mimicking natural daylight, the dynamic lighting system strengthens alertness during the day, which boosts residents’ activity levels and helps them to sleep better at night. “And when they sleep better, then they can be more active during the next day. It truly is a cycle,” Liebel says.
This same logic guided the installation of lighting over the nurses’ stations. The lighting maintains the rich blue hues of natural midday light to suppress melatonin production. As Rahman, Lockley, and fellow researchers determined in a 2020 article in The Joint Commission Journal on Quality and Patient Safety, blue-enriched lighting contributed to a minor reduction in medical errors (6%) but a significant reduction (33%) in high-severity harmful errors. The blue light, Heller notes, also helps these night shift workers remain alert on their drive home, one of the most dangerous times for drivers.
Liebel adds that the basis of the dynamic lighting system’s success may be attributable to a nonvisual photoreceptor first identified in 2002. “We didn’t even know it existed up until that time,” he says. “Very early on, they discovered that there was a connection between that photoreceptor in the eye and the circadian entrainment.”
“We’re working with the most primitive photoreceptor in mammals,” Heller notes. “All it does is turn things on and turn things off inside our body.”
Understanding broader impacts of lighting
This passive solution has significant potential to create safer environments for both residents and employees, but the researchers are still sorting through data to understand additional implications. “The next phase is going to look at cognitive functioning, as well as mood and possibly medication,” Liebel says.
In the meantime, MLI is encouraging other facilities to reach out to participate in the study, which remains open. The commercial cost of installing the lighting system throughout the Brigham facilities averaged $1,700 per bed. Compared to the billions spent on injuries due to falls, however, facilities can see a payback on these upgraded systems within a year, Liebel predicts.
The bigger impact, though, is the improved quality of life for residents. “When you go into these facilities in the morning, instead of five to seven people in the room by the nurses’ station, there are only one or two. So we know they are having a better night’s sleep,” Heller says.