Table 4.

Characteristics of multi-component studies (n = 11)

					Environment		CHP	SPS	CCP
First author, Year)	Design, Number of groups, and type	Setting (number of facilities), Number of participants, Mean age, % Male, Inclusion/exclusion criteria	Description of intervention	Effect (positive, mixed, none, or negative), Measurement of sleep, Main finding(s)	Light	Noise	Melatonin	Physical activity	Individual care	Less disruptions	Mange Sleep wake
Alessi, 1999 [34]	RCT	Nursing home (n = 1); N = 29, mean age 88.3, 10% male, with incontinence	Daytime physical activity and nighttime program to decrease noise and decrease sleep-disruptive nursing care practices 5 days per week for 14 weeks	Positive; Actigraphy; Nighttime sleep increased from 51.7 to 62.5% (p = 0.045)		X		X			X
Alessi, 2005 [65]	RCT	Nursing home (n = 4): N = 118, mean age 86.8, 45% men	Efforts to decrease daytime in-bed time, provide daily sunlight exposure for at least 30 min, increase physical activity, structure bedtime routines, and decrease nighttime noise and light for 5 consecutive days and nights	Mixed; Actigraphy; Modest decrease in nighttime awakenings (p = 0.04) but no effect on % of nighttime sleep or number of nighttime awakenings	X	X		X		X	X
Connel, 2007 [39]	RCT	Nursing home (n = 1), N = 20, mean age 79.7, 95% male, with dementia	1 h of group outdoor structured activity for 10 days (compared with indoor structured activity)	Positive; Actigraphy; Maximum sleep duration increased and total sleep minutes significantly increased	X			X
Dowling, 2008 [66]	RCT	Nursing home (n = 2), N = 50, mean age 86, 14% men, with dementia	Melatonin 5 mg & 1 h of morning bright light (≥  2500 lx) for 5 mid-week days per week for 10 weeks	None; Actigraphy; No significant impact on sleep	X		X
Gammack, 2009 [72]	RCT	Nursing homes (n = 1), N = 24, mean age 79.5, 37.5% men, without dementia	60-min outdoor morning (between 7 am-12 pm) light and structured recreational activity for 21 days	None; Medical Outcome Study Sleep Scale; No differences in sleep scores between treatment and controls	X			X
Ito, 2001 [70]	Quasi-experimental pre-post intervention with comparison (bright light only)	Nursing home, N = 28, mean age 78.3, 42.9% men, with Alzheimer’s disease	Daily Vitamin B12 (1.5 mg for 2 weeks then 3.0 mg for 2 weeks) and 2-h morning (9 am–11 am) bright light (3000 lx) therapy for 4 weeks	None; Actigraphy; No significant improvement in nighttime sleep outcomes	X		X
Martin, 2007 [52]	RCT	Nursing home (n = 4) N = 118, mean age 87.05, 78% men, with sleep disruption	Exposure to outdoor bright light (at least 20,000 lx), efforts to keep residents out of bed during the day, bedtime routine, efforts to decrease nighttime noise and light, and structured physical activity for 10 min to 15 min 3 times per day for 5 days	None; Actigraphy; Significant change only in the active phase of the rest/activity rhythms. Not able to significantly reduce nighttime noise and light.	X			X			X
Ouslander, 2006 [54]	RCT, clustered by facility	Nursing home (n = 8), N = 160, mean age 83.2, 25% men	Daytime activities, keep residents out of bed, evening bright light, consistent bedtime routine, nighttime care routines to minimize disruption, and strategies to reduce nighttime noise for 17 days	None; Actigraphy and polysomnography; No improvement in nighttime sleep	X	X		X		X	X
Riemersma-Van Der Lek, 2008 [27]	RCT, clustered by facility with 4 groups (bright light, melatonin, combination, or none)	Assisted-living facilities (n = 12), N = 189, mean age 85.8, 10% men, with dementia	Whole-day bright light (10,000 lx) and 2.5 mg melatonin for a mean of 15 months	Positive; Actigraphy; Combined treatment (light and melatonin) significantly ameliorated nocturnal restlessness, reduced awakenings, and increased sleep efficiency. Melatonin shortened sleep onset latency and increased sleep duration.	X		X
Schnelle, 1998 [44]	Quasi-experimental pre-post intervention with comparison	Nursing home (n = 4), N = 92, mean age 87.3, 19% men, with incontinence	Individualized nighttime incontinence care (every 2 or 4 h and when awake) and minimized sleep disruption for 5 nights	Positive; Actigraphy; Significant reduction in awakenings due to light and sound (p < 0.001)	X	X			X	X
Schnelle, 1999 [45]	RCT	Nursing home (n = 8), N = 267, mean age 83.95, 82% men, with incontinence	Individualized nighttime incontinence care (every 2 or 4 h and when awake) and noise abatement and staff feedback to reduce noise for 5 nights	Mixed; Actigraphy; Significant reduction in sleep awakenings with noise and light abatement but not in % sleep or sleep duration. Significant reductions in light events but not noise.	X	X			X	X

CHP Complementary Health Practices, SPS Social/Physical Stimulation, CCP Clinical Care Practices, RCT Randomized controlled trial