***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To test the efficacy of an individualized social activity intervention ( ISAI ) on decreasing daytime sleep , improving nighttime sleep , and lowering the day/night sleep ratio and to determine its cost . DESIGN Pretest/posttest r and omized with an experimental and control group . SETTING Seven nursing homes . PARTICIPANTS One hundred forty-seven residents with dementia . INTERVENTION One to 2 hours of individualized social activities for 21 consecutive days . MEASUREMENTS Twenty-four-hour sleep/wake patterns using an Actigraph . RESULTS The ISAI group had significantly less daytime sleep ( P=.001 ) and a lower day/night sleep ratio ( P=.03 ) than the control group , after adjusting for baseline values . Because 40 % of the sample slept 7 or more hours at night , a secondary analysis was conducted . When only those residents with a sleep efficiency of less than 50 % ( n=50 ) were included , the ISAI group ( n=20 ) had less daytime sleep ( P=.005 ) , a lower day/night sleep ratio ( P=.02 ) , fell asleep faster ( P=.03 ) , and were awake less at night ( P=.04 ) than the control group ( n=30 ) , after adjusting for baseline values . The weekly cost of the ISAI was roughly $ 70 per participant . Initial training and supply costs were $ 1,944 . CONCLUSION The ISAI provides an alternative to medications , without side effects Melatonin production decreases with advancing age , leading to insomnia and changes in circadian rhythmicity . Administration of melatonin in variable doses result ing in supraphysiological or physiological night-time blood levels of melatonin has been shown to improve sleep quality in the elderly . To study the effect of low doses of melatonin , which do not affect daytime blood melatonin concentrations , night-time milk containing 10–40 ng/l melatonin was used as a drink with meals . The effect of about 0.5 l night-time milk daily on sleep quality and circadian activity was studied in elderly institutionalized subjects in two long-term double-blind , placebo-controlled , crossover studies . Night-time milk was given for 8 weeks and normal day-time milk for 8 weeks with a 1-week washout period in between . In the first study , which was performed during spring with sleep quality evaluated subjectively by specially trained nurses , 70 demented patients showed only a seasonal effect on their sleep quality . In the second study performed around the winter solstice , 81 fairly healthy subjects living in rest-homes were divided into three groups , two for the crossover study as in the first investigation with a third group consuming only normal daytime milk as a control group to evaluate the effect of season . Caregivers grade d the sleep quality and activity that was monitored separately for the morning before noon and for the evening after noon . In the second study , the effect of season was recognizable in the scores for sleep quality , which increased in all groups after the winter solstice . However , there were no changes in activity in the control group or in the group that consumed night-time milk during the first period of the crossover study , whereas both morning and evening activity increased significantly in the group that consumed night-time milk during the later period . Even ultra-low doses of melatonin may benefit the elderly by increasing their daytime activity CONTEXT Cognitive decline , mood , behavioral and sleep disturbances , and limitations of activities of daily living commonly burden elderly patients with dementia and their caregivers . Circadian rhythm disturbances have been associated with these symptoms . OBJECTIVE To determine whether the progression of cognitive and noncognitive symptoms may be ameliorated by individual or combined long-term application of the 2 major synchronizers of the circadian timing system : bright light and melatonin . DESIGN , SETTING , AND PARTICIPANTS A long-term , double-blind , placebo-controlled , 2 x 2 factorial r and omized trial performed from 1999 to 2004 with 189 residents of 12 group care facilities in the Netherl and s ; mean ( SD ) age , 85.8 ( 5.5 ) years ; 90 % were female and 87 % had dementia . INTERVENTIONS R and om assignment by facility to long-term daily treatment with whole-day bright ( + /- 1000 lux ) or dim ( + /- 300 lux ) light and by participant to evening melatonin ( 2.5 mg ) or placebo for a mean ( SD ) of 15 ( 12 ) months ( maximum period of 3.5 years ) . MAIN OUTCOME MEASURES St and ardized scales for cognitive and noncognitive symptoms , limitations of activities of daily living , and adverse effects assessed every 6 months . RESULTS Light attenuated cognitive deterioration by a mean of 0.9 points ( 95 % confidence interval [ CI ] , 0.04 - 1.71 ) on the Mini-Mental State Examination or a relative 5 % . Light also ameliorated depressive symptoms by 1.5 points ( 95 % CI , 0.24 - 2.70 ) on the Cornell Scale for Depression in Dementia or a relative 19 % , and attenuated the increase in functional limitations over time by 1.8 points per year ( 95 % CI , 0.61 - 2.92 ) on the nurse-informant activities of daily living scale or a relative 53 % difference . Melatonin  shortened sleep onset latency by 8.2 minutes ( 95 % CI , 1.08 - 15.38 ) or 19 % and increased sleep duration by 27 minutes ( 95 % CI , 9 - 46 ) or 6 % . However , melatonin adversely affected scores on the Philadelphia Geriatric Centre Affect Rating Scale , both for positive affect ( -0.5 points ; 95 % CI , -0.10 to -1.00 ) and negative affect ( 0.8 points ; 95 % CI , 0.20 - 1.44 ) . Melatonin also increased withdrawn behavior by 1.02 points ( 95 % CI , 0.18 - 1.86 ) on the Multi Observational Scale for Elderly Subjects scale , although this effect was not seen if given in combination with light . Combined treatment also attenuated aggressive behavior by 3.9 points ( 95 % CI , 0.88 - 6.92 ) on the Cohen-Mansfield Agitation Index or 9 % , increased sleep efficiency by 3.5 % ( 95 % CI , 0.8%-6.1 % ) , and improved nocturnal restlessness by 1.00 minute per hour each year ( 95 % CI , 0.26 - 1.78 ) or 9 % ( treatment x time effect ) . CONCLUSIONS Light has a modest benefit in improving some cognitive and noncognitive symptoms of dementia . To counteract the adverse effect of melatonin on mood , it is recommended only in combination with light . TRIAL REGISTRATION controlled-trials.com/is rct n Identifier : IS RCT N93133646 OBJECTIVES To improve nighttime sleep in nursing home patients . DESIGN Controlled clinical trial . SETTING Eight community nursing homes enrolled two at a time . PARTICIPANTS Of 1,077 patients assessed in the eight nursing homes , 638 ( 59 % ) were eligible , and consent was obtained for 273 ( 43 % of those eligible ) . Of the 230 who underwent baseline assessment s , 173 completed the immediate-intervention phase of the trial ( 77 in the intervention group and 96 in the control group ) . A total of 160 subjects completed the intervention ( 77 in the immediate-intervention group and 83 in the delayed-intervention phase ) . INTERVENTION Trained research staff provided the intervention , which included daytime physical activity and attempts to keep subjects out of bed , evening bright light exposure , a consistent bedtime routine , nighttime care routines design ed to minimize sleep disruption , and strategies to reduce nighttime noise . Subjects from one nursing home received the intervention ( Group 1 ) , whereas subjects in the second nursing home served as a control group ( Group 2 ) ; then Group 2 received the intervention . MEASUREMENTS Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects . Secondary measures included assessment s of mood and behavior using the Neuropsychiatric Inventory , the Geriatric Depression Scale , and behavioral observations . RESULTS There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial . In the 160 subjects who completed the intervention , there were no significant changes in any actigraphic measure of nighttime sleep , nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography . CONCLUSION This multicomponent , nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients . Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible . Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials Research suggests that patients with cancer , particularly in the palliative care setting , are increasingly using aromatherapy and massage . There is good evidence that these therapies may be helpful for anxiety reduction for short periods , but few studies have looked at the longer term effects . This study was design ed to compare the effects of four-week courses of aromatherapy massage and massage alone on physical and psychological symptoms in patients with advanced cancer . Forty-two patients were r and omly allocated to receive weekly massages with lavender essential oil and an inert carrier oil ( aromatherapy group ) , an inert carrier oil only ( massage group ) or no intervention . Outcome measures included a Visual Analogue Scale ( VAS ) of pain intensity , the Verran and Snyder-Halpern ( VSH ) sleep scale , the Hospital Anxiety and Depression ( HAD ) scale and the Rotterdam Symptom Checklist ( RSCL ) . We were unable to demonstrate any significant long-term benefits of aromatherapy or massage in terms of improving pain control , anxiety or quality of life . However , sleep scores improved significantly in both the massage and the combined massage ( aromatherapy and massage ) groups . There were also statistically significant reductions in depression scores in the massage group . In this study of patients with advanced cancer , the addition of lavender essential oil did not appear to increase the beneficial effects of massage . Our results do suggest , however , that patients with high levels of psychological distress  respond best to these therapies Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND Disturbances in rest-activity rhythm are prominent and disabling symptoms in Alzheimer 's disease ( AD ) . Nighttime sleep is severely fragmented and daytime activity is disrupted by multiple napping episodes . In most institutional environments , light levels are very low and may not be sufficient to enable the circadian clock to entrain to the 24-hour day . The purpose of this r and omized , placebo-controlled , clinical trial was to test the effectiveness of morning bright light therapy in reducing rest-activity ( circadian ) disruption in institutionalized patients with severe AD . METHOD Subjects ( n = 46 , mean age 84 years ) meeting the NINCDS-ADRDA ( National Institute of Neurological and Communicative Disorders and Stroke -- the Alzheimer 's Disease and Related Disorders Association ) AD diagnostic criteria were recruited from two large , skilled nursing facilities in San Francisco , California . The experimental group received one hour ( 09:30 - 10:30 ) of bright light exposure ( > or = 2500 lux in gaze direction ) Monday through Friday for 10 weeks . The control group received usual indoor light ( 150 - 200 lux ) . Nighttime sleep efficiency , sleep time , wake time and number of awakenings and daytime wake time were assessed using actigraphy . Circadian rhythm parameters were also determined from the actigraphic data using cosinor analysis and nonparametric techniques . Repeated measures analysis of variance ( ANOVA ) was used to test the primary study hypotheses . RESULTS AND CONCLUSION Although significant improvements were found in subjects with aberrant timing of their rest-activity rhythm , morning bright light exposure did not induce an overall improvement in measures of sleep or the rest-activity in all treated as compared to control subjects . The results indicate that only subjects with the most impaired rest-activity rhythm respond significantly and positively to a brief ( one hour ) light intervention OBJECTIVES Patients with Alzheimer dementia often display both agitated behavior and poor sleep .  Given that the disease is often associated with low endogenous levels of melatonin , exogenous melatonin administration may lead to improvements in sleep and agitation . DESIGN R and omized , placebo-controlled study . SETTING Nursing homes in San Diego , CA , metropolitan area . PARTICIPANTS Subjects were patients with probable Alzheimer disease . INTERVENTION Melatonin ( 8.5 mg immediate release and 1.5 mg sustained release ) ( N = 24 ) or placebo ( N = 17 ) administered at 10:00 P.M. for 10 consecutive nights . The protocol consisted of baseline ( 3 days ) , treatment ( 10 days ) , and posttreatment ( 5 days ) phases . MEASUREMENTS Sleep was measured continuously using actigraphy . Agitation was rated using both 
    Output:
    
Although there was no clear pattern of positive findings , three interventions had the most promising results : increased daytime light exposure , nighttime use of melatonin , and acupressure .
Conclusions Non-pharmacological interventions have the potential to improve sleep for residents of long-term care facilities .