***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: 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 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 the Agitated Behavior Rating Scale and the Cohen-Mansfield Agitation Inventory . Treatment effects were examined both across the 24-hr day and separately by nursing shift . RESULTS There were no significant effects of melatonin , compared with placebo , on sleep , circadian rhythms , or agitation . CONCLUSION : This study failed to find a beneficial effect of exogenous melatonin , consistent with a number of other studies . The lack of efficacy may be related to the absence of a true treatment effect or to the superphysiologic dose of melatonin used We investigated whether low intensity dawn-dusk simulation ( DDS ) , a ' naturalistic ' form of light therapy design ed to embed sleep in its accustomed phase , could improve the disturbed circadian rest-activity cycle , nocturnal sleep and and /or cognitive functions in dementia . A protocol of 3 weeks each of baseline , treatment and follow-up was completed by 13 patients ( 85yr old+/-5yr , MMSE 14+/-5 ; n=9 DDS versus n=4 ' placebo ' dim red light ) who wore an activity/lux monitor throughout . There were no significant changes in clinical or cognitive status , nor modification of circadian stability or amplitude characteristics of the rest-activity cycle . However , two aspects of sleep responded to DDS but not to dim red light . The main sleep episode was 1:14h earlier during treatment ( p=0.03 ) compared with before and after DDS . With respect to actimetry-determined sleep variables , the DDS group tended to have shortened ' sleep latency ' , longer ' sleep duration ' , more nocturnal immobility and less nocturnal activity than the dim red group ( p<0.1 ) . In parallel , nighttime light exposure tended to be reduced ( p=0.07 ) . These promising findings -after only 3 weeks of light treatment in elderly patients with advanced dementia-suggest that the circadian timing system remains functionally responsive even to low intensity DDS light . Increasing zeitgeber strength is an important strategy for improving sleep quality and timing in dementia , and DDS light therapy may provide one of the appropriate means to do so Purpose A link between poor sleep quality and Alzheimer ’s disease ( AD ) has recently been suggested . Since endogenous melatonin levels are already reduced at pre clinical AD stages , it is important to ask whether replenishing the missing hormone would be beneficial in AD and whether any such effects would be related to the presence of sleep disorder in patients . Patients and methods The effects of add-on prolonged-release melatonin ( PRM ) ( 2 mg ) to st and ard therapy on cognitive functioning and sleep were investigated in 80 patients ( men [ 50.7 % ] , women [ 49.3 % ] , average age 75.3 years [ range , 52–85 years ] ) diagnosed with mild to moderate AD , with and without insomnia comorbidity , and receiving st and ard therapy ( acetylcholinesterase inhibitors with or without memantine ) .  In this r and omized , double-blind , parallel-group study , patients were treated for 2 weeks with placebo and then r and omized ( 1:1 ) to receive 2 mg of PRM or placebo nightly for 24 weeks , followed by 2 weeks placebo . The AD Assessment Scale – Cognition ( ADAS-Cog ) , Instrumental Activities of Daily Living ( IADL ) , Mini – Mental State Examination ( MMSE ) , sleep , as assessed by the Pittsburgh Sleep Quality Index ( PSQI ) and a daily sleep diary , and safety parameters were measured . Results Patients treated with PRM ( 24 weeks ) had significantly better cognitive performance than those treated with placebo , as measured by the IADL ( P=0.004 ) and MMSE ( P=0.044 ) . Mean ADAS-Cog did not differ between the groups . Sleep efficiency , as measured by the PSQI , component 4 , was also better with PRM ( P=0.017 ) . In the comorbid insomnia ( PSQI ≥6 ) subgroup , PRM treatment result ed in significant and clinical ly meaningful effects versus the placebo , in mean IADL ( P=0.032 ) , MMSE score ( + 1.5 versus −3 points ) ( P=0.0177 ) , and sleep efficiency ( P=0.04 ) . Median ADAS-Cog values ( −3.5 versus + 3 points ) ( P=0.045 ) were significantly better with PRM . Differences were more significant at longer treatment duration  . PRM was well tolerated , with an adverse event profile similar to that of placebo . Conclusion Add-on PRM has positive effects on cognitive functioning and sleep maintenance in AD patients compared with placebo , particularly in those with insomnia comorbidity . The results suggest a possible causal link between poor sleep and cognitive decline OBJECTIVES To test the effects of walking , light exposure , and a combination intervention ( walking , light , and sleep education ) on the sleep of persons with Alzheimer 's disease ( AD ) . DESIGN R and omized , controlled trial with blinded assessors . SETTING Independent community living . PARTICIPANTS One hundred thirty-two people with AD and their in-home caregivers . INTERVENTIONS Participants were r and omly assigned to one of three active treatments ( walking , light , combination treatment ) or contact control and received three or six in-home visits . MEASUREMENTS Primary outcomes were participant total wake time based on wrist actigraphy and caregiver ratings of participant sleep quality on the Sleep Disorders Inventory ( SDI ) . Secondary sleep outcomes included additional actigraphic measurements of sleep percentage , number of awakenings , and total sleep time . RESULTS Participants in walking ( P=.05 ) , light ( P=.04 ) , and combination treatment ( P=.01 ) had significantly greater improvements in total wake time at posttest ( effect size 0.51 - 0.63 ) than controls but no significant improvement on the SDI . Moderate effect size improvements in actigraphic sleep percentage were also observed in active treatment participants . There were no significant differences between the active treatment groups and no group differences for any sleep outcomes at 6 months . Participants with better adherence ( 4 d/wk ) to walking and light exposure recommendations had significantly less total wake time ( P=.006 ) and better sleep efficiency ( P=.005 ) at posttest than those with poorer adherence . CONCLUSION Walking , light exposure , and their combination are potentially effective treatments for improving sleep in community-dwelling persons with AD , but consistent adherence to treatment recommendations is required BACKGROUND Agitated behaviors are common in dementia patients residing in chronic care setting s. Their occurrence may be associated with lack of adequate exposure to sunlight and with circadian rhythm disturbances . OBJECTIVE Prior research has suggested that bright light therapy ( BLT ) may reduce agitated behaviors in dementia patients . The aim of this study was to test the efficacy of BLT in a r and omized , controlled , crossover clinical trial . METHOD Fifteen patients with dementia and agitated behaviors residing in a chronic care facility were r and omized in a crossover design to morning BLT for 1 hour per day or to a control condition with dim light exposure . Patients were treated in either condition for 4 weeks , followed by 1 week on no treatment , prior to being crossed over to the other condition . RESULTS Eight out of 15 patients completed the entire study . The rest completed at least 2 weeks of study . Patients r and omized to the BLT condition exhibited a statistically significant improvement in nocturnal sleep from a mean of 6.4 hours/night to 8.1 hours/night 4 weeks later ( p<0.05 ) . The sleep of patients in the control condition did not improve significantly . There were no other significant differences between baseline and follow-up , nor between BLT and control treated patients on the other outcome measures , which included the Behavioral Pathology in Alzheimer Disease scale ( Behave-AD ) and the Cornell Scale for Depression in Dementia . CONCLUSION Patients with dementia in chronic care who exhibit agitated behaviors sleep more hours at night when administered morning BLT . However , BLT does not lead to improvements in agitated behaviors in institutionalized patients with dementia with non-disturbed sleep-wake cycles OBJECTIVE To assess the impact of massage versus ear acupuncture on behavior and participation in occupational therapy  of dementia patients . METHODS We performed a controlled , r and omized longitudinal trial approved by the Bioethics Commission of the University of Extremadura . One hundred twenty elderly subjects with dementia institutionalized in residential homes in Extremadura ( Spain ) received treatment based on massage and ear acupuncture over three months . Behavior alterations , sleep disturbance , and participation in rehabilitation and eating were assessed every month during the three months of intervention , and at one and two months of follow-up after the end of treatment . The assessment was performed through a structured question naire with closed format questions done by an occupational therapist not involved in the study . RESULTS There was a statistically significant positive effect of  massage and ear acupuncture  ( P < 0.001 ) on measured variables in the third month of intervention , which were maintained at two months after 
    Output:
    
The nonpharmacological interventions seem to be an efficient , inexpensive , and easy tool for family caregivers .
CONCLUSION Sensory stimulation interventions are inexpensive and practical for dementia caregivers ; however , only bright light therapy seems to be useful to reduce sleeping problems in dementia .