76 CONTENT IN ENGLISH 026 CD the residents in these homes since many of them suffer from Alzheimer, dementia, reduced mobility, vision prob- lems and factors that demand personalized care. By the year 2050 –if no cure for Alzheimer is found–, studies show that the number of people, 65 or older and suffering from this disease in the United States will tripli- cate, going from 5 million people to 13.8 million. The same is expected in the 85 years old population or older, that will grow to 7 million. Despite the efforts of the international scientific community and the pharmaceutical industry that are working against time to find a cure there still is no cure for Alzheimer. These statistics entail an economic impact, as a result of Alzheimer’s disease care and the cost increment it will bring in hospitalization, care and treatment. In the United States, annual costs associated with dementia are higher than 215 billion dollars, numbers that rival diseases such as cancer and heart disease. If these costs continue to grow they will duplicate by the year 2040. Diseases such as Alzheimer not only affect the patient, they also have an impact on his/her family and caregiv- ers. In this situation, a properly designed space for this population group plays a mayor role in their well-being, considering that it can provide a secure and comfortable environment that meets all their needs, and at the same time allows them to have more independence. Interior design can guarantee them more freedom of movement, encourage their nourishment, a healthy physical condition and social contacts. All this without forgetting the six most important areas of the aging process: loss of balance, cog- nitive loss, vision deficiencies, loss of hearing and sensitiv- ity to cold, air drafts and direct sunlight. LOSS OF VISION, DEMENTIA AND ALZHEIMER The decrease in vision and sensory capabilities increases vulnerability and limits a person’s’ quality of life. It be- comes increasingly difficult to carry on daily activities such as bathing, dressing, going for a walk, socializing, etc. Through our senses we connect with our environment. As part of the natural process of age, changes start hap- pening in the nervous system and in the sense organs. With time, the atrophy of these nerve receptors increases and in- teraction with the outside world is reduced, a loss that is exacerbated in the cases of dementia syndrome. Dementia is the loss of the cognitive function to such a degree that it interferes with the social and occupa- tional performance of the patient. Cognitive function in a person operates through five phases; sensory phase, comprehension and perception phase, executive phase and motor phase. The aging process affects the receptors in eyes, ears, nose, mouth and peripheral nerves that also influences the sensory phase and hinders the proper operation of the senses. This in turn, inhibits full understanding of the envi- ronment, whether in the perception phase or the compre- hension phase. Usually, the main feature of dementia is loss of mem- ory but studies contravene this opinion. A large group of people that suffer from alterations in the perception of their environment, become more vulnerable to the dis- ease, they can misinterpret shadows and lights which can distort the perception of walls, furniture and floors. This is aggravated by insufficient attention and the many dis- tractions, paranoia and aggressive responses suffered by these patients. It is worth noting that the amount of light perceived by an elderly person is significantly less than the amount per- ceived by a young adult. This translates into a third of light reaching the retina at 65 years old and a fifth for the 85 years old group. In people with dementia these numbers increase, especially if the person is prone to: extreme sen- sitivity to glare; has difficulty adapting to certain changes in the levels of light, problems with depth perception and suffers from alterations in the sleep rhythm – sleep disor- ders characterized by transposing day and night. As a matter of fact, sleep disorders are very common among this group and give way to episodes where it be- comes habitual to fall asleep in the morning and become active at night. It is estimated that people with this con- dition only spend approximately 40% of the night asleep. This type of sleep disorder wears down the caregivers and family members; it also triplicates the chance of falls and the recuperation is much slower than in a healthy individ- ual. It’s not surprising that aggressiveness in these patients is high; 93% are aggressive with their caregivers and have an interruption in the heart rhythm. These sleep disorders are caused by an interruption in the normal function of the circadian system, which for mammals is controlled in the hypothalamus. The Circadian system organizes every cell in our body to physiologically synchronize it with time; it is responsible of ‘synchronizing’ our inner clock with the 24 hours of the day. Even with this data, the characteristics of lighting in the health centers lack the intensity required by elderly adults. What’s more, in most cases these places increase the levels of lighting during the night to facilitate the patients’ care. As a result of this discordance, a distortion of the informa- tion that reaches the patient’s brain ensues; it is caused by having brighter light at night than during the day. The aforementioned factors coupled with age cause the circa- dian system to become vulnerable. According to various studies, “bright light is effective in reducing depression” in a range of lighting level between 2.500 lux and 10.000 lux. This conclusion was reached after a series of experiments, at a neonatal intensive care center, that proved how cyclical lighting, during the night hours- with reduced levels of lighting-, improved appetite and sleep in the infants. REALITY OF THE HEALTH CARE CENTERS Most health care centers don’t meet the needs of their resi- dents. One of the consequences of old age is the degen- eration of the retina that ceases to maintain a comfortable measure of vision under normal levels of light, disturbing the circadian rhythm and vision in general. For the normal function of this system, it is necessary that individuals be exposed to bright light, something that is lacking in the majority of the health care centers. This insufficiency al- ters the mood and state of mind of the group causing de- pression, sleep disturbances, lack of vitamin D –essential to maintain healthy and strong bones–, among other side effects. These alterations can trigger more adverse effects for the elderly, such as falls and hip fractures. Only in the United States, it is estimated that a 48% of residents at this health care centers have some vision deficiency. Along this line, a survey in four states showed that 53% of retirement homes were lacking when compared with the recommended levels of lighting. Their spaces where deemed inadequate in the following areas: 45% inad- equate lighting in hallways, 17% in common areas and 5% in the dormitories. It’s worth mentioning that ambient light in these spaces is at 50% and 65% of the recommended levels issued by the American legislation. In the rooms, the level of recom- mended light is at 20% and 40%. Exposure to bright light is inconvenient. It causes head- aches and interferes with the normal course of the routine tasks of the center, for the visitors and the caregivers, due to the glare it produces. LIGHTING CAN HAVE A POSITIVE IMPACT IN PATIENTS WITH DEMENTIA As the numerous clinical studies reveal, “light therapy can improve rest and behavior patterns in people with demen- tia”. If these people are exposed to bright light during the morning hours, with lighting levels higher than 1000 lux, with white light of 4100 K, they increase their activity dur- ing the day and depression is reduced; at the same time restlessness during the night decreases. The positive effect of light on the wellbeing of this vul- nerable group was achieved by a simulation of dawn at dusk for a period of three weeks. This was accomplished with a directed lighting system, with a low light level of lighting –of 30 lux–, during the evening hours, which helped the residents sleep. Likewise, Crichton Royal Behavior Rating Scale (CRBRS) proved that, after two weeks of light therapy, with an in- tensity of 10.000 lux every two hours, between 10.00 hours and 12.00 hours of the day, the residents with de- mentia problems were helped. They showed an improve- ment in their disordered conduct after being exposed to this light for half an hour. Despite these encouraging results, it has been proven that exposure to lighting of 1000 lux, in this centers, is nine minutes a day. SOLUTIONS FOR IMPROVEMENT It has been proven that artificial light is no different to the visual field than natural light, however its benefits are not. One example is the regulation of the circadian system that affects mood and the absorption of some nutrients. A 60 year old person requires three times more light than a 20 year person and at 85, this person will need five times more light. Lighting designers of health care centers have to con- sider that levels of light should be substantially elevated, natural and artificial light should be balanced and glare should be avoided. This can be achieved increasing the brightness of the environment, distributing it along the walls, but the best way to control glare is to use indirect lighting, hiding the bright light sources and spreading the diffuse light over a large area. This light goes around the perimeter of a space producing bright light and soft light. The bright light bounces from the ceiling and turns into diffuse ambient light, and the soft light, bathes the walls making them more luminous. The indirect ceiling lights reflect from the ceiling’s surface to distribute and diffuse light. The interior environment of a place is not only key to comfort, it can also be a non-pharmaceutical factor for the treatment of behavior problems in people suffering from dementia since they are very sensitive to their environment. Lighting is very important to improve health and quality of life in people with this disease. We should keep in mind that there is a correlation between lighting levels and the resulting behavior. The sensitivity of people with dementia goes deeper than the physical aspects. For example, if a new invasive technology is placed and curtains move spontaneously, or a noisy ventilation perhaps, it will affect these people. Consequently, we should pursue a healthier interior en- vironment. In this context, efforts are made to eliminate ceiling fluorescent lighting –incandescent light creates a more pleasant ambiance–; avoid low level light; place ex- tra lighting next to the kitchen and near the knives; install lights that can be controlled from the bed and by the doors; position the lamps in the dormitory separated, according to their use, and keep in mind glare control and that ceiling luminaries can be used for light therapy. Most elderly people have difficulty identifying the limits of the different areas and the edges of objects. Therefore, light should be sufficient to identify contrasts between el- ements; this can be achieved increasing the level of general lighting. Uniform and bright lighting can eliminate shadows re- flected from objects, which is something that can cause fear, distraction, hallucinations and confusion. However, high glare should be avoided since it can harm their sensi- tive eyes and many times, it is the reason they avoid look- ing in certain directions. In kitchens and dining areas, lighting should be a tool to increase safety. The kitchens that have closet/cabinet lighting make it possible to find food and utensils with ease. In the dining area, there should be enough lighting to appreciate the food. Several studies show that high levels