Care on the clock (and whose clock counts?)
Imagine you’re staying in a hotel.
You’ve had a broken night — noise from the corridor, an unfamiliar bed — and you’ve finally fallen into a deep sleep at 8am. By 9am, there’s a vacuum cleaner running next door and a card under the door reminding you that breakfast ends at 9:30. You either drag yourself down in a daze or you miss the meal entirely.
Neither option is great.
Now imagine that isn’t a one-off holiday experience. Imagine it is every day, for the rest of your life, and you have no option to check out.
This is closer than we might like to think for many people living in residential care homes today – people who have moved from the relative freedom of their own domestic routines to an institutional environment where, with the best will in the world, the care runs on a schedule optimised for shift patterns and an ‘average’ ageing body clock.
Growing evidence from chronobiology and person-centred care suggests that residents and carers are paying a high, yet largely hidden, cost for that mismatch in terms of circadian disruption, nutritional risk and care omissions – staff simply unable to carry out critical tasks at periods of peak demand. Luckily there are a growing number of evidence-backed, affordable solutions that could close the gap.
The biology of timing
Chronotype — your preferred timing for sleep, attention, physical activity and other physiological functions — varies a lot between people – and that difference persists into later years. Although we tend to become ‘earlier birds’ as we get older, the range of preferences remains. Differential effects of chronotype on physical activity and cognitive performance in older adults. While some may be wide awake before dawn, not all residents of a care home want — or are biologically ready — to be up and dressed by 7am.
And yet research consistently shows that institutional habits override this variation. 25 years ago, a major study concluded that bedtimes and wake times were driven by shift patterns, not personal choice – residents spent an average up to 11 hours in bed at night, much longer than they actually slept – Time spent in bed at night by care-home residents: choice or compromise? a quarter of a century later, despite staff being aware of the problem, the picture is still, sadly, broadly the same.
The vacuum cleaner, in other words, runs on a schedule. And, although this pattern has become the norm, this routine may suit neither residents or those who care for them.
The health consequences of this enforced misalignment extend well beyond disrupted sleep. Chronic discrepancy between biological and behavioural sleep-wake timing — known as “social jet lag” — is linked to significantly elevated risk of type 2 diabetes or conditions that affect your heart or blood vessels impaired cognitive performance, and increased psychiatric vulnerability, even in healthy adults. A 2025 analysis of over 6,700 data points published in the journal Sleep Science and Practice found that individuals experiencing ≥2 hours of social jet lag had 1.92 times the odds of these conditions compared with those experiencing less than one hour of discrepancy – Social jetlag, sleep, and metabolic syndrome in adults: insights of circadian misalignment from NHANES 2017-2020. This is likely to be even worse in a population already at risk.
Your body clock also tells you when to feel hungry
Chronotype does not just drive when people want to sleep. It shapes when they want — and are metabolically primed — to eat. A 2025 paper in The Lancet’s eBioMedicine found that eating out of step with the internal biological clock was independently associated with altered insulin sensitivity, a risk factor in diabetes – Later eating timing in relation to an individual internal clock is associated with lower insulin sensitivity and affected by genetic factors. An evening-chronotype resident who has no appetite at 5pm, and is served their main meal at that time because the kitchen closes, is eating earlier than their internal clock — the same fundamental mismatch as eating too late, just running in reverse.
The nutritional consequences compound over time. If residents are not hungry when food is offered, they struggle to eat enough. Malnutrition affects up to 54% of nursing home residents. with one large-scale analysis noting that over 10% of non-malnourished residents become malnourised within 6 months of admission – Predictors of incident malnutrition—a nutritionDay analysis in 11,923 nursing home residents. Offering genuinely nourishing snacks during the late evening is a nutritional safety net for residents whose appetite peaks after the formal meal schedule has closed – The Attitudes, Beliefs and Perspectives of Registered Nurses on Sleep Health Management in Residential Aged Care Facilities: A Qualitative Study.
What’s that got to do with light?
While building the care routine around personal chronotype preferences is an obvious starting point, it won’t work unless the body clock is running on track.
That’s where the right light at the right time comes in.
A growing number of reviews conclude that ‘cycled’ or ‘circadian’ lighting that mimics the day-night cycle can not only help to set the sleep-wake cycle for older people living with dementia – Dementia Enlightened?! A Systematic Literature Review of the Influence of Indoor Environmental Light on the Health of Older Persons with Dementia in Long-Term Care Facilities, Lights should support circadian rhythms: evidence-based scientific consensus.
Bright light exposure in the morning phase-advances the circadian clock — it shifts sleep-wake timing earlier, which is what is needed for residents whose chronotype runs later than the institutional schedule can accommodate. A 2022 systematic review in the Journal of the American Medical Directors Association (JAMDA) examining light therapy for sleep in long-term care residents found improvements in sleep quality, circadian rhythm robustness, and reductions in night awakenings – Light Therapy to Improve Sleep Quality in Older Adults Living in Residential Long-Term Care: A Systematic Review.
A review in Frontiers in Neuroscience (2020) of bright light therapy in institutionalised elders concluded that as little as 90 minutes of morning bright light for five days produced significant improvements across circadian, sleep, health, and cognitive outcomes – Bright Light Therapy and Circadian Cycles in Institutionalized Elders.
Dawn simulation, or lights that gradually shift in colour temperature and intensity over 30 minutes may offer a useful solution for those who struggle to wake, with one recent study of the impact of a dawn-dusk simulation intervention concluding ‘We found statistically significant correlations between measures of higher quality of life and better mood, greater alertness and circadian rhythm stability – Effects of a dawn-dusk simulation on circadian rest-activity cycles, sleep, mood and well-being in dementia patients.
A practical case for chronotype-informed care planning — including the rostering case
The morning care routine in a typical residential care home represents a concentrated demand peak within a narrow window that aligns with shift handover rather than biological readiness, with implications for quality of care – and staff retention, too. A 2016 study of over 13,500 Nursing Homes used workflow simulation modelling to show how care demand timing affects staffing adequacy: when personal care tasks all cluster into a narrow morning window, even theoretically sufficient overall staffing levels are overwhelmed at that moment — staff simply cannot reach everyone in time, and tasks get skipped or delayed – Determining Nurse Aide Staffing Requirements to Provide Care Based on Resident Workload: A Discrete Event Simulation Model.
These care omissions are in turn associated with avoidable hospitalisation and increased risk of a wide range of conditions from infections and incontinence to pressure ulcers and pain. There’s a clear association between peak nurse workload and exhaustion, burnout and intention to leave, suggesting that chronotype-informed wake and bedtime scheduling could not only support residents, but staff engagement too – Impact of Nurses’ Peak Workload and Time Pressure on Work Exhaustion and Turnover Intention.
Person-centred care is the stated objective of the sector.
Chronotype is one of the most biologically embedded of personal characteristics — shaping not just when we sleep, but when we eat, when we think most clearly, and how well we can manage pain.
Finding ways to respect this powerful internal clock within the inevitable constaints of operational time, leveraging the potential of lighting to set the body clock and ease the transition between day and night could be a win-win-win.
Everyday magic – Candle in the wind
I know open flames are dangerous and LED candles are so much cleaner and safer all round.