Impacts of adapted dance on mood and physical function among persons living with Alzheimer's disease

Abstract

Background

Most individuals living with Alzheimer's disease and related dementias (ADRD) experience one or more neuropsychiatric symptoms, such as agitation which negatively impacts their quality of life. Adapted dance integrates recorded music and movement that is appropriate for people with cognitive limitations. Adapted dance may be an enjoyable activity for persons living with ADRD and may provide psychological and physical benefits.

Objective

The purpose of this pilot study was to assess the feasibility of an adapted dance intervention with persons with ADRD and the impacts of 12 weeks of adapted dancing on agitation, balance, gait, lower extremity strength, and caregiver burden.

Methods

This study used an experimental design with repeated measures. Participants with ADRD were randomly assigned to a usual care or adapted line dance group that met 60 min twice a week. At pre-test, 4-, 8-, and 12 weeks of intervention, measures were collected for agitation, balance, gait, lower extremity strength, and caregiver burden.

Results

The sample consisted of 4 males and 12 females (n = 16) with ADRD whose age ranged from 69–97 years. Twelve weeks of adapted line dance was found acceptable by ADRD participants. Participants attended ≥90% of dance sessions and did not experience loss of balance or fall. ADRD participants danced an average of 70 min per week. Both groups had improvements in agitation from baseline to 12 weeks.

Conclusions

Twelve weeks of adapted dance was shown to be feasible and enjoyable for persons living with ADRD. Clinicians should consider adapted dance as part of an exercise prescription.

Keywords

agitation Alzheimer's disease balance dance dementia gait

Introduction

Almost six million people in the United States have Alzheimer's disease (AD), which is expected to increase by 2030 as 20% of the U.S. population will be 65 or older.¹ Individuals with Alzheimer's disease and related dementias (ADRD) are profoundly impacted by caregiver burden compared to other diseases and conditions.^2–4 Neuropsychiatric symptoms such as agitation are challenging to manage by caregivers and affect 50–75% of all those with ADRD often resulting in alternative placement such as an assisted living facility (ALF).^5–7 At least 90% of persons with ADRD experience one or more neuropsychiatric symptoms including agitation.⁸ Agitation is excessive motor activity with emotional distress. Agitation can manifest as pacing, restlessness, fidgeting, emotional distress, physical or verbal aggressions (shouting, hitting), or repetitive movements (wringing of hands, tapping fingers). It is recommended to provide an agitated person with an outlet to expend this excess energy such as physical activity. However, those living with ADRD are often physically inactive, placing them at risk for declines in physical function.^9,10 Agitation accompanied with declines in physical function may lead to greater dependence on caregivers and increase caregiver burden. Thus, it is critical to explore non-pharmacological, arts-based approaches to reduce agitation, improve physical activity, and reduce caregiver burden. In this study, we explore the feasibility of adapted dance in a community setting (e.g., assisted living and adult daycare) designed to meet the needs of participants with cognitive and/or physical limitations.

Evidence suggests non-pharmacologic interventions are effective at managing neuropsychiatric symptoms and should be considered before starting pharmacological treatment.^11,12 Despite the evidence, antipsychotic, antidepressants, sedative hypnotics, among others are often used to treat agitation that are costly, ineffective, and harmful resulting in increased confusion, stroke, and death.^13–18 To reduce the use of these medications, it is critical that research testing novel non-pharmacologic interventions be conducted. These novel interventions should seek to reduce agitation, improve physical function, and reduce caregiver burden. Exercise is a non-pharmacological approach that offers combined psychological and physical benefits to persons with ADRD and has been shown to be beneficial at reducing agitation in ADRD populations.^19–21

Systematic reviews have shown some evidence that exercise programs are effective at improving agitation for persons with ADRD.^22,23 For example, in a randomized control trial (RCT) of a two-week structured exercise program where moderate stage ADRD hospital patients completed four 20-min sessions per day three days per week, there were significant improvements in agitation and other neuropsychiatric symptoms.²⁴ Similar findings were noted after ADRD persons participated in a three-week combined aerobic and resistance group exercise program for 30 min per day.²⁰ These interventions were short-term and whether these benefits are sustainable over a longer period is unclear. It is also not known what aspects of the exercise intervention impacted agitation symptoms.

In people with dementia, six and twelve months of walking has improved cognition,^25,26 and strength training improves muscle strength and postural and motor functions.^27,28 Lower extremity function has been found to be improved by aerobic exercise and combined muscle strengthening and aerobic exercise.^29–32 Gait has improved from interventions of combined aerobic and muscle-strengthening exercise.^32,33 Managing neuropsychiatric symptoms is complex, and interventions may be most effective when combined strategies are created using a multicomponent approach.³⁴

Adapted dance is a low-impact dance routine where one foot is always in contact with the floor and is appropriate for older adults with cognitive and physical limitations. Adapted dance is suitable for persons with ADRD because the movements are modified to meet the individual needs of the dancer. People with ADRD will not all have the same cognitive and physical abilities. Unlike traditional group dances with specific choreography, adapted line dance allows for flexibility to incorporate alternate dance movements in place of the planned choreography. This adaptation allows the dancer to modify their footwork without impacting the dance's overall structure. Adapted line dance creates an inclusive environment for persons with ADRD who may need to move at a slower pace or perform a different movement.

Adapted dance combines cognitive, physical, and social training that is thought to be effective for ADRD persons for various reasons such as attention to the music and environment, awareness of others, and the use of large muscle groups.^35–38 Adapted dance requires constant feedback from the visual system to guide body movements in relation to visual objects such as other dancers.³⁸ Adapted dance incorporates the auditory system more than other types of training to synchronize movement to music and verbal commands from the instructor.³⁹ Dance movements are planned to synchronize with the music requiring the dancer to pay attention to the musical cues. While musical cues can enhance memory recall of a movement, verbal cues from the instructor facilitate the participants understanding and execution of the dance movement.⁴⁰ Other types of activity such as walking, resistance, or balance training do not provide as much auditory stimulation.

Although balance training may use the somatosensory system, dance requires greater use of this system as the body's position in space is continually changing in response to the demands of the environment.^41–43 Additionally , studies have shown participation in purposeful activities that are meaningful to the ADRD participant can improve their lives and that of the caregiver.^44–46 In our previous studies of adapted dance, older adults reported the activity to be meaningful and enjoyable and the expectation is older ADRD participants will experience the same.⁴⁷ A recent study of dance therapy has shown improvements in quality of life measures among persons with ADRD in long-term care settings.⁴⁸

The purpose of this pilot study was to assess the feasibility of an adapted line dance intervention with persons living with ADRD and assess the impacts of 12 weeks of adapted dancing on agitation, balance, gait, lower extremity strength, and caregiver burden. We hypothesized the adapted dance intervention group would improve in agitation, balance, gait, lower extremity strength, compared to the usual care group. In addition, reductions in caregiver burden were anticipated for the adapted dance group.

Methods

The Institutional Review Board at the University of West Florida approved this study. All participants provided written informed consent prior to participation. Following the explanation of the study by the principal investigator (PI) and prior to obtaining consent, three questions were asked to verify ADRD participants’ understanding of the study. This three-item decisional capacity instrument has been evaluated and found to provide an effective means of assessing understanding of and capacity to give consent.⁴⁹ A summed score of >three indicates the person with ADRD has capacity.⁴⁹ If the participant with ADRD did not have capacity for consent, then their caregiver could provide assent on their behalf with the appropriate documentation such as Durable Power of Attorney documentation.

Study design

This study used an experimental design with repeated measures. A control group is essential to account for the effects of the intervention. The usual care group (control) participated in a social stimulation non-physical activity (e.g., bingo, puzzles). Participants were already familiar with the games played and regularly participated in this activity on a weekly basis. At pre-test, 4 weeks, 8 weeks, and at 12 weeks of intervention, measures were collected for agitation, balance, gait, lower extremity strength, and caregiver burden.

Inclusion/exclusion criteria

The sample was composed of ADRD participants who had a confirmed clinical diagnosis of ADRD and resided either at home or in an ALF. The stage of ADRD was confirmed by a healthcare provider and not solely based on caregiver report. The study began a few months prior to the COVID-19 pandemic at an ALF setting and then during the pandemic shifted to an adult daycare setting. The inclusion/exclusion criteria remained the same for both settings. Inclusion criteria included a Montreal Cognitive Assessment (MoCA) score between 6 and 26,⁵⁰ Timed up and go (TUG)⁵¹ score of less than 20 s, Cohen-Mansfield Agitation Inventory (CMAI)⁵² score of >3. There was no age requirement as we did not wish to exclude someone with ADRD who was younger than 65 years of age. ADRD participants also had to have a caregiver who had to be able to follow and understand directions. Caregivers were asked to participate in the study to complete the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI)⁵³ to assess ADRD resident agitation and the Zarit Caregiver Burden Inventory (ZBI)⁵⁴ to assess caregiver burden. Caregivers did not attend the social stimulation nor the adapted dance classes. Exclusion criteria: ADRD individuals who use portable oxygen or an assistive device. In previous studies of adapted dance, older adults with physical limitations and chronic illness were safely able to participate in dance.^38,39,43 Hence, no other exclusions for morbidity were used.

Recruitment

Participants were recruited from the Northwest Florida community. In Year One, participants were recruited from an ALF and the study took place at this site. In Year Two, because of the pandemic, the study could not continue at the ALF site. We were required to seek another setting to continue the study and changed our study location to an adult daycare community facility. Interested potential participants contacted the PI by phone and were screened for eligibility using approved screening questions to assess for inclusion and exclusion criteria. An appointment was made to obtain written consent and collect baseline data. Testing took place at a community site (Year One- ALF and Year Two-adult daycare) with adequate space and lighting. After screening and enrollment in study, participants were assigned to blocks based on categorical factors of gender, age, and psychotropic medication use to achieve the best possible balance between the groups. Then within each block, participants were randomly assigned to either the intervention or control group.

Sample size

The calculation of the sample size was performed using G*Power 3.1, considering the following parameters: a moderate effect size (d = 0.5), four repeated measurements, probability of detecting effects on the primary outcome of agitation, and α-error of 0.05 and a power of 0.80 (1-ß-error) according to Cohen.^55,56 Based on this calculation, each group needed 11 participants with ADRD for a total of 22 participants.

Dance intervention

The dances were taught by either a community-based dance instructor or the PI. Both team members have experience teaching adapted dance to older adults. The dance instructor helped design the intervention. The adapted dance intervention used simple routines. The dance routines varied with each class and new movements were added with each routine. Participants repeated previously learned dance routines in the following weeks of the intervention (Table 1). The intervention involved continuous integrated movements of the legs and trunk, weight transfers, and postural control. Choreographed movements included walking forward/backward, side to side, turns, pivots, stepping, and stomping that are expected to improve dynamic balance, gait, and lower extremity strength.

Table 1.

Dance routine schedule and modifications.

Dance routines	Modifications (f needed)	Week introduced	Weeks repeated
Routine #1	Replaced toe tap with stepping in place.	1	2–12
Routine #2	Replaced box step with stepping in place.	2	3–12
Routine #3	Replaced vine with side-to-side steps. Replaced brush step with moving hips side to side.	3	4–12
Routine #4	Replaced grapevine with side-to-side steps. Replaced brush step with moving hips side to side.	4	5–12
Routine #5	Replaced Charleston step with stepping forward and backward. Replaced the opening and closing knees with hip swings.	5	6–12

Table 2.

Testing participation.

Test	ADRD participant	Informal caregiver
Cohen-Mansfield Agitation Inventory (CMAI)	No	Yes
Neuropsychiatric Inventory-Clinician Rating Scale (NPI-C)	Yes	Yes
Short Physical Performance Battery (SPPB)	Yes	No
Zarit Burden Inventory (ZBI)	No	Yes

Yes = completes test, No = does not complete test.

Participants were taught six dances throughout the 12-week period with the instructor present at all times. When a new dance routine was being learned, the movements/steps of the routine were repeated at least three times before combining all the movements that made up the entire dance routine. Once all movements/steps were repeated, the dance routine was repeated at least twice during the class. Caregivers were not present during the class.

Dance routines

The first dance routine incorporated side to side steps, foot taps (tapping one foot in front), and ¼ turn. The second dance routine included forward and backward steps, a box step (four step sequence where foot crosses another and feet move to form a square), and hip swings (shifting hips side to side). The third dance routine added more movements with vine steps (stepping one foot behind one another), brush step (striking ball of foot against the floor), forward/backward steps, and step touches. The fourth dance routine built upon steps previously learned and incorporated side to side steps, grapevine (alternate stepping across and behind other foot in successive steps), brush step (striking ball of foot against the floor), ¼ turn, and forward and backward steps. The fifth dance routine introduced the Charleston step which requires a rock step (weight is briefly transferred to another foot before being returned to the first). This routine also included opening and closing the knees at the same time as crossing and uncrossing the arms. The final dance routine learned incorporated mostly upper body movements to allow our participants a break from solely lower body movements. This dance included reaching arms above the head, holding arms straight out in front of the body, clapping, stepping in place, and hip swings. This dance was performed in a circle which was a change from previous dances that were performed in a line. The weekly dance schedule was adjusted based on how the participants responded to the dances each session (Table 1).

Music is essential as it acts as a prompt for self-expression and activates memory centers in the brain. Specifically for people with ADRD, music familiar and associated with youth may trigger the participant to dance. The ages of the participants were a consideration for the music selected for the intervention. For example, songs from the 1950s were played for the dance routines. The dances were repeated the following week to reinforce learning the dance steps. When learning a new dance, the tempo was slow so participants could learn and perform the dance at a slower pace prior to performing at a moderate pace.

Modifications

The PI and research team members observed participants for difficulty with the dance movements and introduced a similar but less challenging movement as a replacement (Table 1). For example, almost all participants had difficulty performing the grapevine pattern of the feet (step across and then behind other foot) and the movement was changed to side-to-side steps to allow the participants to safely continue dancing. Modifications were documented for each session. All but one participant needed modifications to perform the dances.

Procedures

The 60-min dancing class included time to learn the new dance introduced each week, time to practice the new dance, time to rest (average of 15 min), and time to review and perform dances learned in previous classes. Due to rest periods, the time spent dancing ranged from 35–45 min. Twenty to sixty minutes of daily activity matched to the skill level of the ADRD person has been shown to be feasible and beneficial.^21,57 Time spent participating in the adapted dance and reason for stopping the activity were recorded. The classes occurred in a group setting because dancing in a group has been found to increase attendance and participation.⁵⁸ Informal caregivers were not present for the classes. The person teaching dance steps gave verbal instructions and visual cues (e.g., points finger to left) while demonstrating the movements. A common problem associated with physical activity programs for ADRD persons is memory loss, thus, the dance instructor provided verbal encouragement and allowed time to review dances learned each week.⁵⁹ The choreographed dances were performed to music selected by the instructor. When teaching new steps, the instructor demonstrated facing the participants first before facing the opposite direction. The instructor or research team members were always visible to the participant during the dancing. The dance instructor and/or research team members performed the dance movements with the participants. During the pandemic time of the study, the instructor and research team members wore face masks. Participants were not wearing face masks. Dance classes took place in the morning as it is known ADRD persons often are fatigued and tired later in the day.⁶⁰ The classes were in a room with adequate space and lighting. The room did not have a mirror. Participants were asked to wear supportive and comfortable shoes for the classes to allow movement.

Safety monitoring

Prior to starting the study, the participants obtained written approval from their healthcare provider to participate in the adapted dance classes. All testing and interventions took place in a community-based facility that has access to a healthcare provider as well as emergency services. The PI, a registered nurse, monitored participants for safety during the intervention. Chairs were available in the room to allow the participants to rest if needed during the dancing. If a participant reported being tired or presented with signs of fatigue, they were assessed and monitored by the PI. Participants were able to sit and rest at any time. If a participant was determined to need medical attention, then the PI reported this to the staff nurse on site at the facility. There were no adverse events or unanticipated problems during the study.

Adherence

Adherence to adapted dancing was essential to ensure the participant received an adequate amount of the intervention. Attendance was monitored and recorded for each dance class. The PI greeted the participants at each dance session and offered an opportunity for questions. Those participants who did not inform the investigator of their absence were contacted by telephone to let them know they were missed at class and to ascertain if barriers to participation can be addressed. Participants including caregivers in the usual care group were called at the start of intervention and every four weeks to provide an opportunity to ask questions and be acknowledged for their continued participation in the study.

Usual care group

Participants assigned to this group (n = 8) took part in a 60-min social stimulation activity that included sedentary activities without music including bingo, puzzles, crafts, cards, and board games. Since the usual care group acted as a control group, it was important to not incorporate music during this activity as it may have influenced the participant responses. The activity was led by a research assistant at the same time of day as the adapted dance program. During the pandemic, research team members wore face masks. Participants did not wear face masks. Time spent performing the activity was recorded. Informal caregivers of participants were not present.

Testing protocol

The PI administered all the tests and wore a face mask during the pandemic. Participants did not wear face masks. Tests were administered within 4 weeks of intervention starting at 4 and 8 weeks during intervention, and at 12 weeks (completion of intervention). Participants with ADRD and their caregivers take part in the testing (Table 2). Agitation was assessed by caregiver report on the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Clinician Rating Scale (NPI-C). The CMAI is a 29-item observer assessment with each item rated on a 7-point Likert scale (‘Never’ to ‘Several times per hour’) commonly exhibited over the previous two weeks.⁵² Behaviors include aimless wandering, physical aggression such as hitting and kicking, verbal agitation such as cursing or constant request for attention and hoarding. A total score ranging between 29 and 203 can be computed, reflecting overall agitation; there are four separate subscales indicating physically nonaggressive behaviors (PNAB; 9 items), physically aggressive behaviors (PAGB; 12 items), verbally nonaggressive behaviors (VNAB; 4 items) and verbally aggressive behaviors (VAGB; 4 items).⁵² The inter-rater reliability (intraclass correlation) for the total score was 0.41.

Inter-rater reliabilities were also calculated for each of the subtypes of agitated behaviors and were 0.66 for physical aggression, 0.26 for physical non-aggression, and 0.61 for verbal agitation.⁶⁰

The Neuropsychiatric Inventory-Clinician Rating Scale (NPI-C) assesses behavioral domains common in dementia including agitation.⁵³ The NPI-C includes expanded domains of the original version of the Neuropsychiatric Inventory with addition of clinician rating methods.⁶¹ The correlation between agitation and the CMAI for the NPI-C was moderate (r = 0.40).⁶¹

In the NPI-C, ratings for frequency, severity, and distress are provided for each item and summed to create a total domain score. In the clinician rating approach, the caregiver is first asked to provide frequency, severity, and distress ratings for items as described above. The PI interviewed the caregiver and also interviewed the ADRD participant and recorded their ratings. The agitation domain clinician rating was scored for frequency, severity, and associated caregiver distress.

Balance, gait, and lower extremity strength was assessed by the Short Physical Performance Battery (SPPB). The tasks include three balance stances, time to get up from chair, and walking four meters. Scores of 1 to 4 for each test were assigned based on time (quartiles) of performance.⁶² A summary score (0–12) was calculated by adding the scores of each test. The SPPB has been used as a standard measure of physical performance in multi-center randomized control studies of older adults. It is recommended for use in clinical practice as it requires minimal equipment and space.⁶³

Caregiver burden was assessed by the Zarit Burden Interview (ZBI) 22-item version.⁵⁴ This instrument is the most widely used to assess caregiver burden.⁶⁴ The caregiver was interviewed and asked to provide a response to the first 21 items using a 5-point scale with response options ranging from 0 (Never) to 4 (Nearly Always). The 22nd item is scored also on a 5-point scale, but responses range from 0 (Not at all) to 4 (extremely) due to the question asked for item 22. Higher scores indicate having greater caregiver burden. In a study of caregivers of persons with dementia, the ZBI score was strongly correlated to the depressive mood of the caregivers (r = 0.59) and the behavior problems of the care recipients (r = 0.64).⁶⁴

Data analysis

Statistical Analysis System (SAS) Version 9.4 was used for analysis. Descriptive statistics were used to describe the characteristics of the sample and outcome measures including means, standard deviations, 95% confidence intervals, and effect sizes. The primary variables of interest were agitation and physical function as measured by the CMAI, NPI-C, and SPPB. The secondary variable of interest was caregiver burden measured by the ZBI instrument. The independent variables were adapted dance (intervention) or usual care group (control). The dependent variables were summed scores from the CMAI, NPI-C, SPPB, and ZBI measures. To obtain valid statistical two-sample t-tests for the four dependent variables, all data were first tested for Normality with the Shapiro-Wilk Test in SAS, using the procedure UNIVARIATE. In some cases, the normality assumption was rejected while in most cases the assumption of normal data was upheld by the test. To make sure the results are valid, we also used nonparametric tests based on the ranks of differences, such as the Kruskal-Wallis Test and a two-sample t-test based on normal quartiles after the raw data was transformed.

Results

Twenty-five adults were screened for eligibility to participate but eight were excluded because they reported use of assistive device (n = 2), did not have a confirmed clinical diagnosis of ADRD (n = 4), or had a CMAI score below 3 (n = 2). Seventeen participants who met inclusion criteria, and signed a consent form were enrolled in the study and randomized to either the adapted dance group or the usual care group. There was one drop-out from the dance group at six weeks due to relocation and they were removed from the analysis. This yielded 16 participants with eight participants in the adapted dance group and eight participants in the usual care group. The required sample size needed to attain a statistical power of 80% at significance level of 0.05 was 22 participants. Our sample was less than required at 16 participants. Therefore, it was very likely any standard statistical test would be lacking the power to correctly identify differences between the intervention and usual care group. The sample consisted of 4 males and 12 females with ADRD whose age ranged from 69–97 years (M = 78.5, SD = 9.9). There were no significant differences in the demographic (Table 3) and health status characteristics (Table 4) between groups at baseline. No participants missed more than two dance sessions and completed > 90% of the intervention. No adverse events such as falls occurred, including outside of class time or at the participants’ home during the 12-week dance period. All participants participated in testing without difficulty and the frequency of testing (every four weeks) was acceptable.

Table 3.

Demographics of participants with ADRD.

	Total frequency (%) (n = 18)	Dance frequency (%) (n = 8)	Usual care (control) frequency (%) (n = 8)	χ²
Gender
Female	12 (75.0)	7 (90.0)	5 (62.5)	0.248
Male	4 (25.0)	1 (10.0)	3 (37.5)	0.248
Race
White	13 (81.2)	7 (90.0)	6 (75.0)	0.522
Black	3 (18.8)	1 (10.0)	2 (25.0)	0.522
Marital Status
Married	7 (43.7)	4 (50.0)	3 (37.5)	0.867
Widowed	7 (12.5)	3 (37.5)	4 (50.0)
Divorced	2 (43.7)	1 (12.5)	1 (12.5)
Education
Grade 9–12	6 (37.5)	3 (37.5)	3 (37.5)	0.443
Associate degree	5 (31.3)	3 (37.5)	2 (25.0)
Bachelor's degree or higher	5 (31.3)	2 (25.0)	3 (37.5)

Table 4.

Health Status characteristics of ADRD participants.

	Total frequency (%) (n = 16)	Dance frequency (%) (n = 8)	Usual care (control) frequency (%) (n = 8)	χ²
Stage of ADRD
Early	7 (43.8)	2 (25.0)	5 (62.5)	0.117
Mild	8 (50.0)	6 (75.0)	2 (25.0)
Moderate	1 (6.25)	0 (0)	1 (12.5)
Psychotropic Medication Use	5 (31.3)	1 (12.5)	4 (50.0)	0.106
High blood pressure	11 (68.8)	6 (75.0)	5 (62.5)	0.590
Peripheral Vascular Disease	1 (6.25)	0 (0)	1 (12.5)	0.302
Diabetes	1 (6.25)	0 (0)	1 (12.5)	0.302
Neuropathies	2 (12.5)	1 (12.5)	1 (12.5)	1.000
Respiratory disease	0 (0)	0 (0)	0 (0)	—-
Osteoporosis	3 (18.75)	2 (25.0)	1 (12.5)	0.522
Arthritis	4 (25.0)	3 (37.5)	1 (12.5)	0.248
Depression	7 (43.8)	4 (50.0)	3 (37.5)	0.614
Joint Replacement	2 (12.5)	1 (12.5)	1 (12.5)	1.000
Other conditions not listed	4 (25.0)	1 (12.5)	3 (37.5)	0.248

Dance participants actively engaged in dancing 35 min per session totaling 70 min per week. During the dance sessions, none of the ALF participants needed rest breaks, while three participants at the adult daycare center needed rest breaks every dance session weeks 8–12. During these rest periods, the participants were still present in the room and often were observed clapping and tapping their feet when music was playing. Six out of eight dance participants were also noted as being able to recall dance movements for at least three dances learned during the 12-week period. Four of the six participants were noted to have higher MoCA scores than their counterparts. These three dances were learned in the first four weeks of the intervention and were repeated weekly for the duration of the intervention.

No matter which statistical method was used to compare the intervention and usual care (control) groups, the results were not statistically significant at level 0.05. Both the usual care and dance groups had improvements in agitation (CMAI and NPI-C) from baseline to 12 weeks (Table 5). A small effect size of 0.33 was noted for the NPI-C and an effect size of 0.34 for the SPPB. A moderate effect size of 0.58 for the semi-tandem balance stance was also noted. Effect sizes for all tests are reported in Table 6. For all tests, the statistical power was too low to capture significant differences if they existed between the groups.

Table 5.

Mean differences between groups.

	Pretest		Post test
	Usual care mean (SD)	Dance mean (SD)	Usual care mean (SD)	Dance mean (SD)
CMAI	46.5 (16.30)	53.62 (15.51)	44.8 (18.0)	52.75 (12.77)
NPI-C	4.37 (4.34)	3.62 (2.06)	3.63 (3.25)	2.75 (1.83)
SPPB	4.12 (2.35)	4.62 (1.76)	4.38 (1.85)	3.75 (1.75)
Side Balance stance	8.71 (3.52)	7.90 (3.97)	10.0 (0)	10.0 (0)
Semi-tandem Balance stance	6.19 (4.66)	2.08 (3.66)	5.97 (4.25)	3.42 (4.42)
Tandem Balance Stance	3.16 (3.99)	1.25 (3.53)	3.15 (4.59)	1.65 (3.15)
4-meter walk time (gait)	10.10 (2.25)	7.95 (2.20)	8.62 (3.20)	8.57 (3.41)
Chair Rise time (lower extremity strength)	33.94 (22.27)	29.43 (20.82)	28.28 (19.74)	50.79 (17.32)
ZBI	18.62 (9.25)	20.75 (9.57)	22.38 (13.46)	21.88 (13.35)

CMAI: Cohen-Mansfield Agitation Index; NPI-C: Neuropsychiatric Inventory Clinician Rating Scale; SPPB: Short Physical Performance Battery; ZBI: Zarit Burden Inventory.

Table 6.

Calculated effect sizes.

	Cohen's d	95% CI lower	95% CI upper
CMAI	−0.504	−1.49	0.502
NPI-C	0.332*	−0.662	1.31
SPPB	0.347*	−0.647	1.33
Semi-tandem Balance Stance	0.588**	−0.426	1.58
Tandem Balance Stance	0.378*	−0.618	1.36
4-meter walk time (gait)	0.014	−0.966	0.994
Chair Rise time (lower extremity strength)	−1.21	−2.27	−0.118
ZBI	0.037	−0.943	1.01

*small effect; ** medium effect.

Discussion

This study provides evidence that adapted dance is feasible and enjoyable for persons with ADRD. We observed all dance participants either smiling, laughing, giggling, and/or clapping during the dance sessions. The adapted dance choreography was feasible as all dance participants were able to perform the routines and do so without falling or losing their balance over the 12-week period. The frequency of the testing was acceptable to both the person with ADRD and their caregivers. We received no concerns regarding the duration and frequency of the testing sessions. The dance sessions, usual care group activities, and testing were acceptable by participants with ADRD and their caregivers. We solicited feedback from the caregivers regarding the study and the only feedback received was from four caregivers who suggested scheduling dance sessions where caregivers could attend and/or participate in dancing. This is an important consideration as then the caregiver could actively participate with their loved one in an enjoyable activity. These same four caregivers reported observing their loved one with ADRD dancing at different times of the day sometimes without music playing. They all reported they had not observed this type of behavior prior to the dance study participation.

Dance sessions were well attended over a 12-week period with a 90% or greater attendance rate. Similar findings were noted in a tango dance study conducted during the pandemic with dementia participants with an average attendance of 90%.⁶⁵ While studies that included endurance/strength training (not including walking) have had an average attendance rate of 70%.⁶⁶ Although the dance sessions were scheduled for 60 min, ADRD participants were not expected to dance this entire time. As noted previously, 20 to 60 min of physical activity has been found to be beneficial for persons with ADRD.^21,57 Our dance participants actively danced an average of 35 min per session twice per week for 12 weeks. The recommended physical activity for persons with ADRD is to achieve 150 min of physical activity per week as tolerated by the individual.⁶⁷ Since our participants tolerated 35 min per session, increasing the number of sessions per week could have brought us closer to the 150 min per week recommendation. This may also improve our intervention dose-effect on the measured outcomes. Based on the tolerance and high adherence rate of this intervention, we do think future studies should schedule dance three times per week for 30-min sessions.

Another important consideration is the study design. This study planned to use a crossover design to ensure our comparison group (usual care group) received the benefits of the intervention at the end of the 12-week period. However, none of the usual care group participants continued past the initial 12-week study period. In Year One, the pandemic interrupted our study and none of our usual care group participants at the ALF were able to begin the dance sessions. In Year Two at the adult daycare center, feedback was received from 3 of 4 usual care group participants as to why they did not want to attend the dance sessions. Reasons included “I do not like to dance” (n = 1), “I want to play the game (puzzles)” (n = 2), and “My feet hurt too much” (n = 1). The dance sessions were scheduled at the same time as the puzzles or a social activity at the adult daycare center. Thus, these participants may have been accustomed to sedentary (seated) activities, and this had become their routine as it is known persons living with ADRD are highly sedentary and engage in little physical activity.⁶⁸

An interesting finding was the ability of dance participants to recall dance choreography weekly. For example, six out of eight dance participants were able to respond to musical cues and perform the dance movements without any verbal cues from the dance instructor. Two of the six participants had lower MoCA scores, and we did not anticipate they would be able to recall dance movements. We noted this occurred with dance routines taught in weeks 1–3 that were repeated weekly for 10–12 weeks. The repeated exposure to the dance movements likely were easier to recall than the other dance routines. Although we did not intend to assess memory or recall of dance movements, once we observed this occur with one dance participant, we began tracking the dances, participants, and number of sessions where the music was the only cue for the movements. We consider this a significant finding that supports existing research on the music-brain connection.

Clinicians should consider adapted dance as a therapeutic activity and part of an exercise prescription for persons with ADRD. In the United States, more adapted dance prescription opportunities should be available and be covered by health insurance companies. Although our study had choreography, the benefits of movement cannot be overstated. Moving to music, whether structured or improvised, engages people with ADRD in physical activity. Important considerations for planning dance activities are having adequate space, appropriate supervision to ensure safety, duration and frequency of the dancing, time of day, caregiver participation, and selection of music. It is also important to have the ability to adjust the tempo of the music that does not alter the music sound quality. Although we did not observe any participants become agitated during the dance sessions, we recommend having a plan in case this occurs.

Limitations

Year One of this study took place during the COVID-19 pandemic at an ALF that interrupted our ability to offer the dance classes to our control group. These ALF participants were eager to begin dance sessions based on our conversations with them. If we had been able to continue the study at the ALF, we may have seen increased participation in the dance sessions. When comparing the ALF setting to the adult daycare setting, we noted that our dance sessions at the ALF setting were in a separate space without view of other simultaneous activities such as bingo or crafts. While, at the adult daycare setting, our dance sessions were in a room with direct view of other activities taking place which seemed to distract our dance participants. Future studies should ensure to limit distractions as much as possible. Future studies will need to be adequately powered to improve reproducibility and detect potential effects of the intervention. There were a greater number of total participants from the adult daycare than the ALF setting that may have impacted the study findings as those who were adult daycare participants resided at home with their caregivers compared to ALF participants who were not at home. Future studies should ensure participants are from the same setting or at least consider potential impacts of the different environment.

Conclusion

Current recommendations are for persons with ADRD to engage in 150 min per week of physical activity.⁶⁷ Yet, those with ADRD are more likely to remain sedentary that is associated with higher mortality and morbidity.⁶⁸ The goal is to engage persons with ADRD in enjoyable activities that promote lower body movement such as dancing. We recommend people with ADRD dance either at a community site dance class or at home using online resources. If the person with ADRD experiences joy with an activity, then they may be more likely to want to repeat this activity. It is important to design interventions that support joyful moments in the daily lives of people with ADRD. This not only improves the quality of life for the individual living with ADRD but can also positively impact their caregivers. In conclusion, 12 weeks of adapted dance was shown to be feasible and enjoyable for persons living with ADRD whether in an ALF or adult daycare environment. Future studies should consider increasing the frequency of the dance sessions per week and ensuring adequate sample size to assess the impacts of the intervention.

Footnotes

Acknowledgments

The authors would like to acknowledge the Council on Aging of West Florida for their support.

ORCID iD

Crystal G Bennett

Author contributions

Crystal G Bennett (Conceptualization; Formal analysis; Funding acquisition; Investigation; Methodology; Supervision; Writing – original draft); Rodney P Guttmann (Investigation; Methodology; Project administration; Writing – original draft); Madeleine E Hackney (Conceptualization; Methodology; Writing – review & editing); Raid Amin (Formal analysis; Writing – original draft); Savannah Weaver (Writing – original draft).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding support from the Ed and Ethel Moore Alzheimer's Disease Research Program at the Florida Department of Health. Savannah Weaver received funding support from The University of West Florida Office of Undergraduate Research.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Madeleine E Hackney is an Editorial Board Member of this journal but was not involved in the peer-review process of this article nor had access to any information regarding its peer-review. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The data supporting the findings of this study are available on request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.

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