Addressing issues related to geropsychiatry and the well-being of older adults
“I get up. I walk. I fall down. Meanwhile, I keep dancing.” (Rabbi Hillel)
The movement and music associated with dance plays an important role in many individuals' lives and is closely associated with memory. Childhood and adult memories are often filled with moments in which we danced to be free, danced when we were broken and had fallen, danced because we were happy, and danced just because it was in our blood. We each recall moments associated with dancing, such as: mastering skips and gallops in first dance classes, spinning in circles in the long summer grass until falling, dancing until you could no longer stand on your feet on your wedding night, and swing dancing with an older brother when you were 11 years old and flying across the room without a care in the world. It is in these moments that dance, movement, and music become imprinted on the body and mind. Because of its deep connection, dance has the potential to be initiated as individuals age without conscious thought.
In the current article, narrative reflections are shared about experiences with, and the potential of, dance as a therapeutic intervention for older adults diagnosed with dementia-related diseases. The article is structured as a dialogue between the authors. This structure was chosen specifically because it mimics dance as a dialogical encounter between individuals and movement and music.
Personal Origins of Dance in Our Lives
J.L.L.: Before I was a nurse, I first became intrigued with the potential of dance as a therapeutic intervention when working as a personal support worker (PSW) in a long-term care facility. I often worked the evening shift on a locked unit for individuals with dementia-related diseases. We had tea and cookies every evening at 8:00 p.m.—just prior to bedtime. This was an important ritual, which I tended to supplement with a selection of music. We listened to songs, such as Louis Armstrong's “What a Wonderful World,” Frank Sinatra's “You are the Sunshine in My Life,” or Bing Crosby's “I'll be Seeing You,” among many more.This evening ritual led to dancing (or at least some rhythmic movement, such as swaying, clapping, or tapping of hands and feet) and sometimes singing. No matter what the level of anxiety may have been earlier in the evening, it appeared that most patients became relaxed and engaged when I turned on the music. Patients became more enthusiastic when I started dancing or when a few of us would dance together. They would also then begin to mimic the movements.This ritual also led to mood and behavioral modifications. I remember one patient whose usual behaviors involved repetitive walking of laps around the unit and constant mumbling of incomprehensible sounds. However, when the music started, she transformed: a smile would appear on her face and she would begin humming the song and tapping her hands and feet to the rhythm. It was wondrous then to hear her sing a few words, and often she would sing the whole song. Another patient who was new to the unit had some cognitive capacities still intact. He often experienced a high level of distress and anger when he could not articulate what he wanted to say or when he was incontinent. However, he almost always started dancing during this evening ritual. His wife was present one evening and he swept her off her feet and they started dancing. Before she left that night, I recall her saying, “He was always a romantic. We used to always dance like that. I haven't seen that side of him in a long time.” She had tears in her eyes and, at that moment, I recognized the power of dance in bringing you back to the past and enlivening you in the present.
R.B.: I have always known first-hand the physical, psychological, and spiritual benefits of dance, having trained as a professional dancer with Canada's National Ballet School (NBS) and danced with the English National Ballet and Israel Ballet. It was only when I began teaching dance classes for older adults that I realized the universality of these benefits. I was worried the first time I met dance class participants in a long-term care residence for individuals with dementia. When I saw everyone stooped over in wheelchairs, I was not sure if dance could physically or emotionally move them. These fears were squashed as soon as the music and dancing began. It was as if the patients were waking up from a deep sleep and rediscovering their bodies. I remember one woman in particular. She was petite and appeared to have difficulty speaking; her posture was initially that of someone who was tired and weak. All it took was a waltz and bright pink scarf to turn her into a dancer. The figure eights she drew in the air with her scarf extended the range of motion of her joints in which she flexed and extended her arms. “I didn't know she could move like that,” remarked one of the PSWs who worked with her regularly. It was as if all she needed was a good enough reason to move and, with dance, she now had one.Another memory I had from my first few classes teaching this group was one participant's direct feedback. As the music came to a close and one dance ended, there was a pause before the next, at which point the participant shouted to the dance instructors, “You are all doctors—giving injections of happiness.” My suspicions were confirmed: at any age dancing was joy and a reason to keep moving.
Dance and Aging: Finding Its Place
Aging is often associated with alterations in physical functioning and varying degrees of cognitive impairment (Abreu & Hartley, 2013; Kraft, 2012). Subconscious acts (i.e., movement and thinking) can become cumbersome, requiring deliberate and conscious actions for individuals with dementia-related diseases. In this population, the nature of deliberate and conscious actions is complicated by physical and neurological symptoms associated with movement, memory, and language. Dementia-related diseases include a range of cognitive, behavioral, and psychological symptoms (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012). For some individuals, memory issues may present as the primary symptom, whereas for others dementia may manifest as communication, mobility, and emotional difficulties. This variability makes it difficult to develop any single treatment, intervention, and/or programing for this population.
Dance is able to address this challenge of variability in several ways because it is multifaceted and not just physical movement. There is a cognitive component not only in the memory required to repeat a movement, but in the coordination of movements to music. There is also often a narrative component to dance. Even if there is not a specific story being told, the movement is typically directed by some type of idea. In addition, through dance, one is able to express emotion without explicitly using spoken language. Dance has also always traditionally been experienced by an audience. Although scientific theories (e.g., mirror neurons [Berrol, 2006]) may help explain how dance is experienced, it is known that the joy of dance can be experienced simply by viewing it. For individuals with dementia, dance may therefore remain an inclusive activity. Even individuals with limited movement, who are only able to watch, are not left out of the experience.
It is no surprise then that researchers have begun quantifying and qualifying these benefits. From the perspective of caregivers, Palo-Bengtsson and Ekman (2000) found that dance enhanced the emotional well-being of individuals with dementia whether they were dancing or observing others dancing. This finding was corroborated by Ravelin, Isola, and Kylma (2013), who found that observing a dance performance was an active and emotional experience for individuals with dementia. In a randomized controlled trial, Hokkanen et al. (2008) found small effects of dance on cognition and self-care abilities in individuals with dementia. In addition, in a systematic review of 10 studies exploring the effects of dance as a psychosocial intervention in care homes, Guzmán-García, Hughes, James, and Rochester (2013) reported decreases in problematic behaviors, and enhanced mood, cognition, communication, and socializing after dance sessions. However, studying these programs is challenging given the setting and vulnerabilities of this population. Most studies provided sparse descriptions of the actual dance interventions used, making it difficult to replicate and compare. Guzmán-García et al. (2013) made several recommendations for developing this field of research and the evidence base for what many already intuitively know. It is now up to researchers and stakeholders to properly build this literature so that dance may be prioritized appropriately in the care of individuals with dementia.
Dance Programming in Long-Term Care
J.L.L.: Recently, I was invited by the Health Initiatives and Research consultant (R.B.) at NBS to attend a dance session for individuals with dementia in a long-term care facility. As a professionally trained dancer, R.B. was active in developing dance programs for individuals with chronic illnesses. I was instantly intrigued because of my past experiences.
R.B.: The program was developed through a collaboration between dance experts from NBS and experts in aging from Toronto's Baycrest Health Sciences. After learning about the challenges of this population, the dance experts developed a dance program specifically for individuals with moderate to severe dementia in long-term care. Although the NBS–Baycrest program is not the first of its kind for this population, the intention was to develop a systematic approach that could be replicated (i.e., facilitated by anyone trained). When ready for dissemination, this approach will create a quality standardized approach to teaching dance to this population and help lay the foundation to study its effects.
J.L.L.: I was not sure what to expect when R.B., the other instructors, the pianist, and I first arrived in the room. I was expecting something more formal than my informal rituals of dance and music where I worked previously. Although my observations were not part of an actual study, I closely observed participants' responses as I participated in the dance class.Slowly, patients started walking in and some were pushed into the room in wheelchairs. Some patients appeared excited, as if they knew what was going to happen, whereas others had their heads down and appeared disinterested. The first instructor moved into the center and the pianist started playing. The music included familiar, older songs. In a seated position, the instructor began the dancing with movements of varying parts of the body, including hands, arms, and legs. I was impressed when some participants instantly began mimicking the movements and dancing. One man caught my attention. He arrived in a wheelchair with his head down. He began to engage after a couple of dances, particularly when one of the instructors worked with him individually. He continued to engage in the dancing even after the instructor moved back to the center. There were many other examples of participants coming “alive.” After observing these changes and familiarizing myself with the emerging body of literature, I recognized that nurses could learn from dance experts and collaborate regarding dance programming in long-term care.
Embedded in nurses' roles is the responsibility to lead and collaborate with others to develop client-centered programs that result in the best possible outcomes (College of Nurses of Ontario, 2009). For nurses with minimal exposure to dance, an initial step would be to familiarize themselves with the literature and initiate collaborations with dance experts. As current leaders in long-term care, nurses can play a central role in further implementing and adding to the empirical literature about the use of dance as a therapeutic intervention for individuals with dementia-related diseases. In addition, nurses can work with unregulated care providers to assess patients who may be candidates for dance programs and evaluate the impact on physical and mental capacities.
NBS and Baycrest are in the process of refining their dance program for individuals with dementia. The next step is to conduct an evaluation of the program (currently being piloted at Baycrest Health Sciences) and use this information to further tailor the program. Following this evaluation and the development of appropriate dissemination tools, they aim to research the benefits of their specific dance program in terms of its physical and psychosocial impact on individuals with dementia, as well as any potential benefits for health care professionals also participating (e.g., PSWs). The program may then be effectively disseminated and adopted by long-term care facilities in collaboration with dance experts. In addition, the currently ongoing research may be useful in informing and guiding nurses' practices and long-term care facilities' implementation of dance programs. At this stage, interested organizations can contact R.B. (
firstname.lastname@example.org) to follow the program's progress. There are many dance organizations that long-term care facilities could collaborate with, including community dance groups or larger organizations, such as NBS or the equivalent in other countries.
R.B.: The change I see in participants from the beginning to the end of the class is often remarkable. Typically, I catch a few participants even dancing out of the room as the class comes to an end. As I watch them fade down the hall, I wonder how long the dancing, and the joy it has brought them, will last. I also see changes in participants from week to week. There was never an expectation that participants' engagement would improve over time, but it has for many. Although most participants have no idea who we are when we arrive each week, many appear to recognize the dances as movements they have done before. The hope is that the research will someday be able to make sense of these observations and provide answers to our questions. However, in the meantime, we just keep dancing.
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