Dance/Movement Therapeutic Methods In Management Of Dementia

To the Editor: Dance and rhythmic movement has been used in expressing and modifying emotions for centuries. Dance/Movement Therapy (DMT) as a form of art therapy has been used in the Western world since the early 1950s.1-3 Because DMT combines music, light exercise, and sensory stimulation, it would seem to fulfill the American Academy of Neurology's recommendations for nonpharmacological treatment of dementia.4 We developed DMT procedures applicable to dementia nursing homes, where staff does not have formal dance/movement therapist training and evaluated whether weekly DMT sessions over a 4-month period would improve the verbal and cognitive level or alleviate the behavioral symptoms of patients with dementia. Four patients with moderate to severe Alzheimer's disease formed the study group. All patients were receiving cholinesterase-inhibitor treatment and antipsychotic or antidepressant medication, which remained stable during the intervention. The dance/movement group met once a week and was open to other nursing home habitants as well. There were 16 sessions that lasted for 30 to 45 minutes each. The sessions had the same structure each time: warm-up, theme development, and closure. A registered dance therapist (BH) trained the staff and supervised the process. The patients and their spouses signed an informed consent to participate in the study. Overall cognitive level was assessed using the Mini-Mental State Examination (MMSE)5 a week before, during (at Weeks 6 and 15), and 4 weeks after the intervention. Behavioral symptoms were assessed using the Neuropsychiatric Inventory6 at baseline, Week 12, and 4 weeks after the end of the intervention. A picture-description task was used to elicit comparable samples of narrative speech. Assessments were performed twice a week before the beginning of the intervention (double-baseline), during the intervention (at Weeks 1, 6, 10, and 15), and 4 weeks after the end of the intervention. During the intervention, verbal output was measured both before and after each session. Five different pictures were used. The Cookie Theft picture from the Boston Diagnostic Aphasia Test Battery7 was presented in the first (the first baseline) and last (follow-up) test sessions. The other four pictures were prints of colorful paintings with approximately the same number of details. Samples were videotaped, transcribed, and scored using the number of information units (IUs) as a measure of narrative speech.8, 9 The dance/movement group seemed to have a favorable effect on language abilities. The subjects produced on an average more IUs in narrative speech immediately after a group session than before it, although the difference did not reach statistical significance (all four sessions combined, Sign test P = .134). There was individual variability in the increase of IUs, and the immediate effect seemed to be shrinking toward the end of the study period. The subjects also produced more IUs at the last part of the intervention period than at baseline. The number of IUs still remained elevated at the follow-up (Figure 1). The difference between the three measures reached statistical significance (Friedman's analysis of variance P = .018). The effect of a dance/movement group intervention on the mean number of information units measured from narrative speech. Baseline = speech samples recorded on two different days before the beginning of the intervention; Last part = speech samples recorded immediately before group sessions at Weeks 10 and 15; Follow up = speech sample recorded 4 weeks after the end of the intervention. The difference between the three repeated measures was statistically significant. The overall cognitive level of the Alzheimer's patients remained unchanged (MMSE scores mostly within two points). The fact that clear progression was not seen during the 5-month study period can be interpreted positively, given the nature of the disease. The behavioral symptoms also remained relatively stable during the study period. We had anticipated a decrease in apathy or depression, but, in general, such an effect was not found. The staff observed an increase in the willingness to interact socially. This pilot study was able to demonstrate the applicability of DMT in a nursing home setting; the sessions were successfully incorporated into the nursing home schedule, and the staff was able to lead the group with monthly supervision. The results concerning the effects of DMT on dementia symptoms are only preliminary. Although a double-baseline paradigm was used, small group size hinders any meaningful statistical comparison and makes generalizations difficult. We still believe that at least some patients with dementia benefit from DMT intervention. Cognitive performance has traditionally not been the focus of DMT research, and therefore it has seldom been measured. In one study with older patients with brain trauma or nonprogressing stroke, cognitive performance was better in a DMT experimental group than in controls.2 This indicates that, under favorable circumstances, DMT may be beneficial to higher cortical functions. Because this is a pilot study, the main interest was in the applicability of this method. A larger and controlled study on the effects of DMT in dementia management will be launched next.