Exploring dance as a therapy for symptoms and social interaction in a dementia care unit
This pilot study examined whether Wu Tao dance therapy improved symptoms of agitation and interaction between staff and clients in a dementia care facility
Debbie Duignan, BA, RMN, is senior behaviour consultant; Lynne Hedley, BSc, RN, is manager; both at Dementia Behaviour Management Advisory Service, Alzheimer’s Australia WA; Rachael Milverton is fourth-year undergraduate BSc student (occupational therapy), Curtin University of Technology, Perth, Australia.
Duignan, D. et al (2009) Exploring dance as a therapy for symptoms and social interaction in a dementia care unit. Nursing Times; 105: 30, early online publication.
Background: There have been many debates about the use of some atypical antipsychotic drugs in managing agitation in dementia care. Much research has also been carried out in the area of psychosocial interventions, which can include dance therapy.
Aim: To evaluate Wu Tao dance therapy as an intervention for dementia and assess its impact on agitation.
Method: A pilot was carried out lasting four weeks, involving six clients with dementia attending dance sessions with staff members in a residential dementia care facility. Agitation was measured using the Cohen-Mansfield Agitation Inventory (CMAI).
Results: Agitation scores were reduced in four out of six residents and there was an overall average reduction of 6.16 in pre and post scores on the CMAI. The therapy lifted the spirits of both residents and staff, and a therapeutic bond between the two groups developed.
Discussion and conclusion: Wu Tao is an experience for all, and it is possible that this therapy can reduce agitation and bring life and fun to residential facilities.
Keywords: Dementia, Older people, Dance therapy
This article has been double-blind peer-reviewed
The overall aim of this project was to evaluate the effectiveness of Wu Tao dance therapy for people with dementia living in low-care facilities, and to assess the impact on agitation.
The aim was to include care staff in the dance group and monitor carer stress in relation to working with clients experiencing high levels of agitation.
The key objectives of Wu Tao dance therapy are to:
- Lift mood;
- Create a therapeutic bond between staff and residents;
- Create a fun environment;
- Reduce carer stress and increase their confidence;
- Examine and measure changes in client agitation;
- Encourage friendships between residents;
- Provide staff with skills in Wu Tao dance therapy;
- Continue dance therapy in the facility.
The Dementia Behaviour Management Advisory Service (DBMAS) supports carers of people with dementia. It is run under the auspice of Alzheimer’s Australia WA and funded by the Australian government.
The programme provides a range of services including clinical support, assessment, care planning, education and training.
Given the difficulties that people with dementia encounter daily, the DBMAS team felt a new psychosocial intervention/non-pharmacological treatment in the form of dance could be introduced to dementia care facilities. The aim was to alleviate agitation/anxiety and promote a bond between carers and clients.
DBMAS has for the last 12 months implemented many other psychosocial interventions, such as aromatherapy and music therapy, and we have received extremely positive feedback. Therefore, introducing dance therapy was a natural progression, and would incorporate social stimulation and exercise.
The plan was therefore to introduce Wu Tao dance in a facility and try to measure any changes within the group and individuals. While staff hoped to see some positive impact, they were also aware that this experience may have little or no impact on residents. Staff expressed scepticism about the value of this type of therapy before it started.
In researching other articles on dance, it was evident that exercise alone improved physical ability and sleep (Burgener, 2009).
There is limited research on the subject, yet the literature sourced suggested that people can meet and cross all barriers through dance (Greenland, 2009). However, no one had ever tried Wu Tao with this specific client group.
When referring a resident to DBMAS, care facility staff report that they often find the effects of agitated behaviour the most challenging. The DBMAS team receives many referrals relating to this problem and its associated difficulties.
People with severe dementia can be a neglected group regarding their treatment needs (Boller et al, 2002).
Agitated behaviours are particularly common in some people with a dementia-type illness, and may be reported most frequently in those living in residential care (Boller et al, 2002).
Agitation is not a diagnostic term; it is used to describe a group of symptoms including aggression, wandering, calling out, screaming and verbal abuse. These behaviours can pose a challenge for nursing staff.
There has been a gradual introduction of non-pharmacological therapies over recent years to manage agitation (Douglas et al, 2004). These aim to address residents’ unmet needs which may cause these difficulties (Camp et al, 2002). Therefore, a more insightful approach to meeting these needs could decrease feelings of loneliness, boredom and sensory deprivation.
While medication does have a role in treating agitation and dementia, Sultzer (2003) showed that antipsychotics only moderately improve symptoms of agitation and psychological disturbances. There is also some concern about side-effects.
Wu Tao (The Dancing Way)
Wu Tao (pronounced ‘woo dow’) is otherwise known as ‘The Dancing Way’.
This dance was developed by Michelle Locke from Perth in Western Australia (Wu Tao, 2009; see www.wutaodance.com). A former ballet dancer, she was forced into early retirement due to a back injury in 1983. After many years, she found the only effective pain relief was Japanese shiatsu.
Combining her interest in people and emotions with her new-found love of shiatsu, she created Wu Tao.
This therapy combines gentle movement, music and meditation which have been designed to harmonise the flow of energy, and is suitable for people from all walks of life and ages. It has origins in oriental medicine.
Wu Tao consists of five dances that balance the body by activating the meridians (energy channels), which it is said results in a feeling of great harmony. It has been described as allowing the body to be a vehicle for the soul to speak, allowing people to express themselves through movement, however small (Chou et al, 2002).
This dance has dietary, psychological and spiritual aspects which are incorporated into its teaching. Wu Tao involves both movement and stillness, both doing and being. It can bring participants to a place free from chatter and experience the stillness of their own being.
The Wu Tao dance has been described as finding the ability to go with the flow of life, feeling still and ending the struggle, and has recently been launched internationally (Wu Tao, 2009).
Dance has been used as part of creative art therapies in the western world since the 1950s (Nystrom and Lauritzen, 2005).
The creative arts have been shown to have a critical role, since people with dementia often lose their ability to converse in a straightforward way. Through the use of movement and dance, clients can communicate their experience, and relatives’ and carers’ positive role can be enhanced.
Working in a dementia unit can be challenging for many staff, and can result in carer stress (Brodaty, 2003). The stressful nature of providing personal care can easily be underestimated. This can impact strongly on both staff members and care recipients. Over the years, it has been recognised that caring for people with a dementia-type illness is an extremely difficult task (Smith, 1992; Benner and Wrubel, 1989).
Research has shown that encompassing dance as an activity can blur the boundary between carers and those cared for (Coaten, 2001).
Dance can allow a forum of celebration and richness into the lives of everyone taking part. Chou et al (2002) showed that enjoyment and involvement between carers and clients increased job satisfaction.
Hokkanen et al (2003) found staff observed a change in residents’ behaviour during a pilot study of a dance and movement group. Residents appeared to interact more socially, with both each other and care staff.
In February 2009, six residents from a low-care facility were identified with symptoms of agitation according to the Cohen-Mansfield Agitation Inventory (CMAI). Pre-session scores were taken, thus giving a clearer indication of the level of agitation. The average score was 66.83 (inclusion criteria >39).
This cohort consisted of five women and one man, aged between 81 and 92 years, with a mean age of 85.1. All participants had a diagnosis of dementia. The senior behaviour consultant from DBMAS assessed participants using the Global Deterioration Scale (GDS) (Reisberg, 1982), and ratings were identified from moderate to severe in terms of degrees of cognitive loss.
Each client consented to join the Wu Tao dance sessions and had the option to withdraw at any time. Relatives were informed of the sessions, and family members gave consent for those clients who were unable to consent verbally.
The senior behaviour consultant observed all clients through their participation. Any non-verbal/verbal indications that clients did not wish to attend the sessions were therefore acted on. However, it became apparent by verbal indications from clients, observations and staff comments that they enjoyed Wu Tao. These sessions occurred weekly over four weeks.
A therapy room was established in the facility, which was quiet, relaxing and spacious enough to allow movement. Chairs surrounded the dance area, enabling residents to sit down during the session if they wished.
The environment plays an important part; not only does it encourage participation and eliminate risk, but it also enhances spiritual well-being.
Dance sessions can be modified accordingly to account for the client group’s needs; for example, breaking the steps down to be simple and concise, and allowing directions to be followed more easily.
Although the dance session was slightly modified, the instructor said: ‘I thought that we did it [the dance] quite differently, but when I think back we actually didn’t, it was only the stretches at the beginning that really changed.’
It was important to include a midway break in the dance session, which gave residents and the instructor the opportunity for drinks and refreshments. For residents to participate comfortably it is important to wear suitable clothing.
Some residents who participated were unable to express themselves verbally, and were therefore given the opportunity to use Wu Tao dance as a tool for expression. Coaten (2001) suggested that dance could be enlightening, however small the reaction. The opportunity for expression was evident through the communication and connection shown between residents and staff.
Assessors took part in the ongoing dance sessions. This enabled visual assessment of non-verbal cues during the dance to take place. For example, smiling and interaction with staff members was noticed, and residents who usually had disagreements tended to group and bond together.
Changes were monitored via follow-up phone calls each week to the facility and recorded in subjective evidence; see Table 3 and for the question relating to relationship changes and staff observations.
While low cost is seen as a positive factor for Wu Tao as a treatment for agitation in dementia, this still needs to be considered when planning budgets.
The dance pilot indicated a number of positive and negative factors that impacted on the results, including those outlined in Box 1.
Box 1. Positive and negative factors affecting the pilot
|Positive factors||Negative factors|
|Non-pharmacological||Staff acceptance of Wu Tao needed to enable them to encourage residents to participate|
|Easily integrated into daily routine||Sourcing instructors|
|Lowers agitation||Understanding Wu Tao|
|Reduces carer stress||Time constraints for staff|
|Encourages carer/resident interaction||Short trial|
|Physical activity/no limitations apply||May only be appropriate for low to moderate levels of dementia (further research will need to be conducted)|
|Low cost||Staff reluctance and motivation|
A post CMAI measure was used following the final Wu Tao session to identify any changes. The result showed the average score was now 60.67, meaning an average reduction in agitation scores of 6.16 (See Table 1 for all CMAI scores).
Table 1. Cohen-Mansfield Agitation Inventory (CMAI) – Results
|Client||Initial score||Follow-up score|
As Table 1 shows, four out of six participants’ scores decreased, indicating that some reduction in agitation was noted. However, two scores increased. Both residents with increased scores had medication changes throughout the pilot period, which may have contributed to their increased scores.
Questionnaires were also collected during the pilot to monitor resident and staff responses to the intervention. Tables 2 and 3 outline the changes observed and described by both residents and staff from the initial and subsequent Wu Tao sessions (different numbers answered each question in Table 3).
All participants in the dance group, which included residents and staff, indicated that Wu Tao was a pleasurable and enjoyable therapy. Many felt this could be incorporated into their weekly activity programme and, given the correct training, could be an activity where both staff and residents could benefit.
As anticipated, some residents did have difficulty orienting themselves adequately to the instructions. This was mainly left and right side orientation, which is a minor difficulty as the dance can still be completed.
Table 2. Residents’ responses to questionnaires
|Did you enjoy the dance session?||100%||0%|
|Do you feel the dance group has improved your mood, that is, made you happier?||83%||17%|
|Do you feel the dance has helped you? How?||83%||17%|
|Would you like to attend a group like this each week?||83%||17%|
|Did you think it was good that staff joined in your group?||100%||0%|
|Did the dance group make you feel differently?||83%||17%|
Table 3. Staff responses to questions
|Do you feel that the Wu Tao dance group was beneficial to residents and staff? If so, how?||100%||0%|
|Do you feel it has increased your job satisfaction?||92%||8%|
|Have you noticed any relationship changes in the group?||60%||40%|
|Did you notice any changes in residents’ behaviours throughout or following the sessions? And if so what did you notice?||83%||17%|
|Do you feel these groups could be introduced into your facility by staff? And if so, would it be useful to continue?||100%||0%|
|Did you attend the dance session?||100%||0%|
|Do you feel that relationships between residents in the group may have changed? In what ways?||75%||25%|
|Have you noticed changes in the way that residents who participated in Wu Tao react differently to those who did not?||50%||50%|
|Do you feel that a weekly dance group involving staff and residents could increase your own well-being? If so how?||100%||0%|
Initially, many residential staff were hesitant about Wu Tao as a therapy. Many did not believe it could reduce agitation in clients with a long-standing history of dementia behavioural disturbances.
However, after education sessions on dance therapy and its positive impact, staff were willing to be involved in the Wu Tao pilot.
Many said they were pleasantly surprised by the relaxing and enjoyable experience. By the end of the first session, Wu Tao was very well received by both staff and residents. Many staff reported they were eager to continue the dance sessions outside their work environment.
Staff at the facility noted that the group dynamics had changed significantly, becoming more positive among both residents and staff. A positive working environment is critical in dementia care, and this highlights the value of Wu Tao and dance in enabling expression both verbally and non-verbally.
To enable dance sessions to be conducted in a facility environment, education and support for care staff is extremely important. The positive approach from staff helps to promote a relaxed and social environment for all involved, allowing the group to form a therapeutic bond.
It is important to anticipate negative reactions to alternative therapies when starting sessions. These reactions could be due to a lack of existing research on dance therapy in residential facilities, along with stereotyped views towards alternative forms of treatment (Normann, 1999).
Symptoms of agitation make living with dementia more difficult for both clients and those who support them. From a subjective point of view, it seems that Wu Tao has possibly improved the lives of those with dementia.
It may provide a non-pharmacological way to aid treatment and prevention of agitation in dementia; this may not only help integrate staff and residents but also lift the spirits of those involved.
Wu Tao is an experience for all, and it is possible that this therapy can reduce agitation and bring life and fun to both residents and staff in residential facilities.
For further information on Wu Tao in dementia, click here.
We would like to thank the facility of Brightwater Care Group in Joondalup for taking part in this pilot study, and for their dedication and support for older adults with dementia. Without this facility and their involvement, this project would not have been possible.
We would also like to thank Kaye Patullo and Michelle Locke, the Wu Tao dance instructors, for their patience and enthusiasm in this pilot.
- Wu Tao lifted the spirits of both residents and staff, through increased communication and laughter during and after each session.
- Staff interacted with each other more easily and a greater level of relaxation was noted.
- A therapeutic bond between staff and residents developed. When asked ‘What did you think about the staff joining your group?’ one resident replied: ‘It teaches them to be like us.’ Much laughter and verbal interaction was evident from participants.
- Staff indicated that this form of therapy would be beneficial to their own well-being. One staff member said it provides a ‘lighter side of the work’; the number of requests from staff to attend ‘out of work’ classes also suggested this.
- Agitation, through the results of the CMAI, was reduced for four residents.
- The facility aims to continue the dance therapy, provided funding allows.
Benner, P., Wrubel, J. (1989) The Primacy of Caring. Menlo Park, CA: Addison-Wesley.
Boller, F. et al (2002) Clinical features and assessment of severe dementia: a review. European Journal of Neurology; 9: 2, 125–136.
Brodaty, H. (2003) Nursing home staff attitudes towards residents with dementia: strain and satisfaction with work. Journal of AdvancedNursing; 44: 6, 583–590.
Burgener, C.S. (2009) Effectiveness of community–based, non-pharmacological interventions for early-stage dementia. Journal ofGerontological Nursing; 35: 3, March 2009.
Camp, C.J. et al (2002) Mental health services in nursing homes: Use of nonpharmacologic interventions among nursing home residents with dementia. Psychiatric Services; 53: 1397–1404.
Chou, S. et al (2002) Staff satisfaction and its components in residential aged care. International Journal for Quality in Health Care; 14: 3, 207–217.
Coaten, R. (2001) Exploring reminiscence through dance and movement. Journal of Dementia Care; 9: 19–22.
Douglas, S. et al (2004) Non-pharmacological interventions in dementia. Advanced Psychiatry Treatment; 10: 3, 171–177.
Hokkanen, L. et al (2003) Dance and movement therapeutic methods in management of dementia: A randomized controlled study. Journal ofthe American Geriatrics Society; 56: 4, 771–772.
Greenland, P. (2009) Five minute love affair. Journal of Dementia Care; 17: 1, 30-31.
Normann, H. (1999) Alternative treatments in dementia. Journal of Clinical Nursing; 8: 4, 353–359.
Nystrom, K., Lauritzen, S. (2005) Expressive bodies: demented persons’ communication in a dance therapy context. Health (London); 9: 3, 297–317.
Reisberg, B. et al (1982) The Global Deterioration Scale for assessment of primary degenerative dementia. The American Journal of Psychiatry; 139: 1136-1139.
Smith, P. (1992) The Emotional Labour of Nursing. Macmillan: Basingstoke.
Sultzer, D.L. (2003) Psychosis and antipsychotic medications in Alzheimer’s disease: clinical management and research perspectives. Dementia and Geriatric Cognitive Disorders; 17: 1–2, 78–90.
Wu Tao (2009) About Us. Creator of Wu Tao – Michelle Locke.