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Effects of Chinese square dancing on older adults with mild cognitive impairment
ARTICLE IN PRESS Geriatric Nursing 000 (2019) 1 7
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Effects of Chinese square dancing on older adults with mild cognitive impairment Shuo Wang, PhD, Huiru Yin, PhD, Xiangfei Meng, Master, Binghan Shang, Master, Qiuyan Meng, Master, Lufang Zheng, Master, Lisheng Wang, PhD*, Li Chen, PhD* School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, Jilin 130021, China
A R T I C L E
I N F O
Article history: Received 29 June 2019 Received in revised form 29 October 2019 Accepted 30 October 2019 Available online xxx Keywords: Cognition Depression Mild cognitive impairment Quality of life Square dancing
A B S T R A C T
The present study aimed to explore the effects of square dancing on global cognition, depressive symptoms, balance, and quality of life of older adults with mild cognitive impairment. We studied 66 older adults with mild cognitive impairment in a large nursing home. Participants were assigned to the intervention group (n = 33) or the control group (n = 33), according to their residential floor, which was determined by coin tossing. The intervention group underwent a 12-week Chinese square dancing routine, while the control group maintained usual lifestyle (without square dancing). Outcomes were assessed at baseline and at weeks 6 and 12. The results showed positive effects of square dancing on all outcomes assessed, especially on depressive symptoms and quality of life-related mental well-being of the participants. This study showed that square dancing is a promising strategy for older adults with mild cognitive impairment and that long-term adherence can be beneficial. © 2019 Elsevier Inc. All rights reserved.
Introduction Mild cognitive impairment (MCI) is a transition state between healthy aging and dementia.1,2 People with MCI have higher conversion rates to dementia than healthy older adults.3 On the other hand, MCI can also reverse to normal cognition or remain stable at the MCI state.4 MCI is characterized by the decline of cognitive function, which is the principal symptom and diagnostic basis of the disease. Compared to the normal population, the MCI population has been shown to have a higher incidence of neuropsychiatric symptoms, of which depression is the most common,5 and is also a risk factor for progression to Alzheimer's Disease (AD).6,7 Similarly, gait dysfunction is more common in the MCI population,8 who are more likely to fall.9 For these reasons, the overall quality of life of older adults with MCI can severely decline over time.10 Therefore, seeking effective strategies to delay or even to reverse cognitive decline at an early stage of MCI is of paramount importance. Currently, non-pharmacological strategies are gaining more popularity due to the uncertain efficacy and possible negative side effects of pharmacological strategies.11 One of the major non-pharmacological interventions is exercise, of which dance is a sophisticated version, one which not only requires mind and body coordination but also the involvement of other components, such as aerobics, music, *Corresponding authors. E-mail addresses: [email protected] (L. Wang), [email protected] (L. Chen). https://doi.org/10.1016/j.gerinurse.2019.10.009 0197-4572/$ see front matter © 2019 Elsevier Inc. All rights reserved.
social interaction and an enriched social environment.12,13 Indeed, studies have already been conducted using ballroom dancing,12,14,15 traditional Greek dancing,16 and specially designed aerobic dancing17,18 for MCI populations. The intervention period for ballroom dancing was 4012,14 or 4815 weeks, and found positive effects on global cognition12,14,15 and mood.12,15 The 24-week traditional Greek dancing showed positive effects on balance and quality of life.16 In contrast, the 12-week specially designed aerobic dancing did not show positive effects on depression, balance, quality of life, or global cognition assessed with scales, though it did show a positive effect on cognitive function, which was assessed with resting‑state functional magnetic resonance imaging (RS-fMRI).17,18 For the Chinese MCI population, there is a lack of dance forms that can be widely applied, primarily due to the complexity and cultural unfamiliarity of ballroom dance and traditional Greek dance, as well as to the uncertain efficacy of specially designed aerobic dance. Square dancing was introduced in China around 2004 and is believed to be an expansion of line dancing.19 Square dancing integrates Chinese style dancing and music with energetic and similar rhythms.20 This dance form consists of music, a group of dancers and leader(s), and is usually conducted in large public spaces. The dance forms are varied, ranging from gymnastic forms to folk dance, disco, and modern dance.21 Square dancing is easy to learn, affordable and equally as entertaining as other popular dance forms. Perhaps this explains why square dancing is becoming popular among middleaged and older Chinese women, with an estimated 100 million practitioners in China.21 Social interaction with peers and the subsequent
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amelioration of loneliness and isolation are significant benefits that accompany square dancing and, importantly, they are also known determinants of active aging.22,23 In this study, we aimed to explore the effects of square dancing on older Chinese adults with MCI. The primary aim was to explore the effect on global cognition, and the secondary aims were to investigate the effects on depressive symptoms, balance, and quality of life. The study hypotheses were as follows. The primary hypothesis: After a 12-week intervention, older adults with MCI in the experimental group (square dancing classes) would show significantly better global cognition compared with those in the control group (usual lifestyle). The secondary hypotheses: After a 12-week intervention, the experimental group would show significantly less depressive symptoms, better balance ability, and higher quality of life compared with the control group. Methods Study design and participants A single-blinded non-randomized controlled trial was conducted to test our hypotheses. The study was set up in a large nursing home in Changchun, China between October 2018 and January 2019. Participants were assigned to the intervention group or the control group according to the floor they lived in, which was determined by coin tossing. The staff responsible for the evaluation were blinded to the allocation of the participants. The study protocol was approved by the Ethics Committee of the School of Nursing of Jilin University (2018102401), and was registered in the Chinese Clinical Trial Registry (ChiCTR1800019116). All the participants provided written informed consent prior to the study. A sample size of 33 was decided to gain enough statistical power for subsequent analyses. This was based on the effective size of dance calculated in a study by Lazarou et al.12 With 80% power and 5% type I error, we estimated that at least 28 participants were required in each group. To achieve these numbers, and allowing for a 20% dropout, we calculated 33 participants were needed per group. Participants were recruited by word-of-mouth, posters and flyer advertisements. Participants were at least 60 years old and met the following four diagnostic criteria of MCI24 26: the participants (1) had shown subjective cognition decline in the previous year; (2) had scored > 24 (primary school education: >20, illiteracy: >17) on the Mini-Mental State Examination (MMSE); (3) had scored < 26 on the Montreal Cognitive Assessment (MoCA) (if education years 12 years, one point was added); and (4) had scored < 26 on Activities of Daily Living (ADL). The participants were excluded if they had been: (1) receiving treatment or taking medicine to treat cognitive impairment or depression recently; (2) suffering from other conditions that could affect cognitive function; (3) suffering from chronic diseases that could affect their ability to exercise; (4) having visual or hearing impairment that could affect communication; (5) exercising regularly in the past six months (30 min/d, 3 d/w). Intervention We chose Jiamusi happy dance aerobics as the intervention. This type of dance aerobics originated in Jiamusi City, Heilongjiang Province, China. It is a moderate-intensity marching aerobics comprised of eight sections that require the use of all the major body parts, including movements of the upper limbs, shoulders, chest-expansion, lateral body bending, lateral body turning, waist and abdomen, and lower limbs followed by cooling down routine. Each section consists
of 3 5 symmetrical and straightforward actions with various movements of the upper limbs that last 3 5 min. For the upper limbs movements, participants swing their arms straight in different directions. When moving the shoulders, participants move their shoulders up and down. For chest-expansion, the participants spread the shoulders back to expand the chest. When doing lateral body bending, the participants swing sideways from the axis of the waist. For lateral body turning, participants rotate the waist 45° to both sides to drive the upper body to rotate. The participants then move the waist and abdomen forward. For the lower limbs movements, participants stand on one leg and kick the other in different directions. Then when cooling down, the participants swing their hips to both sides. The dance is 30 min long, with each section assigned to a piece of music. In the original version, participants lined up and moved forward, making the movements and following the rhythm of the music. However, in the version used for this study, we modified the dance as an in-situ stepping exercise to prevent falls. Participants stood in a queue and stepped in situ but did not move forward. All the movements remained constant. Because the study was conducted during winter, all the dance activities were carried out inside the activity hall of the nursing home. A research staff acted as the lead dancer and danced in the front. Each session lasted 40 min, including a 5-min warm-up (finger gymnastics, joint movements, and stretching), a 30-min dance, and a 5-min cool-down (deep breathing and stretching). The intervention lasted for 12 weeks, with three sessions per week. Participants in the control group maintained their usual lifestyle. Outcome evaluations The outcomes that were assessed in the study were global cognition, depressive symptoms, balance, and quality of life of participants at baseline and weeks 6 and 12. The staff responsible for evaluation received homogenous and comprehensive training. The evaluation staff was blind to the group in which participants belonged, and the participants were instructed by the training staff to not reveal the allocation information when receiving the evaluations. Cognitive function was the primary outcome, whereas the rest were secondary outcomes. All instruments were translated to Chinese and have established evidence of reliability and validity. Global cognition was assessed with MMSE and MoCA, which are both popular tools for assessing cognition. MMSE is particularly recommended for dementia screening (sensitivity: 80 90%, specificity: 70 80%),27 while MoCA is recommended for MCI screening (sensitivity: 90%, specificity: 83%).28 They both have a maximum score of 30, with higher scores indicating better cognition. The test-retest reliability of the Chinese version of MMSE is 0.91, with good content validity and concurrent validity (p < 0.001).29 Similarly, the testretest reliability of MoCA is 0.857, and Cronbach's a is 0.818. The content validity, concurrent validity and construct validity are also good (p < 0.01).30 Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS-15),31 which requires participants to answer with yes or no for a total score of 15. Higher scores indicate more depressive symptoms. For the GDS scale, the test-retest reliability is 0.728, Cronbach's a is 0.793, and discriminant validity is good (p < 0.001).32 Balance ability was assessed with the Berg Balance Scale (BBS).33 The scale includes 14 items, with the score of each item ranging from 0 to 4 that sums to a score of 56, with higher scores indicating better balance ability. For this scale, the inter-observer reliability is 0.992 0.998, the test-retest reliability is 0.968 0.985, and the content validity (p < 0.01) is good.34
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Quality of life was assessed with the Short-Form 12 health survey (SF-12), which is a simplified version of the SF-3635 and shows high correlation with SF-36.36 The scale includes the assessment of general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health. The first four indicators are used to assess the physical component summary (PCS), while the last four are used to assess the mental component summary (MCS). Higher scores indicate a better quality of life. For this scale, Cronbach's a is 0.775, and the criterion validity is good (p < 0.001).37 Treatment fidelity Before the intervention, two staff members with prior professional dance training taught two classes as practice classes. Each class lasted for one hour, with a one day gap between the two classes. In the first class, the two staff explained the essentials and health benefits of the different movements and instructed participants to practice them. After the class, the participants were allowed to familiarize themselves with the movements by watching a dance video with the standard movements. In the second class, the two staff examined whether participants could dance correctly and provided instructions until all participants had adequately learned the movements. During the intervention, one of the staff led the dance in front of the group, and the other staff supervised the movements and guided the participants to ensure that they performed the dance movements correctly. Additionally, some nursing home staff were responsible for safety supervision. The regular allotment of small gifts was used to motivate participants. Participants were required to sign in at the end of each class. Then, at the end of the third class of each week, we gave small gifts to those who did not miss a single class that week. The attendance rate ranged from 63.89% to 100%, averaging 80.29%. Participants missed attending the class only if they were uncomfortable or had plans to go out or had visitors at the time of the class. Statistical analysis Statistical analyses were conducted using SPSS 22.0. The distribution of data was tested using the Shapiro Wilk test, where continuous variables that conformed to the normal distribution were described with means and standard deviations (SD), and those that did not conform to the normal distribution were described with medians and quartiles. Frequency and percentage were used for categorical variables. Baseline characteristics of the intervention and control groups were compared using independent t-tests, nonparametric tests or x2 tests. To measure the outcomes over time, we used a linear mixed-effect model to analyze the effects of time, group and time-by-group. Intergroup and intragroup comparisons were conducted using independent t-tests and paired t-tests (the differences were normally distributed)/nonparametric tests, respectively. The p-value of two-sided tests <0.05 was considered to be statistically significant. All the analyses were conducted based on the intention-to-treat principle, and missing data were imputed with the most recent data.
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the study because of falls (not due to square dancing) (n = 3), discharge from the nursing home (n = 1), or unwillingness to continue the study (n = 1). As a result, 61 participants (31 in the dance group and 30 in the control group) remained and completed the study. The baseline characteristics of the participants are presented in Table 1. The average age of the participants was 81.08 (§6.36) years old, and females accounted for 71.21% of the sample. There were no significant differences (p > 0.05) between the intervention and the control groups in baseline characteristics, including age, gender, education level, body mass index, marital status, comorbidity, the MoCA, MMSE, GDS, BBS, PCS, and MCS scores. Outcome measures Outcomes comparison between dance and control groups across time are presented in Table 2. Fig. 2 shows visual representation of the changing trend. With regard to the results from the linear mixedeffect model, the interaction effects of group-by-time were significant on all outcomes (p < 0.001). Intergroup comparisons at week 6, displayed a significantly lower GDS score in the dance group (DG) (3.48 § 2.32) compared to the control group (CG) (5.06 § 2.72; p = 0.014), and a significantly higher MCS score in DG (65.87 § 17.77) compard to CG (55.72 § 18.60; p = 0.027). However, MoCA scores (DG: 19.97 § 2.97; CG: 18.88 § 4.36; p = 0.240), MMSE scores (DG: 25.33 § 1.90; CG: 24.39 § 3.73; p = 0.204), BBS scores (DG: 44.33 § 6.06; CG: 40.73 § 8.50; p = 0.052), and PCS scores (DG: 64.89 § 21.15; CG: 55.87 § 23.01; p = 0.102) were not significantly different between the two groups. At week 12, the trend persisted with significantly lower GDS scores in DG compared to CG (DG: 2.61 § 1.71; CG: 5.12 § 2.77; p < 0.001), and significantly higher MCS scores in DG compared to CG (DG: 72.08 § 14.57; CG: 54.17 § 17.26; p < 0.001). Unlike week 6, at week 12, MMSE scores (DG: 26.21 § 1.93; CG: 24.06 § 3.88; p = 0.006), BBS scores (DG: 45.15 § 5.96; CG: 40.67 § 8.41; p = 0.015) and PCS scores (DG: 68.18 § 18.25; CG: 52.95 § 21.23; p = 0.003) were also significantly higher in DG compared to CG. However, the MoCA scores (DG: 20.55 § 3.23; CG: 18.79 § 4.62; p = 0.078) still remained insignificant between the two groups at week 12. Regarding the results of intragroup comparisons, we could see that in the dance group, the scores of PCS and MCS were significantly higher at week 6 (PCS: p < 0.001; MCS: p = 0.004) as well as week 12 (PCS: p < 0.001; MCS: p < 0.001) compared to those at the baseline; the GDS scores were markedly lower compared to baseline at week 6 (p < 0.001) and week 12 (p < 0.001); the MoCA scores (p = 0.001), MMSE scores (p < 0.001), and BBS scores (p < 0.001) were significantly higher from the baseline only at week 12. While in the control group, the scores at weeks 6 and 12 were not significantly different from those at the baseline for all the outcomes (p > 0.017). Adverse events During the 12 weeks, no adverse events related to the intervention occurred.
Results Discussion Baseline characteristics The flowchart showing the recruitment and dropout of participants is presented in Fig. 1. We completed the recruitment in October 2018, screening 120 potential participants for the 66 positions. Based on the inclusion and exclusion criteria, 54 people were excluded. During the 12-week intervention, five participants withdrew from
The results from this study provide evidence that Chinese square dancing has positive effects on global cognition, depressive symptoms, balance, and quality of life in older adults with MCI. To our knowledge, this is the first study that explored the effects of Chinese square dancing on people with MCI. We chose square dancing because it is not only easy to learn, but because it is also easy to
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Fig. 1. Flowchart showing recruitment and dropout of participants.
Table 1 Baseline characteristics of the participants.
Age, years Gender, male Education, years BMI, kg/m2 Widowed/divorced/ separated/single Comorbidity MoCA MMSE GDS BBS PCS MCS
Dance group (n = 33)
Control group (n = 33)
p-value
81.06 § 5.17 7 (21.20%) 8 (5.5, 11) 24.17 (21.43, 26.13) 24 (72.7%)
81.09 § 7.44 12 (36.40%) 8 (3, 12) 25.12 § 3.11 20 (60.6%)
0.985 0.174 0.861 0.121 0.296
1 (0, 2) 19.39 § 3.00 25.03 § 2.01 4.88 § 2.85 44.03 § 6.02 52.46 § 21.08 56.86 § 19.85
1 (0, 2) 18.97 § 4.71 24.36 § 3.32 4.88 § 2.77 40.82 § 8.62 54.39 § 23.20 57.99 § 17.37
0.973 0.664 0.328 1.000 0.085 0.724 0.805
Note: Continuous variables were presented as Means § Standard Deviations/Medians (Quartile 1, Quartile 3). Abbreviations: BMI, Body Mass Index; MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
popularize due to the social platform it provides, which is especially beneficial for older participants with MCI. Good attendance and no adverse events supported the feasibility of the intervention. Main findings and interpretations As for the primary outcome, the results of the linear mixed-effect model showed that the changing trends of the MMSE and MoCA scores were significantly different between the two groups. The results of intragroup comparisons showed that, during the 12 weeks, scores in the dance group rose significantly, while scores in the control group presented no significant change. These outcomes indicate that square dancing has the potential to improve cognitive function in people with MCI. The result of MMSE in intergroup comparisons showed a significantly positive effect of 12-week square dancing on cognition in people with MCI. This result is consistent with multiple studies,12,14,38,39 but is inconsistent with the result of Qi et al.18; this could be due to the small sample size (19 participants per group) in their study. Even though the study by Qi et al. was inconsistent with ours, the
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Table 2 Comparisons of outcomes between dance and control groups across time. Scale
Time
MoCA
Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12
MMSE
GDS
BBS
PCS
MCS
Dance group
Control group
Linear mixed-effects model (p-value)
(n = 33)
(n = 33)
Group
19.39 § 3.00 19.97 § 2.97 20.55 § 3.23 25.03 § 2.01 25.33 § 1.90 26.21 § 1.93 4.88 § 2.85 3.48 § 2.32 2.61 § 1.71 44.03 § 6.02 44.33 § 6.06 45.15 § 5.96 52.46 § 21.08 64.89 § 21.15 68.18 § 18.25 56.86 § 19.85 65.87 § 17.77 72.08 § 14.57
18.97 § 4.71 18.88 § 4.36 18.79 § 4.62 24.36 § 3.32 24.39 § 3.73 24.06 § 3.88 4.88 § 2.77 5.06 § 2.72 5.12 § 2.77 40.82 § 8.62 40.73 § 8.50 40.67 § 8.41 54.39 § 23.20 55.87 § 23.01 52.95 § 21.23 57.99 § 17.37 55.72 § 18.60 54.17 § 17.26
0.253
0.075
0.021*
0.041*
0.142
0.026*
Time
Group * time
0.006**
0.077
***
<0.001
<0.001***
<0.001***
**
0.006
Change from baseline (p-value) Dance group
Control group
<0.001*** 0.023 0.001#
0.439 0.243
0.265 <0.001##
0.910 0.299
<0.001## <0.001##
0.451 0.319
0.02 <0.001##
0.366 0.190
<0.001## <0.001##
0.252 0.502
0.004# <0.001##
0.264 0.059
<0.001***
***
<0.001
<0.001***
<0.001***
***
<0.001
Inter-group comparisons (p-value) 0.664 0.240 0.078 0.328 0.204 0.006** 1.000 0.014* <0.001*** 0.085 0.052 0.015* 0.724 0.102 0.003** 0.805 0.027* <0.001***
Note: The scores of scales were presented as Means § Standard Deviations. Linear mixed-effects model and Inter-group comparisons: *p < 0.05; **p < 0.01; ***p < 0.001. Intra-group comparisons: #p < 0.017; ##p < 0.001. Abbreviations: MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
study18 demonstrated the positive effect of aerobic dance on cognitive function, using a quantitative method RS-fMRI, which revealed that 3-months of aerobic dance classes significantly increased the activity of the bilateral frontotemporal cortex. On the contraty, our MoCA result in intergroup comparisons did not show a significantly positive effect. The different results between the two scales assessing global cognition might be due to the fact that the level of difficulty of the MoCA test is higher than that of the MMSE test,40 and 12 weeks might not be enough time to obtain an observable difference between the intervention and the control groups in MoCA. This is supported by the fact that, in previous studies,12,15,17 a 3-month aerobic dance class did not bring significant changes in the MoCA score in people with MCI compared to that in the control group,17 while 40 and 48-weeks of international ballroom dancing classes led to markedly positive results.12,15 In future studies, more detailed analyses should be conducted to explain the different results in both scales. The positive effect of square dancing on cognitive function could be beneficial due to multiple factors: First, it has been shown that aerobic exercise could significantly improve the cognition in individuals with MCI.41 Second, it has been reported that dance could significantly reduce the depression level in older adults,12 which is a significant risk factor for MCI to develop into AD.6,7 Third, repetitive dance movements can help older people learn memory techniques.42 Fourth, an enriched social environment, social interaction, and musical accompaniment can demonstrate additional effects on cognition.13 As for the secondary outcomes, our results showed positive effects of square dancing on all outcomes. The scores of GDS and MCS in the dance group were significantly lower and higher, respectively, than those in the control group at week 6. This could be because, unlike the control group, the intervention group was provided with plaform for more social interactions, which could have helped to allieviate loneliness and help elevate the subjects’ moods.22 Significant differences in the BBS and PCS scores between the two groups was seen at week 12. Such a positive effect of square dancing on balance was inconsistent with the results produced by Qi et al.,18 which could be due to the fact that additional movements contributing to improving balance such as lateral body bending and turning, rather than
just movements of the lower limbs, were included in our study. The positive effect on physical well-being was supported by the fact that regular, moderate-intensity exercise was promising in improving the immune system and physical condition of older adults.43 Overall, we conclude that square dancing is a promising non-phamacological intervention strategy for older adults with MCI. We found that a 12-week exercise routine can lead to significantly positive effects on global cognition, depressive symptoms, balance, and quality of life in an older MCI population. Moreover, this particular exercise can be easily applied in nursing homes and communities to promote the health of older adults in different settings. The cognitive status of older adults should be examined regularly to detect early signs of MCI, which will stimulate early, when necessary. Nursing home managers and community nurses can group the participants. The format of the exercise suggests a collective group, which makes dancing more interesting and promotes participants’ communication. In such a setting, participants are more motivated, which can improve subjects’ moods and is likewise beneficial for cognition. The frequency and period are suggested to be at least three sessions per week for 12 weeks, and long-term adherence could lead to better effects. What calls for special attention is that specialized personnel are always required to monitor and ensure the safety of participants during the exercise. For researchers in this field, larger sample sizes and randomized controlled trials should be carried out in the future, and objective outcomes evaluating cognitive function such as fMRI and biochemical indexes should be measured.
Limitations The results of this study should be treated with caution due to several limitations: First, the sample was small. The participants were collected from a single site and were selected by the criteria that all had to have only some mild cognitive impairment and had provided consent to participate. The sample might not be representative enough, and we could not conduct a randomized controlled trial.
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Fig. 2. The change trends of outcomes in dance and control groups over time. Abbreviations: MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
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Second, the instruments for assessing outcome measures were all scales, which may have lacked objectivity. Conclusions This study demonstrated that Chinese square dancing is an accessible, safe, and promising intervention for older adults with MCI. A 12-week exercise intervention could improve cognitive function, mood, balance, and quality of life in people with MCI. Moreover, continuous exercising for a more extended period could produce better outcomes. Declaration of Competing Interest The authors declare no conflicts of interest. Funding statement This work was supported by the Health Commission Of Jilin Province, China [grant number 2018Q031]. Acknowledgments None. References 1. Petersen RC, Caracciolo B, Brayne C, Gauthier S, Jelic V, Fratiglioni L. Mild cognitive impairment: a concept in evolution. J Intern Med. 2014;275:214–228. https://doi. org/10.1111/joim.12190. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 2013. 3. Petersen RC, Doody R, Kurz A, et al. Current concepts in mild cognitive impairment. Arch Neurol. 2001;58:1985–1992. https://doi.org/10.1001/archneur.58.12.1985. 4. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the guideline development, dissemination, and implementation subcommittee of the american academy of neurology. Neurology. 2018;90:126–135. https://doi.org/10.1212/WNL.0000000000004826. 5. Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA. 2002;288:1475–1483. https://doi.org/ 10.1001/jama.288.12.1475. 6. Gabryelewicz T, Styczynska M, Luczywek E, et al. The rate of conversion of mild cognitive impairment to dementia: predictive role of depression. Int J Geriatr Psychiatry. 2007;22:563–567. https://doi.org/10.1002/gps.1716. 7. Modrego PJ, Ferrandez J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of alzheimer type: a prospective cohort study. Arch Neurol. 2004;61:1290–1293. https://doi.org/10.1001/archneur.61.8.1290. 8. Verghese J, Robbins M, Holtzer R, et al. Gait dysfunction in mild cognitive impairment syndromes. J Am Geriatr Soc. 2008;56:1244–1251. https://doi.org/ 10.1111/j.1532-5415.2008.01758.x. 9. Delbaere K, Kochan NA, Close JC, et al. Mild cognitive impairment as a predictor of falls in community-dwelling older people. Am J Geriatr Psychiatry. 2012;20:845– 853. https://doi.org/10.1097/JGP.0b013e31824afbc4. 10. Tsutsumimoto K, Doi T, Shimada H, Makizako H, Suzuki T. Effects of group exercise programmes on quality of life in older adults with mild cognitive impairment: preliminary results from a randomized controlled trial. Psychogeriatrics. 2016;16:327–328. https://doi.org/10.1111/psyg.12165. 11. Rodakowski J, Saghafi E, Butters MA, Skidmore ER. Non-pharmacological interventions for adults with mild cognitive impairment and early stage dementia: an updated scoping review. Mol Aspects Med. 2015;43-44:38–53. https://doi.org/ 10.1016/j.mam.2015.06.003. 12. Lazarou I, Parastatidis T, Tsolaki A, et al. International ballroom dancing against neurodegeneration: a randomized controlled trial in greek community-dwelling elders with mild cognitive impairment. Am J Alzheimers Dis Other Demen. 2017;32:489–499. https://doi.org/10.1177/1533317517725813. 13. Dhami P, Moreno S, DeSouza JF. New framework for rehabilitation - fusion of cognitive and physical rehabilitation: the hope for dancing. Front Psychol. 2014;5:1478. https://doi.org/10.3389/fpsyg.2014.01478. 14. Doi T, Verghese J, Makizako H, et al. Effects of cognitive leisure activity on cognition in mild cognitive impairment: results of a randomized controlled trial. J Am Med Dir Assoc. 2017;18:686–691. https://doi.org/10.1016/j.jamda.2017.02.013. 15. Dominguez JC, Del Moral MCO, Chio JOA, et al. Improving cognition through dance in older filipinos with mild cognitive impairment. Curr Alzheimer Res. 2018;15:1136–1141. https://doi.org/10.2174/1567205015666180801112428.
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16. Douka S, Zilidou VI, Lilou O, Tsolaki M. Greek traditional dances: a way to support intellectual, psychological, and motor functions in senior citizens at risk of neurodegeneration. Front Aging Neurosci. 2019;11:6. https://doi.org/10.3389/ fnagi.2019.00006. 17. Zhu Y, Wu H, Qi M, et al. Effects of a specially designed aerobic dance routine on mild cognitive impairment. Clin Interv Aging. 2018;13:1691–1700. https://doi.org/ 10.2147/CIA.S163067. 18. Qi M, Zhu Y, Zhang L, Wu T, Wang J. The effect of aerobic dance intervention on brain spontaneous activity in older adults with mild cognitive impairment: a resting-state functional MRI study. Exp Ther Med. 2019;17:715–722. https://doi.org/ 10.3892/etm.2018.7006. 19. Li Z. The research on four elements of line dance’s rise. Journal of Chengdu Sport University. 2011;37:54–57. 20. Zhou L. Music is not our enemy, but noise should be regulated: thoughts on shooting/conflicts related to dama square dance in China. Res Q Exerc Sport. 2014;85:279–281. https://doi.org/10.1080/02701367.2014.935153. 21. Xiao J, Hilton A. An investigation of soundscape factors influencing perceptions of square dancing in urban streets: a case study in a county level city in china. Int J Environ Res Public Health. 2019;16:840. https://doi.org/10.3390/ijerph16050840. 22. Liao J, Chen S, Chen S, Yang YJ. Personal and social environmental correlates of square dancing habits in chinese middle-aged and older adults living in communities. J Aging Phys Act. 2019;25:1–7. https://doi.org/10.1123/japa.2018-0310. 23. World Health Organization. Active ageing: a policy framework. https://www.who. int/ageing/publications/active_ageing/en/; 2002 Accessed 30 April 2019. 24. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med. 2004;256:183–194. https://doi.org/10.1111/j.1365-2796.2004.01388.x. 25. Sungkarat S, Boripuntakul S, Kumfu S, Lord SR, Chattipakorn N. Tai chi improves cognition and plasma bdnf in older adults with mild cognitive impairment: a randomized controlled trial. Neurorehabil Neural Repair. 2018;32:142–149. https:// doi.org/10.1177/1545968317753682. 26. Hou J. Progress in screening programmes for mild cognitive impairment. Chin J Gerontol. 2013;33:2464–2466. https://doi.org/10.3969/j.issn.1005-9202.2013.10.129. 27. Scazufca M, Almeida OP, Vallada HP, et al. Limitations of the mini-mental state examination for screening dementia in a community with low socioeconomic status: results from the sao paulo ageing & health study. Eur Arch Psychiatry Clin Neurosci. 2009;259:8–15. https://doi.org/10.1007/s00406-008-0827-6. 28. Nasreddine ZS, Phillips NA, Bedirian V, et al. The montreal cognitive assessment, moca: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–699. https://doi.org/10.1111/j.1532-5415.2005.53221.x. 29. Wang Z, Zhang M. Application of the chinese version of the mini-mental state examination (MMSE). Shanghai Spirit Med. 1989;7:108–111. 30. Zhang L, Liu X. A study on reliability and validity of moca scale of Chinese version. Chin Nurs Res. 2007;21:2906–2907. https://doi.org/10.3969/j.issn.10096493.2007.31.044. 31. Sheikh JI, Yesavage JA. Geriatric depression scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–173. 32. Tang D. Application of short form geriatric depression scale (GDS-15) in chinese elderly. Chin J Clin Psychol. 2013;21:402–405. https://doi.org/10.16128/j. cnki.1005-3611.2013.03.036. 33. Berg K, Wooddauphine S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Canada. 1989;41:304–311. https://doi.org/10.3138/ptc.41.6.304. 34. Jin D, Yan T, Zeng H. Validity and reliability of Berg balance scale on assessing balance function. 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Effects of mind-body exercise on cognitive function in older adults with cognitive impairment: a systematic review and meta-analysis. J Nerv Ment Dis. 2018;206:913–924. https://doi.org/10.1097/ NMD.0000000000000912. 40. Sun Y, Qin B. The application of Chinese version moca and MMSE in the diagnosis of amnestic mild cognitive impairment. Chin J Neuroimmunol Neurol. 2011;18:91– 93. https://doi.org/10.3969/j.issn.1006-2963.2011.02.005. 41. Song D, Yu DSF, Li PWC, Lei Y. The effectiveness of physical exercise on cognitive and psychological outcomes in individuals with mild cognitive impairment: a systematic review and meta-analysis. Int J Nurs Stud. 2018;79:155–164. https://doi. org/10.1016/j.ijnurstu.2018.01.002. 42. Buckner RL, Wheeler ME, Sheridan MA. Encoding processes during retrieval tasks. J Cogn Neurosci. 2001;13:406–415. https://doi.org/10.1162/08989290151137430. 43. Simpson RJ, Kunz H, Agha N, Graff R. Exercise and the regulation of immune functions. 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Effects of Chinese square dancing on older adults with mild cognitive impairment Shuo Wang, PhD, Huiru Yin, PhD, Xiangfei Meng, Master, Binghan Shang, Master, Qiuyan Meng, Master, Lufang Zheng, Master, Lisheng Wang, PhD*, Li Chen, PhD* School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, Jilin 130021, China
A R T I C L E
I N F O
Article history: Received 29 June 2019 Received in revised form 29 October 2019 Accepted 30 October 2019 Available online xxx Keywords: Cognition Depression Mild cognitive impairment Quality of life Square dancing
A B S T R A C T
The present study aimed to explore the effects of square dancing on global cognition, depressive symptoms, balance, and quality of life of older adults with mild cognitive impairment. We studied 66 older adults with mild cognitive impairment in a large nursing home. Participants were assigned to the intervention group (n = 33) or the control group (n = 33), according to their residential floor, which was determined by coin tossing. The intervention group underwent a 12-week Chinese square dancing routine, while the control group maintained usual lifestyle (without square dancing). Outcomes were assessed at baseline and at weeks 6 and 12. The results showed positive effects of square dancing on all outcomes assessed, especially on depressive symptoms and quality of life-related mental well-being of the participants. This study showed that square dancing is a promising strategy for older adults with mild cognitive impairment and that long-term adherence can be beneficial. © 2019 Elsevier Inc. All rights reserved.
Introduction Mild cognitive impairment (MCI) is a transition state between healthy aging and dementia.1,2 People with MCI have higher conversion rates to dementia than healthy older adults.3 On the other hand, MCI can also reverse to normal cognition or remain stable at the MCI state.4 MCI is characterized by the decline of cognitive function, which is the principal symptom and diagnostic basis of the disease. Compared to the normal population, the MCI population has been shown to have a higher incidence of neuropsychiatric symptoms, of which depression is the most common,5 and is also a risk factor for progression to Alzheimer's Disease (AD).6,7 Similarly, gait dysfunction is more common in the MCI population,8 who are more likely to fall.9 For these reasons, the overall quality of life of older adults with MCI can severely decline over time.10 Therefore, seeking effective strategies to delay or even to reverse cognitive decline at an early stage of MCI is of paramount importance. Currently, non-pharmacological strategies are gaining more popularity due to the uncertain efficacy and possible negative side effects of pharmacological strategies.11 One of the major non-pharmacological interventions is exercise, of which dance is a sophisticated version, one which not only requires mind and body coordination but also the involvement of other components, such as aerobics, music, *Corresponding authors. E-mail addresses: [email protected] (L. Wang), [email protected] (L. Chen). https://doi.org/10.1016/j.gerinurse.2019.10.009 0197-4572/$ see front matter © 2019 Elsevier Inc. All rights reserved.
social interaction and an enriched social environment.12,13 Indeed, studies have already been conducted using ballroom dancing,12,14,15 traditional Greek dancing,16 and specially designed aerobic dancing17,18 for MCI populations. The intervention period for ballroom dancing was 4012,14 or 4815 weeks, and found positive effects on global cognition12,14,15 and mood.12,15 The 24-week traditional Greek dancing showed positive effects on balance and quality of life.16 In contrast, the 12-week specially designed aerobic dancing did not show positive effects on depression, balance, quality of life, or global cognition assessed with scales, though it did show a positive effect on cognitive function, which was assessed with resting‑state functional magnetic resonance imaging (RS-fMRI).17,18 For the Chinese MCI population, there is a lack of dance forms that can be widely applied, primarily due to the complexity and cultural unfamiliarity of ballroom dance and traditional Greek dance, as well as to the uncertain efficacy of specially designed aerobic dance. Square dancing was introduced in China around 2004 and is believed to be an expansion of line dancing.19 Square dancing integrates Chinese style dancing and music with energetic and similar rhythms.20 This dance form consists of music, a group of dancers and leader(s), and is usually conducted in large public spaces. The dance forms are varied, ranging from gymnastic forms to folk dance, disco, and modern dance.21 Square dancing is easy to learn, affordable and equally as entertaining as other popular dance forms. Perhaps this explains why square dancing is becoming popular among middleaged and older Chinese women, with an estimated 100 million practitioners in China.21 Social interaction with peers and the subsequent
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amelioration of loneliness and isolation are significant benefits that accompany square dancing and, importantly, they are also known determinants of active aging.22,23 In this study, we aimed to explore the effects of square dancing on older Chinese adults with MCI. The primary aim was to explore the effect on global cognition, and the secondary aims were to investigate the effects on depressive symptoms, balance, and quality of life. The study hypotheses were as follows. The primary hypothesis: After a 12-week intervention, older adults with MCI in the experimental group (square dancing classes) would show significantly better global cognition compared with those in the control group (usual lifestyle). The secondary hypotheses: After a 12-week intervention, the experimental group would show significantly less depressive symptoms, better balance ability, and higher quality of life compared with the control group. Methods Study design and participants A single-blinded non-randomized controlled trial was conducted to test our hypotheses. The study was set up in a large nursing home in Changchun, China between October 2018 and January 2019. Participants were assigned to the intervention group or the control group according to the floor they lived in, which was determined by coin tossing. The staff responsible for the evaluation were blinded to the allocation of the participants. The study protocol was approved by the Ethics Committee of the School of Nursing of Jilin University (2018102401), and was registered in the Chinese Clinical Trial Registry (ChiCTR1800019116). All the participants provided written informed consent prior to the study. A sample size of 33 was decided to gain enough statistical power for subsequent analyses. This was based on the effective size of dance calculated in a study by Lazarou et al.12 With 80% power and 5% type I error, we estimated that at least 28 participants were required in each group. To achieve these numbers, and allowing for a 20% dropout, we calculated 33 participants were needed per group. Participants were recruited by word-of-mouth, posters and flyer advertisements. Participants were at least 60 years old and met the following four diagnostic criteria of MCI24 26: the participants (1) had shown subjective cognition decline in the previous year; (2) had scored > 24 (primary school education: >20, illiteracy: >17) on the Mini-Mental State Examination (MMSE); (3) had scored < 26 on the Montreal Cognitive Assessment (MoCA) (if education years 12 years, one point was added); and (4) had scored < 26 on Activities of Daily Living (ADL). The participants were excluded if they had been: (1) receiving treatment or taking medicine to treat cognitive impairment or depression recently; (2) suffering from other conditions that could affect cognitive function; (3) suffering from chronic diseases that could affect their ability to exercise; (4) having visual or hearing impairment that could affect communication; (5) exercising regularly in the past six months (30 min/d, 3 d/w). Intervention We chose Jiamusi happy dance aerobics as the intervention. This type of dance aerobics originated in Jiamusi City, Heilongjiang Province, China. It is a moderate-intensity marching aerobics comprised of eight sections that require the use of all the major body parts, including movements of the upper limbs, shoulders, chest-expansion, lateral body bending, lateral body turning, waist and abdomen, and lower limbs followed by cooling down routine. Each section consists
of 3 5 symmetrical and straightforward actions with various movements of the upper limbs that last 3 5 min. For the upper limbs movements, participants swing their arms straight in different directions. When moving the shoulders, participants move their shoulders up and down. For chest-expansion, the participants spread the shoulders back to expand the chest. When doing lateral body bending, the participants swing sideways from the axis of the waist. For lateral body turning, participants rotate the waist 45° to both sides to drive the upper body to rotate. The participants then move the waist and abdomen forward. For the lower limbs movements, participants stand on one leg and kick the other in different directions. Then when cooling down, the participants swing their hips to both sides. The dance is 30 min long, with each section assigned to a piece of music. In the original version, participants lined up and moved forward, making the movements and following the rhythm of the music. However, in the version used for this study, we modified the dance as an in-situ stepping exercise to prevent falls. Participants stood in a queue and stepped in situ but did not move forward. All the movements remained constant. Because the study was conducted during winter, all the dance activities were carried out inside the activity hall of the nursing home. A research staff acted as the lead dancer and danced in the front. Each session lasted 40 min, including a 5-min warm-up (finger gymnastics, joint movements, and stretching), a 30-min dance, and a 5-min cool-down (deep breathing and stretching). The intervention lasted for 12 weeks, with three sessions per week. Participants in the control group maintained their usual lifestyle. Outcome evaluations The outcomes that were assessed in the study were global cognition, depressive symptoms, balance, and quality of life of participants at baseline and weeks 6 and 12. The staff responsible for evaluation received homogenous and comprehensive training. The evaluation staff was blind to the group in which participants belonged, and the participants were instructed by the training staff to not reveal the allocation information when receiving the evaluations. Cognitive function was the primary outcome, whereas the rest were secondary outcomes. All instruments were translated to Chinese and have established evidence of reliability and validity. Global cognition was assessed with MMSE and MoCA, which are both popular tools for assessing cognition. MMSE is particularly recommended for dementia screening (sensitivity: 80 90%, specificity: 70 80%),27 while MoCA is recommended for MCI screening (sensitivity: 90%, specificity: 83%).28 They both have a maximum score of 30, with higher scores indicating better cognition. The test-retest reliability of the Chinese version of MMSE is 0.91, with good content validity and concurrent validity (p < 0.001).29 Similarly, the testretest reliability of MoCA is 0.857, and Cronbach's a is 0.818. The content validity, concurrent validity and construct validity are also good (p < 0.01).30 Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS-15),31 which requires participants to answer with yes or no for a total score of 15. Higher scores indicate more depressive symptoms. For the GDS scale, the test-retest reliability is 0.728, Cronbach's a is 0.793, and discriminant validity is good (p < 0.001).32 Balance ability was assessed with the Berg Balance Scale (BBS).33 The scale includes 14 items, with the score of each item ranging from 0 to 4 that sums to a score of 56, with higher scores indicating better balance ability. For this scale, the inter-observer reliability is 0.992 0.998, the test-retest reliability is 0.968 0.985, and the content validity (p < 0.01) is good.34
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Quality of life was assessed with the Short-Form 12 health survey (SF-12), which is a simplified version of the SF-3635 and shows high correlation with SF-36.36 The scale includes the assessment of general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health. The first four indicators are used to assess the physical component summary (PCS), while the last four are used to assess the mental component summary (MCS). Higher scores indicate a better quality of life. For this scale, Cronbach's a is 0.775, and the criterion validity is good (p < 0.001).37 Treatment fidelity Before the intervention, two staff members with prior professional dance training taught two classes as practice classes. Each class lasted for one hour, with a one day gap between the two classes. In the first class, the two staff explained the essentials and health benefits of the different movements and instructed participants to practice them. After the class, the participants were allowed to familiarize themselves with the movements by watching a dance video with the standard movements. In the second class, the two staff examined whether participants could dance correctly and provided instructions until all participants had adequately learned the movements. During the intervention, one of the staff led the dance in front of the group, and the other staff supervised the movements and guided the participants to ensure that they performed the dance movements correctly. Additionally, some nursing home staff were responsible for safety supervision. The regular allotment of small gifts was used to motivate participants. Participants were required to sign in at the end of each class. Then, at the end of the third class of each week, we gave small gifts to those who did not miss a single class that week. The attendance rate ranged from 63.89% to 100%, averaging 80.29%. Participants missed attending the class only if they were uncomfortable or had plans to go out or had visitors at the time of the class. Statistical analysis Statistical analyses were conducted using SPSS 22.0. The distribution of data was tested using the Shapiro Wilk test, where continuous variables that conformed to the normal distribution were described with means and standard deviations (SD), and those that did not conform to the normal distribution were described with medians and quartiles. Frequency and percentage were used for categorical variables. Baseline characteristics of the intervention and control groups were compared using independent t-tests, nonparametric tests or x2 tests. To measure the outcomes over time, we used a linear mixed-effect model to analyze the effects of time, group and time-by-group. Intergroup and intragroup comparisons were conducted using independent t-tests and paired t-tests (the differences were normally distributed)/nonparametric tests, respectively. The p-value of two-sided tests <0.05 was considered to be statistically significant. All the analyses were conducted based on the intention-to-treat principle, and missing data were imputed with the most recent data.
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the study because of falls (not due to square dancing) (n = 3), discharge from the nursing home (n = 1), or unwillingness to continue the study (n = 1). As a result, 61 participants (31 in the dance group and 30 in the control group) remained and completed the study. The baseline characteristics of the participants are presented in Table 1. The average age of the participants was 81.08 (§6.36) years old, and females accounted for 71.21% of the sample. There were no significant differences (p > 0.05) between the intervention and the control groups in baseline characteristics, including age, gender, education level, body mass index, marital status, comorbidity, the MoCA, MMSE, GDS, BBS, PCS, and MCS scores. Outcome measures Outcomes comparison between dance and control groups across time are presented in Table 2. Fig. 2 shows visual representation of the changing trend. With regard to the results from the linear mixedeffect model, the interaction effects of group-by-time were significant on all outcomes (p < 0.001). Intergroup comparisons at week 6, displayed a significantly lower GDS score in the dance group (DG) (3.48 § 2.32) compared to the control group (CG) (5.06 § 2.72; p = 0.014), and a significantly higher MCS score in DG (65.87 § 17.77) compard to CG (55.72 § 18.60; p = 0.027). However, MoCA scores (DG: 19.97 § 2.97; CG: 18.88 § 4.36; p = 0.240), MMSE scores (DG: 25.33 § 1.90; CG: 24.39 § 3.73; p = 0.204), BBS scores (DG: 44.33 § 6.06; CG: 40.73 § 8.50; p = 0.052), and PCS scores (DG: 64.89 § 21.15; CG: 55.87 § 23.01; p = 0.102) were not significantly different between the two groups. At week 12, the trend persisted with significantly lower GDS scores in DG compared to CG (DG: 2.61 § 1.71; CG: 5.12 § 2.77; p < 0.001), and significantly higher MCS scores in DG compared to CG (DG: 72.08 § 14.57; CG: 54.17 § 17.26; p < 0.001). Unlike week 6, at week 12, MMSE scores (DG: 26.21 § 1.93; CG: 24.06 § 3.88; p = 0.006), BBS scores (DG: 45.15 § 5.96; CG: 40.67 § 8.41; p = 0.015) and PCS scores (DG: 68.18 § 18.25; CG: 52.95 § 21.23; p = 0.003) were also significantly higher in DG compared to CG. However, the MoCA scores (DG: 20.55 § 3.23; CG: 18.79 § 4.62; p = 0.078) still remained insignificant between the two groups at week 12. Regarding the results of intragroup comparisons, we could see that in the dance group, the scores of PCS and MCS were significantly higher at week 6 (PCS: p < 0.001; MCS: p = 0.004) as well as week 12 (PCS: p < 0.001; MCS: p < 0.001) compared to those at the baseline; the GDS scores were markedly lower compared to baseline at week 6 (p < 0.001) and week 12 (p < 0.001); the MoCA scores (p = 0.001), MMSE scores (p < 0.001), and BBS scores (p < 0.001) were significantly higher from the baseline only at week 12. While in the control group, the scores at weeks 6 and 12 were not significantly different from those at the baseline for all the outcomes (p > 0.017). Adverse events During the 12 weeks, no adverse events related to the intervention occurred.
Results Discussion Baseline characteristics The flowchart showing the recruitment and dropout of participants is presented in Fig. 1. We completed the recruitment in October 2018, screening 120 potential participants for the 66 positions. Based on the inclusion and exclusion criteria, 54 people were excluded. During the 12-week intervention, five participants withdrew from
The results from this study provide evidence that Chinese square dancing has positive effects on global cognition, depressive symptoms, balance, and quality of life in older adults with MCI. To our knowledge, this is the first study that explored the effects of Chinese square dancing on people with MCI. We chose square dancing because it is not only easy to learn, but because it is also easy to
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Fig. 1. Flowchart showing recruitment and dropout of participants.
Table 1 Baseline characteristics of the participants.
Age, years Gender, male Education, years BMI, kg/m2 Widowed/divorced/ separated/single Comorbidity MoCA MMSE GDS BBS PCS MCS
Dance group (n = 33)
Control group (n = 33)
p-value
81.06 § 5.17 7 (21.20%) 8 (5.5, 11) 24.17 (21.43, 26.13) 24 (72.7%)
81.09 § 7.44 12 (36.40%) 8 (3, 12) 25.12 § 3.11 20 (60.6%)
0.985 0.174 0.861 0.121 0.296
1 (0, 2) 19.39 § 3.00 25.03 § 2.01 4.88 § 2.85 44.03 § 6.02 52.46 § 21.08 56.86 § 19.85
1 (0, 2) 18.97 § 4.71 24.36 § 3.32 4.88 § 2.77 40.82 § 8.62 54.39 § 23.20 57.99 § 17.37
0.973 0.664 0.328 1.000 0.085 0.724 0.805
Note: Continuous variables were presented as Means § Standard Deviations/Medians (Quartile 1, Quartile 3). Abbreviations: BMI, Body Mass Index; MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
popularize due to the social platform it provides, which is especially beneficial for older participants with MCI. Good attendance and no adverse events supported the feasibility of the intervention. Main findings and interpretations As for the primary outcome, the results of the linear mixed-effect model showed that the changing trends of the MMSE and MoCA scores were significantly different between the two groups. The results of intragroup comparisons showed that, during the 12 weeks, scores in the dance group rose significantly, while scores in the control group presented no significant change. These outcomes indicate that square dancing has the potential to improve cognitive function in people with MCI. The result of MMSE in intergroup comparisons showed a significantly positive effect of 12-week square dancing on cognition in people with MCI. This result is consistent with multiple studies,12,14,38,39 but is inconsistent with the result of Qi et al.18; this could be due to the small sample size (19 participants per group) in their study. Even though the study by Qi et al. was inconsistent with ours, the
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Table 2 Comparisons of outcomes between dance and control groups across time. Scale
Time
MoCA
Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12 Baseline Week 6 Week 12
MMSE
GDS
BBS
PCS
MCS
Dance group
Control group
Linear mixed-effects model (p-value)
(n = 33)
(n = 33)
Group
19.39 § 3.00 19.97 § 2.97 20.55 § 3.23 25.03 § 2.01 25.33 § 1.90 26.21 § 1.93 4.88 § 2.85 3.48 § 2.32 2.61 § 1.71 44.03 § 6.02 44.33 § 6.06 45.15 § 5.96 52.46 § 21.08 64.89 § 21.15 68.18 § 18.25 56.86 § 19.85 65.87 § 17.77 72.08 § 14.57
18.97 § 4.71 18.88 § 4.36 18.79 § 4.62 24.36 § 3.32 24.39 § 3.73 24.06 § 3.88 4.88 § 2.77 5.06 § 2.72 5.12 § 2.77 40.82 § 8.62 40.73 § 8.50 40.67 § 8.41 54.39 § 23.20 55.87 § 23.01 52.95 § 21.23 57.99 § 17.37 55.72 § 18.60 54.17 § 17.26
0.253
0.075
0.021*
0.041*
0.142
0.026*
Time
Group * time
0.006**
0.077
***
<0.001
<0.001***
<0.001***
**
0.006
Change from baseline (p-value) Dance group
Control group
<0.001*** 0.023 0.001#
0.439 0.243
0.265 <0.001##
0.910 0.299
<0.001## <0.001##
0.451 0.319
0.02 <0.001##
0.366 0.190
<0.001## <0.001##
0.252 0.502
0.004# <0.001##
0.264 0.059
<0.001***
***
<0.001
<0.001***
<0.001***
***
<0.001
Inter-group comparisons (p-value) 0.664 0.240 0.078 0.328 0.204 0.006** 1.000 0.014* <0.001*** 0.085 0.052 0.015* 0.724 0.102 0.003** 0.805 0.027* <0.001***
Note: The scores of scales were presented as Means § Standard Deviations. Linear mixed-effects model and Inter-group comparisons: *p < 0.05; **p < 0.01; ***p < 0.001. Intra-group comparisons: #p < 0.017; ##p < 0.001. Abbreviations: MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
study18 demonstrated the positive effect of aerobic dance on cognitive function, using a quantitative method RS-fMRI, which revealed that 3-months of aerobic dance classes significantly increased the activity of the bilateral frontotemporal cortex. On the contraty, our MoCA result in intergroup comparisons did not show a significantly positive effect. The different results between the two scales assessing global cognition might be due to the fact that the level of difficulty of the MoCA test is higher than that of the MMSE test,40 and 12 weeks might not be enough time to obtain an observable difference between the intervention and the control groups in MoCA. This is supported by the fact that, in previous studies,12,15,17 a 3-month aerobic dance class did not bring significant changes in the MoCA score in people with MCI compared to that in the control group,17 while 40 and 48-weeks of international ballroom dancing classes led to markedly positive results.12,15 In future studies, more detailed analyses should be conducted to explain the different results in both scales. The positive effect of square dancing on cognitive function could be beneficial due to multiple factors: First, it has been shown that aerobic exercise could significantly improve the cognition in individuals with MCI.41 Second, it has been reported that dance could significantly reduce the depression level in older adults,12 which is a significant risk factor for MCI to develop into AD.6,7 Third, repetitive dance movements can help older people learn memory techniques.42 Fourth, an enriched social environment, social interaction, and musical accompaniment can demonstrate additional effects on cognition.13 As for the secondary outcomes, our results showed positive effects of square dancing on all outcomes. The scores of GDS and MCS in the dance group were significantly lower and higher, respectively, than those in the control group at week 6. This could be because, unlike the control group, the intervention group was provided with plaform for more social interactions, which could have helped to allieviate loneliness and help elevate the subjects’ moods.22 Significant differences in the BBS and PCS scores between the two groups was seen at week 12. Such a positive effect of square dancing on balance was inconsistent with the results produced by Qi et al.,18 which could be due to the fact that additional movements contributing to improving balance such as lateral body bending and turning, rather than
just movements of the lower limbs, were included in our study. The positive effect on physical well-being was supported by the fact that regular, moderate-intensity exercise was promising in improving the immune system and physical condition of older adults.43 Overall, we conclude that square dancing is a promising non-phamacological intervention strategy for older adults with MCI. We found that a 12-week exercise routine can lead to significantly positive effects on global cognition, depressive symptoms, balance, and quality of life in an older MCI population. Moreover, this particular exercise can be easily applied in nursing homes and communities to promote the health of older adults in different settings. The cognitive status of older adults should be examined regularly to detect early signs of MCI, which will stimulate early, when necessary. Nursing home managers and community nurses can group the participants. The format of the exercise suggests a collective group, which makes dancing more interesting and promotes participants’ communication. In such a setting, participants are more motivated, which can improve subjects’ moods and is likewise beneficial for cognition. The frequency and period are suggested to be at least three sessions per week for 12 weeks, and long-term adherence could lead to better effects. What calls for special attention is that specialized personnel are always required to monitor and ensure the safety of participants during the exercise. For researchers in this field, larger sample sizes and randomized controlled trials should be carried out in the future, and objective outcomes evaluating cognitive function such as fMRI and biochemical indexes should be measured.
Limitations The results of this study should be treated with caution due to several limitations: First, the sample was small. The participants were collected from a single site and were selected by the criteria that all had to have only some mild cognitive impairment and had provided consent to participate. The sample might not be representative enough, and we could not conduct a randomized controlled trial.
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Fig. 2. The change trends of outcomes in dance and control groups over time. Abbreviations: MoCA, Montreal Cognitive Assessment; MMSE, Mini-mental State Examination; GDS, Geriatric Depression Scale; BBS, Berg Balance Scale; PCS, Physical Component Summary; MCS, Mental Component Summary.
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Second, the instruments for assessing outcome measures were all scales, which may have lacked objectivity. Conclusions This study demonstrated that Chinese square dancing is an accessible, safe, and promising intervention for older adults with MCI. A 12-week exercise intervention could improve cognitive function, mood, balance, and quality of life in people with MCI. Moreover, continuous exercising for a more extended period could produce better outcomes. Declaration of Competing Interest The authors declare no conflicts of interest. Funding statement This work was supported by the Health Commission Of Jilin Province, China [grant number 2018Q031]. Acknowledgments None. References 1. Petersen RC, Caracciolo B, Brayne C, Gauthier S, Jelic V, Fratiglioni L. Mild cognitive impairment: a concept in evolution. J Intern Med. 2014;275:214–228. https://doi. org/10.1111/joim.12190. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association; 2013. 3. Petersen RC, Doody R, Kurz A, et al. Current concepts in mild cognitive impairment. Arch Neurol. 2001;58:1985–1992. https://doi.org/10.1001/archneur.58.12.1985. 4. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the guideline development, dissemination, and implementation subcommittee of the american academy of neurology. Neurology. 2018;90:126–135. https://doi.org/10.1212/WNL.0000000000004826. 5. Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA. 2002;288:1475–1483. https://doi.org/ 10.1001/jama.288.12.1475. 6. Gabryelewicz T, Styczynska M, Luczywek E, et al. The rate of conversion of mild cognitive impairment to dementia: predictive role of depression. Int J Geriatr Psychiatry. 2007;22:563–567. https://doi.org/10.1002/gps.1716. 7. Modrego PJ, Ferrandez J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of alzheimer type: a prospective cohort study. Arch Neurol. 2004;61:1290–1293. https://doi.org/10.1001/archneur.61.8.1290. 8. Verghese J, Robbins M, Holtzer R, et al. Gait dysfunction in mild cognitive impairment syndromes. J Am Geriatr Soc. 2008;56:1244–1251. https://doi.org/ 10.1111/j.1532-5415.2008.01758.x. 9. Delbaere K, Kochan NA, Close JC, et al. Mild cognitive impairment as a predictor of falls in community-dwelling older people. Am J Geriatr Psychiatry. 2012;20:845– 853. https://doi.org/10.1097/JGP.0b013e31824afbc4. 10. Tsutsumimoto K, Doi T, Shimada H, Makizako H, Suzuki T. Effects of group exercise programmes on quality of life in older adults with mild cognitive impairment: preliminary results from a randomized controlled trial. Psychogeriatrics. 2016;16:327–328. https://doi.org/10.1111/psyg.12165. 11. Rodakowski J, Saghafi E, Butters MA, Skidmore ER. Non-pharmacological interventions for adults with mild cognitive impairment and early stage dementia: an updated scoping review. Mol Aspects Med. 2015;43-44:38–53. https://doi.org/ 10.1016/j.mam.2015.06.003. 12. Lazarou I, Parastatidis T, Tsolaki A, et al. International ballroom dancing against neurodegeneration: a randomized controlled trial in greek community-dwelling elders with mild cognitive impairment. Am J Alzheimers Dis Other Demen. 2017;32:489–499. https://doi.org/10.1177/1533317517725813. 13. Dhami P, Moreno S, DeSouza JF. New framework for rehabilitation - fusion of cognitive and physical rehabilitation: the hope for dancing. Front Psychol. 2014;5:1478. https://doi.org/10.3389/fpsyg.2014.01478. 14. Doi T, Verghese J, Makizako H, et al. Effects of cognitive leisure activity on cognition in mild cognitive impairment: results of a randomized controlled trial. J Am Med Dir Assoc. 2017;18:686–691. https://doi.org/10.1016/j.jamda.2017.02.013. 15. Dominguez JC, Del Moral MCO, Chio JOA, et al. Improving cognition through dance in older filipinos with mild cognitive impairment. Curr Alzheimer Res. 2018;15:1136–1141. https://doi.org/10.2174/1567205015666180801112428.
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