Article

Introducing a Latin ballroom dance class to people with dementia living in care homes, benefits and concerns: A pilot study

Dementia 12(5) 523–535 ! The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301211429753 dem.sagepub.com

Azucena Guzma´n-Garcı´a North East London NHS Foundation Trust, UK

Elizabeta Mukaetova-Ladinska Newcastle University, UK

Ian James Northumberland Tyne and Wear NHS Foundation Trust, UK

Abstract The objective of the study was to investigate the effect of introducing a dance-based psychomotor intervention using Danzo´n (Latin ballroom) for people with dementia in care homes. This was a grounded theory qualitative study. Thirteen of the 22 participants had dementia and were carehome residents. The remaining participants were care staff and facilitators of the dance sessions. Interviews were undertaken with seven people with dementia and nine staff, resulting in two separate sets of grounded theory methodologies. Two conceptual models, outlining positive outcomes and negative concerns of the use of Danzo´n were developed, depicting the experiences of people with dementia and care staff respectively. Danzo´n psychomotor intervention was found to enhance positive emotional states and general levels of satisfaction for both people with dementia and care staff. The details of these findings have been used to design a quantitative study. Keywords dementia, psychomotor dance, Danzo´n, long-term care settings, non-pharmacological interventions

Corresponding author: Azucena Guzma´n-Garcı´a, Dementia Research Centre, North East London NHS Foundation Trust, R&D Department, 1st Floor Maggie Lilly Suite, Goodmayes Hospital, Barley Lane, Ilford, Essex IG3 8XJ, UK. Email: [email protected]

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Introduction A recent UK report regarding the use of antipsychotic medication for people with Behavioural and Psychological Symptoms in Dementia (BPSD) was commissioned by the Department of Health (Banerjee, 2009). Owing to the problematic side-effect profile of these drugs, the report called for a reduction in the use of anti-psychotics by 66% over a period of 36 months. There are currently a number of non-pharmacological interventions available for people with dementia which may be used, such as: reality orientation, validation, cognitive stimulation therapy, aromatherapy and psychomotor and physical exercise (see James & Fossey, 2008; Livingston, Johnston, Katona, Paton & Lyketsos, C, 2005). Included in the group of physical activities is dance (Arakawa-Davis, 1997; Bower, 1967; Coaten, 2001; Duignan, Hedley & Milverton, 2009; Hill, 2009; Hokkanen et al. 2008; Palo-Bengtsson & Ekman, 2002; Ravelin, 2009). In addition to the above studies, which showed promise, anecdotal reports suggest benefits for staff as well as clients (Cormier Parsons, 1999; Hayes, 2006; Heymanson, 2009; Hirsh, 1990; Jerrome, 1999; Kindell & Amans, 2003). Our study focuses on the use of a dance called Danzo´n, a Latin ballroom style which is widely practised by older adults in Mexico. Danzo´n is of moderate intensity and consists of small steps, defined and stopped at each music bar, ensuring that the dancer is at a low risk of physical injury. Danzo´n steps involve a technique with gentle hip and body movements which can be divided into short sections to be facilitated by teachers with or without dance teaching experience. We report the results of the first dance-based psychomotor intervention using Danzo´n in older adults with dementia living in residential care homes in the UK. In our work we included the views of people with dementia. Not all of the dancers with dementia were either able or willing to participate in the interviews, and the qualitative methodology provided the flexibility for their opinions to be comprehensively recorded. Interviews were carried out by the first author, who undertook the intervention.

Methods A qualitative pilot study using grounded theory methodology (Corbin & Strauss, 2008) was used to analyse the effect of Danzo´n Psychomotor Intervention (DPI) on residents and care staff in two care homes in Newcastle-upon-Tyne, UK. The study was registered and approved by the Research and Clinical Effectiveness Department (Northumberland, Tyne and Wear, NHS Trust) as a service improvement project.

Materials In addition to the interview equipment other materials used were: colourful ribbons, Danzo´n music, CD player and mnemonic aids (photographs of Danzo´n choreography). The latter were shown to participants and staff to enhance retention of movements.

Participants Older people with dementia (OPWD). Thirteen residents (ten females and three males; mean age 80.5  6.81 years) – were recruited into the dance intervention across two private care homes

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on the basis of the recommendations of care home managers. Participants were assessed by a consultant old age psychiatrist in relation to physical and mental health needs, and suitability for taking part in a psychomotor study. The diagnoses were as follows: eight people with Alzheimer’s Disease (AD), two Fronto Temporal Dementia (FTD), one Vascular Dementia (VaD), one mixed (AD and VaD) and one Parkinson’s Disease Dementia (PDD). Participants were mobile, stable on their medication and were not taking part in other physical or cognitive activity programmes during the time of the study. Seven residents were able to provide interviews regarding their experiences of the dancing (five females, two males; mean age 82.4  4.68 years). Four of the seven interviewees presented behavioural problems such as: wandering, social withdrawal and verbal and physical aggression. Participants completed the Mini-Mental State Examination (MMSE; Folstein, Folstein & McHugh, 1975) of 2–25/30 points (mean 11.71  7.69). Care staff. Nine care staff members were interviewed (seven females, two males). Staff experience of working in care ranged from one to 18 years (mean 7.67  5.701) with training in dementia care from NVQ level 2, 3, 4, including: Challenging Behaviour; Protection of older adults and Registered Managers Award.1

Procedure The DPI was led by the first author and facilitated by care staff from the homes. Each DPI session lasted for 35 minutes, and was conducted twice a week over a six-week period. OPWDs’ mean attendance was 10.23 (2.048) out of 12 sessions. A description of a typical session is summarized in Table 1. Interviews were conducted with both the staff and OPWDs after the six-week intervention. They were asked to give their impressions of the dance sessions, both positive and negative features. The interviews were audio-taped and transcribed in accordance with grounded theory methodology. In accordance with the methodology, each participant was interviewed twice; in the primary interview, the themes were derived, and the second was a confirmatory interview in which the emerging model was checked for validity. Data was anonymised by removing identifying information.

Data analysis Following grounded theory general guidelines, categories and themes were developed. Using constant comparison, further linkage between categories, re-categorization, (splitting categories into subcategories and combining them) and theoretical sampling (asking specific questions about emerging concepts in later interviews to generate contrast and develop theoretical criteria). Corbin and Strauss (2008) suggest choosing a central category to represent the main theme of the research and to relate this to the other categories, and reporting of memos and diagrams, as these are reflections of analytic thought, and important part of the analysis process.

Results A total of 32 interviews were conducted and coded: 18 (9  2) for staff and 14 (7  2) for OPWDs. Two theoretical models were produced (Figure 1). In relation to the staff there were

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Table 1. Key features of Danzo´n Psychomotor Intervention Units

Technique Points

Warm up (10 min)

In a group circle combine stretches and mobilizers. Danzo´n steps are introduced through implicit cues.* Show mnemonic aid to cue steps prior to each session Set in pairs, dancers repeat choreography  4 times minimum: 1st: Danzo´n ‘entrance’ by holding hands standing next to each other 2nd: Pair face and counterbalance in a waltz-like embrace 3rd: Danzo´n ‘box step’ in six tempos (slow part of the song) 4th: Pair take turns to perform a twirl and combine with box step (quicker part of the song). * Participants exchange dance partners and dance freely to Danzo´n music. Set in group circle, combine stretches and mobilizers less energetically and taper to stillness. Session closure by praising dance group participation. *

Danzo´n-practice (15 min)

Danzo´n-free style (5 min) Cool down (5 min)

*Stop by relaxing and breathing in/out in between dance movements, clapping for motivation and cue for upright posture. Session 1 should be flexible as dance group needs to get comfortable with each other, sessions’ fluidity and structure shapes towards session 3. More details upon request to the authors.

Danzón Psychomotor Intervention

Care staff model

Residents’ model

Dancerresidents

Care Staff

Affective States Behaviour Socialising Mental Stimulation Mobility Reminiscence Physical Health

Caring Strategies Professional satisfaction Expectations Possible difficulties

Spectatorresidents Affective States Reminiscence Mobility

Benefits

Mood

Mobility

Family members

Socialising and Communicating

Behaviour

Enjoyment

Mental Stimulation

Reminiscence

Positive Activity

Figure 1. Diagram of the two emerged models from care staff and residents; categories are in bold and subcategories are inside the boxes.

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Table 2. Quotes from care staff A. Benefits on residents who danced Subcategories

Quotes

Behaviour

P1: ‘Mr H wanted to be smart; he was looking forward to it [the dance] which was nice’ P2: ‘Mrs A can get agitated; she wants to go into town and stuff. After the dancing, she didn’t seem to think about that, she focused more on the dancing’ P2: ‘Sometimes Mrs P got a bit jealous if somebody was dancing with Mr G, and that could have caused a friction between them.’ P3: ‘Really, they are more free in themselves, not just sitting, and I don’t know, just free.’ P9: ‘We found more people enjoying it, especially the male residents who don’t want to play bingo, who don’t want to do art and crafts and pictures, cards or things like that.’ P5: ‘When we dance we do not have to think about the movement, they would move in their way. Whereas with Danzo´n, they were told how to dance. They had to think and remember how to dance. So, stimulates their brain activity and makes them think.’ P8: ‘It definitely tells you that they are learning whatever degree that might be. May be a little bit, they might just remember one step, some might remember five you know but that doesn’t really matter you can just see that they are trying to take it in.’ P7: ‘Having three floors everybody could meet different people. Residents of this floor would not necessarily see the ones upstairs, but in the dancing sessions they were seeing each other and dancing with each other, socialising.’ P5: ‘I just think that it’s a different thing as we usually do games, bingo, puzzles, we never had dancing really. So, it was something nice, a different thing, fun! It was good; it was nice to go around dancing, instead of sitting down on the chair.’ P1: ‘For example Mrs Y used to watch and talk about when she was a girl and when she used to dance.’ P9: ‘Because a lot of people are just sitting around they find it harder to empty their bowels. So by doing exercises, it helps them to go to their toilet more and we found that by doing more activities, a lot less people were constipated. Previously a lot of them were on Senna.’

Affective States

Mental Stimulation

socialising and Communicating

Mobility

Reminiscence

Physical Health:

(continued)

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Table 2. Quotes from care staff B. Benefits on spectator-residents Subcategories

Quotes

Affective States

P1: ‘It was an activity that even though they were not doing it, they still wanted to watch it.’ P9: ‘When other people were dancing, they were actually sitting and talking when they used to be able to dance. About how lovely it was, how they enjoyed going to dance halls.’ P8: ‘Others had mobility problems and can’t get up and dance, just enjoying it from the chair obviously by clapping.’

Reminiscence

Mobility

C. Benefits on family members Positive Activity

D. Benefits on care staff Professional Satisfaction

Caring Strategies:

Expectations

Possible Difficulties

P5: ‘When they come to visit them, they [residents] don’t actually say that they’ve done the activities. So, it was nice when they [families] came in and got involved in the dancing. They enjoyed and talked about it with their families.’ P7: ‘I think it helped us to build up trust, communication, stuff like.’ P9: ‘Residential residents are kept from EMIs [residents] and it was lovely to see the mixing. There was no agitation or nothing, they were socialising and chatting.’ P2: ‘I danced a bit with [resident] E, A, a bit with G, and I dance along in the corridor with D, so when they are down or anxious. . . Yeah, it is like, so to cheer them up.’ P8: ‘I think that the carers did get a benefit because it gave us a little bit of a break. It gave us time to enjoy the residents, and just have fun and interact with them instead of just doing personal care tasks.’ P8: ‘Their balance may have improved, because of the way they are learning the steps. But whatever their activity level in general is better.’ P9: ‘Danzo´n was an activity that they actually loved and really enjoyed. We brought that into the home and actually start using it as an activity.’ P5: ‘For some carers, they like to be seen as ‘‘the carer’’, they don’t want to be seen as ‘‘friend’’. There is a line between a carer and a resident who is being cared for. You don’t want to cross that line of being friends because you can get attached to certain residents.’ (continued)

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Table 2. Quotes from care staff D. Benefits on care staff Professional Satisfaction Subcategories

Quotes P8: ‘I think that some carers don’t like to participate maybe because they are embarrassed. They are a bit shy or maybe dancing is not one of their things. But I would say most of the people that I work with like participating and just find it enjoyable.’ P9: ‘In some homes, some carers need a prompt, they need a little push to say ‘‘come on you are not here to sit around and take them to the toilet and bath and feed them’’. You know who they are, but really they’re here to make their [residents’] lives as happy as possible.’

P: participant

four categories; the central one was ‘Benefits’. Such benefits extended to people with dementia, staff and family. The nature of the benefits (e.g. mental stimulation, socialising, behaviour, reminiscence and mobility) were identified as sub-categories. In relation to the residents, only one central category was apparent, ‘Enjoyment’, and five subcategories were outlined. In the following sections, data is presented in terms of two separate models from care staff and residents’ interviews respectively. Tables 2 and 3 provide some examples of quotes from the two groups of participants, illustrating the categories and subcategories outlined in Figure 1.

Model emerging from care staff Category A: Benefits on residents who danced. Each of the four subcategories is outlined below. Care staff reported that DPI had an effect on different areas of the residents who danced. Subcategories identified were: Behaviour, Affective States, Mental Stimulation, Socialising/ Communication, Mobility, Reminiscence and Physical Health (Table 2, section A). Staff noted residents looking forward to DPI and emphasized some behavioural changes such as lowering anxiety, decrease of both frustration and wandering after each dance session as residents reduced their agitation. Interviewees gave particular weight to the effect on dancers’ affective states, by reporting that dancers showed positive mood, looked happier and were more enthusiastic. Also, it was observed that dancers manifested a sense of achievement, confidence and joy. It was also noted that there was a greater degree of male participation in dancing compared with other activities. One care staff member reported a possible feeling of jealousy among a couple of participants when exchanging partners. DPI was seen as a form of mental stimulation, regardless of residents’ dementia stage, by stimulating brain activity with the music selected. It was mentioned that dancers were paying ‘attention’, listening to instructions while observing the modelling. Staff noticed that dancers increased their ability to socialize and interact with other residents. It was noted there was a

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Table 3. Quotes from residents with dementia Category: Enjoyable Time Subcategory

Quotes

Mood

P5: ‘You try to feel good in your mind, but when you get over 80 it is hard to feel young. . .but I manage.’ P6: ‘I find it exciting when I dance.’ P7: ‘Well, I just can say that if you are feeling miserable and you dance, it cheers you up and that’s what I can say about it.’ P1: ‘Well I’ve got other things to do, not necessarily in dance, but, for what I do for living. . .but our times, I was looking forward to coming here.’ P5: ‘I would not worry as long as I am enjoying myself, get on well with other dancers and don’t winge.’ P3: ‘Just everybody was there; everybody was part of each other.’ P5: ‘Oh yes, instead of sitting alone. . .no, no, I like people and nice company.’ P2: ‘I was on stage a few times. . .dance tap, uh!, quite a lot.’ P3: ‘I enjoyed dancing. . .I used to hang out with dancers.’ P5: ‘I was in the ladies’ army, so I did a lot of dancing, fashion dancing, you know, anything, just enjoying ourselves, I enjoyed my life.’ P1: ‘I don’t remember them [steps] but you’ve got to learn parts of dancing.’ P4: ‘It’s easy to do, aye, because I already know [hums dancing tune] then you said that’s it!, then you felt old, you know, nice. . .’ P6: ‘Yes, breathe in – breathe out. I’ve learnt that!’ P6: ‘Yes, I like dancing; I can dance [silence] I don’t do much to get up and rather prefer get up and dance.’ P7: ‘You feel good, because you can manage to stretch on as best as you can. I mean some people have to struggle on but they can still manage quite easily, that’s it.’

Behaviour

Socialising

Reminiscence

Mental Stimulation

Mobility

P: participant

change in residents’ mobility after taking part in DPI such as moving joints and limbs rather than sitting down. Also, reminiscence was reported, with residents talking about their youth and previous dance experiences and one carer spoke about how DPI might relieve constipation. Category B: Benefits on spectator-residents. Residents who observed the session, but did not dance due to mobility problems, showed an effect on their Affective States, Reminiscence and Mobility. These areas were noted (Table 2) as spectators expressed more interest in entering the room to see DPI than watching television, showed a sense of joy and pleasure and were helped by reminiscing about their past experiences and talking about them with staff and other spectators.

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Category C: Benefits on family members. Staff reported that family members noticed that the residents were happier and commented on a positive activity for the home environment. Category D: Benefits on care staff. Staff provided reflective statements on being a DPI facilitator or observer and four subcategories emerged. Carers reported that promoting socialising between ‘elderly mentally infirmed’ (EMI) residents’ and people without dementia provided a sense of professional satisfaction. Specific caring strategies were: the building of trust through dancing; providing a means for acceptable social touch; exchanging learning between care staff and residents, enhancing verbal and non-verbal communication; reassuring and interacting with residents; discovering details of people’s lives and capabilities. According to one staff member, she was able to reduce a resident’s anxiety by having a ‘little Danzo´n dance with her in the corridor’ outside the sessions. Regarding expectations and possible difficulties, staff mentioned that they hoped the care home management would continue the DPI after the end of the study. In relation to difficulties, staff commented on the unsatisfactory layout of some settings and staff shortages as potential problems. Likewise, one staff member reflected on whether there was a need to set boundaries between being a carer or a friend, remarking the fear of loss due to increased emotional attachment when the resident died. In general the staff viewed the use of DPI positively. Furthermore, one staff commented that the introduction of DPI might be cost-effective, as hiring entertainers to sing with residents costs approximately »80 for one hour. No attrition, falls or sexual disinhibited behaviours were reported during the study.

Model emerging from residents A theoretical model emerged from 14 interviews with the residents (7  2). The identified main category was ‘Enjoyment’ as many interviewees stated that dancing provided joy. Table 3 shows the central theme and five subcategories (Mood, Behaviour, Socialising, Reminiscence, Mental Stimulation and Mobility). In relation to mood, residents stated that dancing produced positive emotions and feelings, often making them feel joyful, excited and cheerful. They commented that it made them feel younger and reminded some that they were not as mobile and graceful as they used to be. Residents also reported looking forward to the dancing activity. They also manifested their attitude towards DPI by expressing their likes and dislikes of the individual sessions. Participants clearly identified with their fellow dancers and felt part of a group. There seemed to be a clear sense of a new identity. Once a group was formed, its members socialized more with each other. The experience also cued past memories, with participants recalling dancing experiences. There was also evidence of learning taking place; as competence increased, so did pride and enjoyment. Some residents commented about having renewed vigour and a sense of fitness and vitality.

Discussion This pilot study aimed to investigate the effect of DPI in people with dementia living in care homes. The findings showed that Danzo´n had beneficial effects for a ‘naturalistic’ group of residents, who at various stages of the dementing process were able to participate. The analysis of the interviews resulted in two theoretical models, from carers and

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residents respectively. The care staff model found benefits for residents, staff and families. Such benefits were experienced as enjoyment by the residents, and this feature formed the core theme of their model. The reason for this general positivity is multi-dimensional as discussed below. First, care staff and residents mentioned that DPI was easy to learn and they did not find it frustrating. This can be contrasted with some ‘dance therapies’ where it has been argued that ‘dance learning’ can be threatening for people with dementia (Nystro¨m & Lauritzen, 2005). However, DPI elements, such as repetition, implicit cues and use of mnemonic material, seemed to help residents and staff perform the set of Danzo´n choreography over 12 sessions. Staff and residents reflected that despite Danzo´n being new to them, it was ‘happy music’ and felt comfortable dancing to it. In fact, a study by Gagnon, Fu¨lo¨p and Peretz (2009) found that participants with Alzheimer’s disease could differentiate happy from sad music. The latter study suggests that Danzo´n music, the rhythm and social interaction perceived as ‘cheerful’, is another important element for this psychomotor intervention. In the present investigation, one resident’s daughter reported having the opportunity through a DPI session to interact with her mother in a dynamic and enjoyable way. Similarly, residents recalled positive memories related to dancing experiences. These memories were discussed with other residents who might not have spoken with each other before despite living at the same home. It can be argued that DPI might facilitate residents’ relationships within the home and with family members. Second, the physical component of DPI encourages participants to hold hands in either circle or pairs (i.e. Danzo´n entrance step). This ‘social touch’ through dance might suggest tactile stimulation among residents and staff. Interestingly, one carer encouraged a ‘little Danzo´n dance’ in the corridor to reduce one resident’s anxiety. It remains unclear how these skills are used by other carers in other situations. Third, carers who acted as DPI facilitators reported the sessions as opportunities to ‘have a break in a fun way with residents’, and interact in another context apart from cleaning and feeding. Although, it has been argued that a dance therapist is more effective for delivering interventions (Bowie & Mountain, 1997; Stockley, 1992), contrasting arguments mention that stressful reactions or anxiety are reduced when care staff or familiar faces are present (De Vresse, Fiorovanti, Neri, Belloi & Zanetti, 2001). Our findings are in line with previous studies where reminiscence emerged from dancers with dementia (Arakawa-Davis 1997; Coaten 2001), where agitation was reduced (Duignan et al. 2009) and where people with dementia could perform new motor skills (Ro¨sler et al. 2002). There were several limitations in the present pilot study. For instance, the first author had a dual role of researcher–therapist. However, staff and residents rectified and approved the developed models. The number of participants interviewed was small, as data reached saturation after the ninth and seventh interview with care staff and residents respectively, as no new categories were found. This study may also be criticised for the largely qualitative nature of the work. However, the method allowed for the exploration of core themes prior to undertaking a quantitative analysis, as the DPI approach is a new intervention. This research strategy is consistent with the Medical Research Council (MRC) framework (Milne et al., 2008) regarding the exploration of new interventions, dovetails with the staff-training recommendation (Banerjee, 2009) and supports the objective of optimising an effective workforce for people with dementia in care homes stated in the National Dementia

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Strategy (2009). Of note, the next phase of the investigation of Danzo´n psychomotor intervention has already commenced using a multiple-baseline single-case research (Guzma´n-Garcı´ a et al., in preparation), and the methodology for this has been informed by the findings of the present study. In conclusion, it was evident that residents benefited by participating in the dance classes. Introducing dancing was a different way to enhance interactions between residents and care staff and other positives across a number of diverse dimensions. Staff also reported a positive impact in terms of the residents’ and their own levels of well-being and satisfaction. Anecdotal evidence suggested that residents observing the dancing gained benefits too. Tentative evidence suggests that this form of dance is suitable for people with dementia of mixed severity, as it was observed that staff simplified the requested dancing commands to reduce frustration in the more severe cases. Future research will focus in the costeffectiveness of DPI on the care-homes’ budget, with the intention of investigating how to reduce the cost of acquiring medication to treat BPSD. These findings provide a platform on which a more thorough quantitative investigation may be based and for future investigations into adherence and supervision of the dancing intervention. Acknowledgements The authors are grateful to the residents and staff for taking part in this study. Thank you to Rachel Betty and Pauline Hudson for assistance and external observation, Challenging Behaviour Service at formerly Newcastle General Hospital for support and guidance. Special thanks to Rosario Maza and Miguel Castillo, Danzo´n consultants and educators to AGG. A preliminary abstract of this paper was presented in 2009 at the XIXth IAGG World Congress of Gerontology and Geriatrics in Paris, France.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.

Conflict of interest statement None.

Description of authors’ roles AGG and IJ designed the study. AGG collected data, carried out qualitative and quantitative data and drafted the paper. EML assisted with data collection. All of the authors contributed to the interpretation of data, reviewed the paper and approved the final version.

Note 1. Discontinued and replaced by Leadership & Management in Care Services (LMCS) Award.

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Azucena Guzma´n-Garcı´ a has recently been awarded a PhD from the Institute for Ageing and Health, Newcastle University, UK. Her background is in Neuropsychology and Rehabilitation and she has studied Psychomotor Practice at the Institut Supe´rieur de Re´e´ducation Psychomotrice in Paris, France. Elizabeta Mukaetova-Ladinska is a Clinical Senior Lecturer (PhD) at Newcastle University and Old Age Psychiatry Consultant at Centre for the Health of the Elderly, formerly Newcastle General Hospital, Northumberland, Tyne and Wear, NHS Trust, UK. Ian James is a Researcher (PhD) and Consultant Clinical Psychologist, Newcastle Older Adult Psychology Service, formerly Newcastle General Hospital, Northumberland, Tyne and Wear, NHS Trust, UK.