ARTICLE IN PRESS

Geriatric Nursing ■■ (2018) ■■–■■

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Geriatric Nursing
j o u r n a l h o m e p a g e : w w w. g n j o u r n a l . c o m

Effect of music intervention on apathy in nursing home residents

with dementia
Qiubi Tang, RN a, Ying Zhou, RN, PhD b,*, Shuixian Yang, RN a, Wong Kwok Shing Thomas, RN, PhD c,
Graeme D. Smith, RN, BA FEANS PhD d, Zhi Yang, RN c, Lexin Yuan, RN c,
Joanne Wai-yee Chung, RN, R.N.T., BA ppSc(nursing), BA(Hond)Ed, MHA, PhD c
a Guangzhou Huiai hospital, Affiliated Brian Hospital of Guangzhou Medical University, Guangzhou, China
b
School of Nursing, Guangzhou Medical University, China
c Guangzhou Medical University, China
d
School of Health and Social Care, Edinburgh Napier University, Edinburgh UK

A R T I C L E I N F O A B S T R A C T

Article history: This study examined the effectiveness of group music intervention in the treatment of nursing home resi-
Received 27 March 2017 dents with apathy. Apathy can clinically defined with a score of 40 or above on the apathy evaluation
Received in revised form 26 January 2018 scale (AES). Seventy-seven residents were randomly assigned to the intervention or control group. The
Accepted 5 February 2018
intervention group was given a music intervention programme, which included listening to traditional
Available online
music, including nostalgic songs, and playing musical instruments three times a week, for a total of twelve
weeks. Results demonstrated a decrease in apathy scores in the intervention group (z = 4.667, P < 0.01),
Keywords:
but not in the control group (z = −1.810, P > 0.05). Cognitive function, as assessed by Mini Mental State
Apathy
Music intervention Examination (MMSE) score, was stable in the intervention group (t = 1.720, P > 0.05), but declined in the
Dementia control group (t = −1.973, P < 0.05). We conclude that music intervention has the potential to be an ef-
Older people nursing fective therapy for the treatment of apathy in the early stages of dementia.
© 2018 Elsevier Inc. All rights reserved.

Introduction tients’ rehabilitation with dementia.1,9 However, due to the heavy

As a neuropsychiatric symptom, apathy is a strong predictor of
the progression of the illness that has a significant influence on the
quality of life of both the patients with dementia and their caregivers.1
Patients with symptoms of apathy are characterized by decreased
goal-oriented motor behaviour, decreased goal-oriented cognition and
decreased affective reaction.2 In Levy’s opinion, apathy plays an im-
portant role in the reduction of goal-directed behaviours and self-
generated motivation.3 In addition, studies have considered apathy
to be a symptom associated with of the loss of emotional feelings.4
Previous studies, have reported symptoms of apathy to be com-
monly present in patients with dementia, especially those who reside
in a long-term nursing care home.5–8 Due to the lack of initiative
and interest in their environment, patients with apathy often have
serious restrictions on social participation. The presence of apathy,
a neuropsychiatric symptom, appears during the progression of de-
mentia, may accelerate the deterioration of dementia and can deprive
patients of normal activities and reduce levels of consciousness.9,10
Apathy has becomes an important factor that can influence pa-
* Corresponding author. Tutor of postgraduates in Nursing school of Guangzhou
Medical University, China.
E-mail address: zhouying0610@163.com (Y. Zhou).
burden and emotional stress of providing caregiving for older people
with dementia, as well as the difficult to identify symptoms, of
apathy, it can be overlooked by caregivers, resulting in subopti-
mal care. During routine care in dementia, apathy may fail to attract
a comparable level of attention to other symptoms, such as memory
deterioration, aggression and agitation.11,12 Thus, older people with
apathy may sit in solitude, experiencing boredom, with limited in-
teraction, which may in turn exacerbate symptoms of apathy.11
Previous research has confirmed that apathy can have a negative
impact on an individual’s overall quality of life, impair the treat-
ment response and increase burden on the caregiver.13,14
Although apathy is the most common symptom in patients with
dementia, there is currently no definitive treatment for this symptom
in dementia, drug therapy such as ritalin can only improve or relieve
the symptoms for a certain period of time.15,16 Moreover, there are
presently no approved pharmacological guidelines for manage-
ment of the symptoms of apathy and insufficient evidence to
substantiate the efficacy of any drugs.17,18 With these limitations and
side effects of drug therapy, which can place a heavy financial burden
on families, an increasing number of academics have suggested that
non-pharmacological interventions may have a role to play in the
management of the dementia. To date, however, studies of non-
pharmacological intervention approaches in dementia care are lacking.

0197-4572/$ — see front matter © 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.gerinurse.2018.02.003
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Several studies have specifically examined the effects of music
as a therapy in the management of symptoms of dementia, sug-
gesting the positive effect in the treatment of anxiety, irritability
and memory impairment.19–21 However, only a few published non-
pharmacological treatment trials have specifically aimed at relieving
symptoms of apathy.12,16,22,23
When listening to music, the reticular structures in the brain stem
receive impulses from the body, viscera and other sensory systems.24
After integration and adjustment, the impulses reach the cerebral
cortex through the thalamus with no specificity, which can cause
a reaction. Via transmission of the stimulation to the cerebrum
through the auditory system, music plays a potentially important
role in the regulation of the central nervous system and emotion-
al adjustment; it can control the internal and external physiological
reactions and influence endocrine function.24,25 Simultaneously, in
the degenarative process of cerebral function, the part of brain that
is associated with music programs is relatively well preserved. Thus,
the cerebral cortex has been shown to be sensitive to the stimu-
lation and reflexes associated with music, promoting the conduction
of the peripheral nerve pathway when affected by musical
interventions.26
Despite limited evidence of the efficacy of music interventions
in the management of psychological symptoms in older people, no
study to date has specifically looked at the effectiveness of music
interventions in the management of symptoms of apathy, associ-
ated with dementia. It was therefore, the main aim of our study was
to explore the effect of group music intervention on the motor, af-
fection and cognitive behaviours of older people in residential homes
with symptoms of apathy associated with dementia.
Subjects and methods
Participants
The participants in this study were recruited from a 1000 bed
residential nursing facility, which specializes in the management
of dementia-related symptoms in Guangzhou, China. For older adults
with MMSE of 27 or below, informed consent was provided by either
a close relative or a legally authorized representative as proxy of
the older person. Although the overall size of the nursing home is
1000 beds, only 150 beds on two floors specifically manage indi-
viduals with dementia. From 150 potentially eligible residents, one
hundred and twenty were wiling to consent to participate and
twenty-three residents refused.
After written informed consent was obtained in accordance with
the University’s ethical Institutional Review Board’s procedures, par-
ticipants were screened by a member of medical staff using the
Structured Clinical Interview for International Classification of
Diseases-Tenth Revision (ICD-10) to ensure confirmation of de-
mentia diagnosis, the Apathy Evaluation Scale-Clinician (AES-C) and
the Mini Mental State Exam (MMSE) scores were also collected at
this time-point. The inclusion criteria for entry into this study was
aged 60 years or older, mild to moderate dementia (defined by a
MMSE score ranging from 10 to 27), meeting the AES-C diagnostic
criteria for apathy, no other serious co-morbidities and voluntary
participation and the ability to communicate and cooperate with
the research assistant to complete the questionnaires. The exclu-
Table 1
Music intervention weekly schedule.
Time Monday Tuesday
9:00~9:50 am subgroup 1 subgroup 2
10:00~10:50 am subgroup 3 subgroup 4
sion criteria included the absence of apathy, severe dementia
(defined by a MMSE score of 9 or below), other severe chronic dis-
eases, previous trauma, poor compliance, failure to communicate
and other factors that may affect the delivery and assessment of
the musical intervention.
Using ICD-10 classification, 101 residents from the original
sample of 127 were diagnosed with mild to moderate dementia.
Of these, 77 residents met the diagnostic criteria for apathy, re-
cording an AES-C score of 40 or above. All participants and their
relatives or legal guardians were provided with relevant informa-
tion sheet outlining the study and given a full explanation of study
procedures, if they agreed a consent form was signed. Then the older
residents were randomly divided into an intervention group and
a control group, using a computer-based random number alloca-
tion method, resulting in 39 cases in intervention group and 38 in
the control group.
Design and procedure
This was a randomized, controlled, parallel, partially masked
(rater) twelve-week interventional clinical trial. The participants in
the intervention group were randomly divided into four indepen-
dent subgroups. There were approximately nine older people in each
subgroup. The schedule for the weekly music intervention is pre-
sented in Table 1. During the intervention each patient subgroup
had one trained therapist with overall responsibility for implemen-
tation of music intervention, someone who was responsible for
recording the participants’ emotional reactions during the inter-
vention process and the performance of the interaction, and one
research assistant, predominantly providing assistance to the ther-
apist and the participants. The intervention group received the 50-
minute music intervention three times a week for a period of 12
weeks (36 sessions in total). Those participants who were absent
from the intervention five times or more were removed from in-
tervention group, and their assessment results were excluded,
although they were allowed to continue to receive the interven-
tion. The control group did not receive any special interventions
except those regularly provided regularly in the nursing homes, such
as watching television. The therapist, recorder and research assis-
tant excluded from any participation in the evaluation work, which
occurred one week before and after delivery of the intervention,
using the AES-C scale, the MMSE scale and Holden’s communica-
tion scale.
Ethical approval to conduct the study was obtained from the Gua-
ngzhou Medical University Human Research Ethics Committee and
the older people’s residential facility (Table 2).
Intervention
Sensory stimulation with music
The primary goal of the music intervention in this study was to
promote the residents’ receptive ability of perception by listening
to music. Individuals with dementia commonly exhibit a loss of con-
nection with reality and disordered perceptions of time, place, people
and surrounding environment.27 After listening to music or songs,
participants were asked to distinguish the sounds of various musical
instruments (e.g., drum, gong, mouth organ, flute), different sounds
Wednesday Thursday Friday Saturday
subgroup 3 subgroup 4 subgroup 1 subgroup 2
subgroup 1 subgroup 2 subgroup 3 subgroup 4
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Table 2
Music intervention content.
Sensory stimulation with music
The sounds of various musical instruments (e.g., drum, gong, mouth organ, flute)
Different sounds in nature (e.g., wind, rain, thunder)
Different sounds of animals (e.g., birds, goats, horses, chooks)
Note: All three of these music interventions were provided each session with a step-by-step approach.
from the natural world (e.g., wind, rain, thunder), and different
sounds of animals (e.g., birds, goats, horses, chooks). This process
was aimed at helping the participants re-establish a connection with
the natural environment.
Singing nostalgic songs
The nostalgic songs chosen in this study were divided into three
categories, i.e., nostalgic red songs (red songs are the true portray-
al of revolutionary practice that express the people’s love and praise
for their motherland), nostalgic nursery rhymes and nostalgic Can-
tonese opera. “Dong fang hong” is a representative red song, “Luo
yu da, Shui jin jie” is a representative nursery rhyme, and “Di nv
hua” is a representative Cantonese opera (“Dong fang hong”, “Luo
yu da, Shui jin jie” and “Di nv hua” are the most popular classic songs
in China. These songs may re-create images of the participants’ lives
when they are younger, and provide opportunity for reflection upon
life and cultural perspectives of that era. It was anticioated that most
participants would have some feeling about these songs. At the be-
ginning of the intervention, the participants were merely asked to
listen to music. During the listening phase of the process, the ther-
apist paid specific attention to the reaction or resonance produced
by the participants. Secondly, the therapist asked the participant
to sing the song together with them if they were able to do so. During
this part of the intervention, participants who were unfamiliar with
the song or could not sing at all were given additional support and
specific training, involving texplanation of the lyrics and repeated
practice. Finally, while the participants were singing, the thera-
pist encouraged them to clap their hands following the rhythm of
music so that the participants could engage more deeply into the
melodies of the music.
Playing musical instruments
In this part of the music intervention, a xylophone was used as
the instrumental intervention (xylophones are musical instru-
ments with a set of wooden bars of different lengths that are hit
with hammers). With eight scales (do,re,mi,fa,sol,la,si,do), the xy-
lophone can be used to play fairly simple music. The participants
were initially asked to try to distinguish the digital numbers that
were marked beside the scales by the group members. Next, they
were asked to hit the bars one by one following the therapist’s order.
For example, when the therapist said “1”, the older resident had
to hit the “do” scale, which was labelled with “1”. After the par-
ticipants became familiar with each number, the therapist attempted
to put the numbers together and led them to hit related scales, such
as 1-2-3 and 1-2-3-1. The final goal of this phase of the interven-
tion was to enable the participants to play a complete simple song,
such as “Two Tigers”, which is a simple song with the following
pattern: “1-2-3-1, 1-2-3-1, 4-5-6, 4-5-6, 5-6-5-4-3-1, 5-6-5-4-3-1,
2-5-1, 2-5-1”.
Assessment and outcome measures
The baseline demographic data were collected during January
2016 by the nursing staff of the residential home, and clinical data
was collected by specially trained research assistants for baseline
measurement. The raters, who also were data collectors, were trained
in the use of these measurement instruments over three days in a
3
Singing nostalgic songs Playing musical instruments
Nostalgic red songs (“Dong fang hong”) Xylophone
Nostalgic nursery rhymes, (“Luo yu da, Shui jin jie”)
Nostalgic Cantonese opera, (“Di nv hua”)
group-teaching setting, in local geriatric psychiatry units. Raters in
the study who were blinded to the delivery of the music interven-
tion performed scoring. Post-intervention measurements were
collected immediately after the intervention.
The selected assessment instruments have all demonstrated good
reliability and validity in Chinese AD population. The inter-rater re-
liability of Apathy Evaluation Scale-clinician (AES-C,)2 was 0.967,
and the test-retest reliability was 0.906. For the scale of Mini Mental
State Examination (MMSE),28 the inter-rater reliability range from
0.55 to 0.91, and the test-retest reliability ranges from 0.80 to 1.
Primary outcome
The primary outcome variable in this study was apathy, as mea-
sured with AES-C scale, which consists18 items that are phrased
as questions that are to be answered by the specially trained re-
search assistants. The total score for this measure ranges from 0 to
72, with higher scores indicating greater severity of apathy, assess-
ment was made just prior to delivery of the music intervention and
at the end of the twelve-week intervention.
Secondary outcomes
The MMSE was used to assess the severity of dementia, as a sec-
ondary outcome MMSE scores can range from 0 to 30, higher scores
indicating better cognitive function. An MMSE score of 27 or higher
is seen as normal, 21~26 indicates presence of mild dementia, 10~20
indicates moderate dementia, and 0~9 indicates severe dementia.
Additionally, the communication scale developed by Holden (1995)
was used to assess communication and presentation ability. This
is a 5-point scale with three dimensions and 12 items. The total score
ranges from 0~48 points, and higher scores indicate worsening com-
munication abilities.
Statistical analysis
Descriptive analysis was performed to calculate the scores of each
of the measurement scales. Comparisons of the intervention and
control groups at baseline for the demographic data and the scores
on the AES-C, MMSE and Holden communication scale were per-
formed using one-way ANOVAs. To determine the influence of music
intervention on apathy, we analysed the pre/post intervention
changes in each subgroup. To compare the mean differences of AES-
C, MMSE and Holden communication scale scores, independent
t-tests and paired t-tests were performed.
The data analyses were performed using the SPSS statistical
package, version 21.0 (IBM SPSS Statistics, IBM Corporation, Armonk,
NY). All statistical tests were two-sided, and an alpha below 0.05
was considered statistically significant.
Results
A total of 77 residents, with a mean age of 75.88 years (SD = 5.09;
range: 65 to 90 years; 38 women) were included in the study. The
mean MMSE score was 16.09 (SD = 4.74; range: 10 to 26), defined
as mild to moderate dementia. At baseline, the mean score on the
AES apathy scale was 54.82 (SD = 9.09; range from 35 to 70). The
mean score on the Holden communication scale was 21.18 (SD = 9.29,
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Table 3
Demographic data of control and intervention groups.

Variable Overall Intervention Control group P

group (n = 38) (n = 39)

Age 75.88 ± 5.09 76.39(±4.86) 75.38(±4.94) t = 1.47 >0.05

Gender x2 = 0.326 >0.05
Male 39(50.6%) 21 18
Female 38(49.4%) 17 21
Education x2 = 6.209 >0.05
Illiterate 14(18.2) 9 5
Primary school 29(37.7) 11 18
Junior middle school 18(23.4%) 11 7
Senior high school 8(10.4) 2 6
Undergraduate 8(10.4) 5 3
Marital status x2 = 0.001 >0.05
Single, Divorced or Widowhood 16(20.8%) 8 8
Married 61(79.2%) 30 31
Children x2 = 2.10 >0.05
0 4(5.2%) 3 1
1–2 46(59.7%) 20 26
3 or more 27(23.4%) 15 12
Able to say what music they like x2 = 0.025 >0.05
Yes 51(66.2%) 26 25
No 26(33.8%) 12 14
Time in nursing home x2 = 0.639 >0.05
0–2 years 39(50.6%) 21 18
3–4 years or more 38(46.8%) 17 21

range from 4 to 42). Baseline comparison of the two groups age,
education, marriage, children, and the time spent living in a nursing
home are presented in Table 3. The baseline results of the study
outcome measures, including the AES, MMSE and Holden commu-
nication scores, are provided in Table 4. The two groups did not differ
significantly in terms of any of the relevant variables.
After the intervention, there were 37 subjects in the interven-
tion group and 39 in the control group. One evaluation result was
omitted from comparison as the participant accidentally fell down
when he went to toilet at night, resulting in a fracture and hospi-
tal admission. Of the 37 subjects, 35 had full attendance at all the
music intervention sessions, but two participants were absent for
one time because of physical illness. After the 12-week music in-
tervention, the apathy of the intervention group was significantly
improved (difference in scores between baseline and post-
intervention, z = 4.516, P < 0.001) as did the level communication
ability (difference in scores between baseline and post-intervention,
z = 4.667, P < 0.001). The level of cognitive function remained stable;
the overall average score was higher than before, but this differ-
ence was not significant. No significant effect was found with respect
to apathy the in control group. However, there were differences in
communication ability and cognitive function. After 12 weeks, the
communication ability had declined when compared to the base-
line (z = −2.134, P = 0.033), and average score for cognitive function
decreased significantly by 0.76 (t = −1.973, P < 0.05; Table 5).
Discussion
Apathy is a clearly recognised early stage symptom of demen-
tia. To date, minimal attention has been given to the management

Table 4
Comparison of the two groups before and after intervention.

Variable Group Pre-intervention P Post-intervention P

( x±S) ( x±S)

Apathy (AES) IG 55.13 ± 9.27 z = 0.332 >0.05 52.08 ± 9.56 z = 1.377 >0.05
CG 54.51 ± 9.03 55.31 ± 8.49
MMSE IG 16.42 ± 4.89 t = 0.600 >0.05 16.71 ± 5.03 t = 1.381 >0.05
CG 15.77 ± 4.64 15.01 ± 4.52
Holden Communication IG 21.05 ± 9.41 z = 0.240 >0.05 19.68 ± 8.97 z = 1.229 >0.05
CG 21.31 ± 9.30 21.82 ± 8.54

Note: IG represents the intervention group, and CG represents the control group.

Table 5
Within group comparisons for each group before and after the intervention.

Variable Control group P Intervention group P

( x±S) ( x±S)

Apathy (AES) Pre-intervention 54.51 ± 9.31 z = −1.810 >0.05 55.13 ± 9.27 z = 4.667 <0.05
Post-intervention 55.31 ± 8.49 52.08 ± 9.56
MMSE Pre-intervention 15.77 ± 4.64 t = −1.973 <0.05 16.42 ± 4.88 t = 1.720 >0.05
Post-intervention 15.01 ± 4.52 16.71 ± 5.03
Holden Communication Pre-intervention 21.31 ± 9.30 z = −2.134 <0.05 21.05 ± 9.40 z = 4.516 <0.05
Post-intervention 21.82 ± 8.54 19.68 ± 8.97
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of symptoms of apathy in older people. To our knowledge, this is
the first interventional study to examine the effect of music inter-
vention in the management of apathy. We observed a significant
decrease in scores of apathy in the intervention group, but not in
the control group, after 12 weeks of music intervention. If un-
treated, apathy can quickly exacerbate over time,7 remission of the
participants’ apathy in the face of disease progression indicates that
our intervention was potentially beneficial, despite the absence of
significant improvement in cognition levels in the intervention group.
Whilst, listening to music, our neurones and bodies can vibrate har-
moniously with the same rhythm and melody of the music, which
increases the cell activity level, and the compensatory function
becomes increasingly obvious.26,29From this perspective, the atten-
tion and memory of residents may have improved.
Apathy may be an early indicator of the progression of the de-
mentia disease process and has demonstrable influences on the self-
care ability, quality of life, treatment and rehabilitation effects, and
the survival time of residents after rehabilitation.20 Our results in-
dicated that the occurrence of apathy was closely related to the level
of severity of dementia (r = 0.306, P < 0.01). Previous studies have
demonstrated6,30,31 that the incidence of apathy in residents with
dementia ranges from 32.1% to 93.2%, including 42% in mild, 80%
in moderate, and approximately 92% in severe cases of dementia.
Moreover, if the residents live in nursing homes or hospitals for pro-
longed periods of time and the prevalence rate of apathy in dementia
can reach as high as 93.2% in this population. In one study, con-
ducted by Robert,32 214 participants with mild cognitive dysfunction
were recruited. This study used anxiety, depression and apathy as
measurement indices and explored the relationship between these
factors over a three-year period. The findings revealed that the resi-
dents who suffered from severe apathy (as assessed with the AES
score) were more likely to develop more severe dementia. Con-
versely, more serious cognitive dysfunction (as assessed with the
MMSE score) was associated with a greater likelihood of the ap-
pearance of apathy. Starkstein33 shared the same opinion that apathy
is an important behavioural index of the deterioration or progres-
sion of cognitive function and that more serious apathy is indicative
of more serious behavioural problems and emotional disorders.
Additionally, apathy is closely related to cognitive impairment.
In one French study, Lechowski34 focused on 272 female subjects
with MMSE scores ranging from 10 to 26, concluding that apathy
was the main factor that led to the overall decline of cognitive func-
tion. If the older people in residential homes suffered from apathy
for more than one year, their cognitive function (MMSE score)
dropped off by an average of 3 points. If this was not the case, the
score decreased by only 1 point per year. This finding is similar to
those held by Sarazin35 who believed that patients with poor
memory, due to mild cognitive impairment, were more prone to
develop apathetic symptoms and that the cognitive function of pa-
tients with apathy is significantly lower than that of control groups.
One longitudinal study36 revealed that the mechanisms of apathy
and cognitive dysfunction are related to the interrupted contact of
the mid-frontal lobe and the anterior cingulate cortex. This pre-
sumption has been confirmed in other neurological diseases
associated with apathy37
By stimulating the cerebral limbic system that is associated with
emotion, music intervention can regulate the function of the ce-
rebral cortex, and it can release the activity substance in the body
and the sense of pleasure.25,38 All of these factors potentially play
a role in alleviating apathy, depression, anxiety and pain. Music in-
tervention has made some remarkable achievements in
neurodegenerative diseases and has received increasing attention
in the rehabilitation and nursing care of dementia patients.
As demonstrated in our study, during the 12-week interven-
tion period, the music intervention played a potentially important
5
role in delaying the progression of Alzheimer’s disease. It effec-
tively reduced the symptoms of apathy and improved the residents’
cognitive function and communication ability. However, in our re-
search, there remains much to be further improved. For example,
we did not examine whether the effects of music intervention can
last after 12 weeks or whether residents can receive a greater im-
provement with a longer intervention duration (longer than 12
weeks). Additionally, further research is needed to confirm the dif-
ferent effects among residents with different degrees of apathy
because we could not resolve this questions due to a sample size
limitation. To date, randomized controlled trials dealing with non-
pharmacological interventions and the sustainability of their effects
are rarely reported.39 Therefore, the results found here may make
a significant contribution to effectiveness of music intervention for
apathy, which suggests that clinical workers should consider non-
pharmacological interventions in the treatment of apathy in patients
with dementia.
Conclusion
Music intervention appeared to play a significant and impor-
tant role in delaying the process of deterioration in the symptoms
of dementia. In comparison with the control group, music inter-
vention effectively maintained cognitive function in older residents
with dementia, alleviating the symptoms of apathy, and im-
proved verbal communication ability. All of the above would
potentially help to improve the residents’ overall quality of life and
may reduce the impact of caregivers’ burden. In the long-term care
of residents with dementia, closer attention towards music inter-
vention in management of dementia is strongly recommended.
Although the sustainability of the effects beyond 12 weeks has yet
to be confirmed, as a simple and cost-effective treatment music in-
tervention requires further promotion.
Acknowledgement
We would like to give our sincere thanks to Professor Wong Kwok
Shing Thomas, Joanne Wai-yee Chung and Graeme D. Smith who
made an academic contribution provided helpful comments and sug-
gestions. We also wish to thank the staff of the Guangzhou Songhe
Nursing Home who provided laboratory equipment. Additionally,
we thank all of the participants.
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