JAMDA xxx (2014) 1e6

JAMDA
journal homepage: www.jamda.com

Original Study

The Effect of Dance on Depressive Symptoms in Nursing

Home Residents
Hana Vankova MD a, b, *, Iva Holmerova MD, PhD a, b, Katerina Machacova PhD b,
Ladislav Volicer MD, PhD, FGSA, FAAN c, Petr Veleta PhD b,
Alexander Martin Celko MD, PhD a
a
Charles University in Prague, Third Faculty of Medicine, Prague, Czech Republic
b
Centre of Expertise in Longevity and Long-term Care, Faculty of Humanities, Charles University in Prague, Prague, Czech Republic
c
University of South Florida, Tampa, FL

a b s t r a c t

Keywords: Objective: To evaluate the effect of a dance-based therapy on depressive symptoms among institution-
Dance therapy alized older adults.
depressive symptoms Design: Randomized controlled trial.
nursing home
Setting: Nursing homes.
Participants: Older adults (60 years or older) permanently living in a nursing home.
Intervention: Exercise Dance for Seniors (EXDASE) Program designed for the use in long-term care set-
tings performed once a week for 60 minutes for 3 months.
Measurements: Baseline measures included sociodemographic characteristics, ability to perform basic as
well as instrumental activities of daily living, basic mobility, self-rated health, and cognitive status.
Outcome measures were collected before and after the intervention and included assessment of
depressive symptoms using the geriatric depression scale (GDS).
Results: Comparison of participants with MMSE of 15 or higher showed that GDS scores in the inter-
vention group significantly improved (P ¼ .005), whereas the control group had a trend of further
worsening of depressive symptoms (P ¼ .081). GLM analysis documented highly statistically significant
effect of dance therapy (P ¼ .001) that was not influenced by controlling for intake of antidepressants and
nursing home location. Dance therapy may have decreased depressive symptoms even in participants
with MMSE lower than 15 and resulted in more discontinuations and fewer prescriptions of antide-
pressants in the intervention group than in the control group.
Conclusion: This study provides evidence that dance-based exercise can reduce the amount of depressive
symptoms in nursing home residents. In general, this form of exercise seems to be very suitable and
beneficial for this population.
Ó 2014 - American Medical Directors Association, Inc. All rights reserved.

Prevalence of depressive symptoms among older adults is high,
especially among those living in long-term care settings.1e4 Late-life
depression may carry a high illness burden,5e8 and is associated with
higher cost of health care services9 and increased mortality.10e12 Sub-
syndromal depression (known also as subthreshold, minor, or clinical)
has been associated with the same negative consequences.13,14 Among
This publication was supported by the grant NT11325 of the Internal Grant
Agency of the Ministry of Health of the Czech Republic.
The authors declare no conflicts of interest.
* Address correspondence to Hana Vankova, MD, Charles University in Prague
2.interní klinika, Third Faculty of Medicine, Ruská 87, Praha 10, 10000 Praha, Czech
Republic.
E-mail address: h.van@seznam.cz (H. Vankova).
the oldest, depression is often underdiagnosed and undertreated
because depressive symptoms are often thought to be part of other
confounding conditions caused by medication or illness.2,4,15 There-
fore, the importance of prevention and treatment of depression, even
subsyndromal, in long-term care residents is apparent.
There are several effective ways to treat depression. Recent evi-
dence emphasizes nonpharmacological treatment as a safe and cost-
effective method16 that is especially efficient among older adults
with subsyndromal depression.17 Furthermore, a review of available
literature showed that nursing home (NH) residents have only modest
response to antidepressant medication.18 Most physical activity in-
terventions were found to significantly reduce depressive symptoms
and proved to be effective in depression prevention among the elderly

1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jamda.2014.04.013
2 H. Vankova et al. / JAMDA xxx (2014) 1e6
population,16,19e22 although more evidence is still needed because not
all of the studies provided positive results23 and many of them have
methodological limitations. Nevertheless, physical activity influences a
number of biological processes associated with depression.24 A study
conducted by Dekker et al25 provided evidence that starting with
alternative treatment as opposed to pharmacotherapy may be prefer-
able in mildly and moderately depressed patients.
Studies designed to assess the effect of physical activity on depres-
sive symptoms included endurance and strength training19,26e28 or
complex physical activity more suitable for low-functioning individuals
in late life, such as Tai Chi,29e31 Qigong,32e33 or dance34e39 in-
terventions. However, the evidence is still sparse and research on resi-
dents who are dependent in activities of daily living (ADLs)/
instrumental ADLs (IADLs) of NHs is missing.
Dance is a unique type of physical activity because it integrates
physiological, psychological, and sociological components40 and also
provides an opportunity for reminiscing. All these qualities are
enhanced by music, which itself proved to have a positive effect on
depression.41e44 This is especially important for depressed older adults
who are at risk for diminished enjoyment of physical activity, resulting
in low attendance rate.
Therefore, a randomized controlled trial was conducted to evaluate
the effects of a dance intervention designed for the use in long-term
care settings called “EXDASE” (Exercise Dance for Seniors).45 The ef-
fect of EXDASE on lower body mobility was already examined within a
pilot study and found to be positive.46 This study was designed to
analyze effects of EXDASE on symptoms of depression because, to the
best of our knowledge, no one to date has examined the effects of
dance-based exercise on depressive symptoms among older adults
living in long-term care settings such as an NH.
Methods
Research Design and Participants
The present study was a randomized controlled trial of a dance-based
intervention among older adults conducted in 7 NHs in the Czech Re-
public. Older adults permanently living in NHs tend to be sedentary and
low functioning as compared with the population still living in home
settings.47e49 Selected NHs included 1278 eligible individuals who met
the following inclusion criteria: (1) being a permanent resident of one of
the facilities, (2) being 60 years or older, and additional inclusion criteria
for statistical analysis of Geriatric Depression Scale (GDS) score changes
were (3) Mini-Mental State Examination (MMSE) score of at least 15
points, which is a recommended cutoff score for the use of the GDS in-
strument,50 and (4) no change in antidepressant medication during the
study so that the results cannot be biased by the change. To obtain a study
sample that well represents a wide range of all NH residents, even those
without or with only a few depressive symptoms were included in the
study. The same approach was used elsewhere23 and also enabled us to
address aspects of prevention. From the list of residents, 254 were
randomly selected to join either the intervention or the control group;
216 of them agreed to participate, with a response rate of 85%. Five
participants were excluded because they were younger than 60 years, 6
participants did not complete baseline tests, and 9 participants did not
complete exit tests for the following reasons: refusal (3), death (5), or
long-term illness (1). Nineteen participants were not included in the
statistical analysis because of a low MMSE and 15 because of medication
change. The participants with a low MMSE and medication change were
followed and are described in a separate section of results.
Therefore, the final sample for the statistical analysis in the pre-
sent study included 162 participants who were randomly assigned to
the intervention (n ¼ 79) or control group (n ¼ 83). It is important to
note that participants in the control group were offered participation
in the dance sessions later after the study trial ended (waiting list
design). The study was approved by the Ethical Committee and
Institutional Review Board at the Internal Grant Agency of the Min-
istry of Health of the Czech Republic. The informed consent form was
signed by all participants.
Intervention
Dance classes designed for ADL/IADL-dependent residents of NHs,
including those in wheelchairs and/or with cognitive impairment,
were given once a week for 1 hour for 3 months and consisted of a 10-
minute warm-up period, 40-minute main period, and 10-minute cool-
down period. All parts were accompanied by suitable music supporting
a reminiscence effect. The main period covered techniques of ballroom
dance, including foxtrot, waltz, cha-cha, cancan, and so forth in a
combination. The warm-up period included various slow-paced leg
and arm movements mostly in a seated position, whereas the cool-
down period used relaxation techniques, such as deep breathing and
stretching exercises. The dance instructor always helped to adapt the
exercise for participants dancing in wheelchairs according to individual
capacities. Throughout the intervention, all participants were moti-
vated to take more and more challenging moves and to increase the
intensity to provide maximum benefits; however, the overall goal of
the dance instructor was to make each class enjoyable for all partici-
pants. The music was chosen to further stimulate and motivate par-
ticipants. The control group participated in regular activities of the NH.
Study Measures
All data, including the outcome variable (GDS), were administered
by qualified research assistants. All research assistants collecting data
were blinded to the group assignment. Both baseline data and pretests
of the outcome variable were collected within a week before inter-
vention and posttests of the outcome variable were collected within a
week after the intervention.
Baseline Data
Sociodemographic characteristics included age (years), gender, and
education. Ability to perform basic ADLs was assessed by Barthel Index
designed to evaluate the degree of independence in basic daily tasks.51
ADL score ranged from 0 to 100; a higher number meant more inde-
pendence in tested activities. IADLs were assessed by questions
focused on independence in more advanced daily tasks.52 IADL score
ranged from 0 to 8; again, a higher number meant more independence
in tested activities. The get up and go test53 was used to assess overall
mobility. The test was slightly adapted and standardized for use in the
Czech Republic54 with scores ranging from 0 to 12, instead of 0 to 5, as
in the original version. The test started while sitting in a straight-
backed chair. The participant was asked to (1) get up; (2) walk for-
ward 3 meters; (3) turn around a cone, walk back to chair, and turn;
and (4) sit again. Each of the 4 steps was assessed by a score ranging
from 0 (cannot perform) to 3 (performs without any problems), re-
sulting in the total score between 0 and 12. Self-rated health was as-
sessed by a single-item measure where participants rate their overall
health on a 5-point scale. MMSE,55 with scores ranging from 0 to 30,
was used to assess global cognition. Higher scores indicated partici-
pants with fewer cognitive impairments.
Outcome Variable
The 15-item, dichotomously coded GDS was used (GDS 15),56 with
scores ranging from 0 to 15. The screening scale GDS 15 is used
extensively to assess depressive symptoms in older populations.23,57
 H. Vankova et al. / JAMDA xxx (2014) 1e6 3

Recommended cutoff score for depression is 6 symptoms; however, 5 represented by the results of the get up and go test. Average score of
symptoms also have been used.23 The short version GDS 15 has suf- GDS was higher than 5 and 43% of the participants had a high level of
ficient sensitivity (93%)58 even for those with mild to moderate depressive symptoms (GDS score 6). However, fewer than 18% of the
cognitive limitations50,59 and good reliability (Cronbach’s alfa 0.80).60 participants were taking antidepressant medication at baseline. The
The GDS scale has been frequently used for NH residents3,23 and is average attendance rate was 84.6% and everyone completed more than
considered to be sufficiently sensitive to detect longitudinal changes 50% of the classes. The most common reasons to omit dance sessions,
in depressive symptoms.15,61 The Czech language version standard- such as weather (heat, humidity), actual health status, or a visit from
ized for the use in the Czech Republic was used.62 Administration of family member(s), were reasonable and unavoidable. One participant
antidepressants was recorded in both pre- and posttests. stopped attending dance classes after the second lesson because of
long-term illness; however, this participant did not complete exit tests
Statistical Analysis for the same reason as mentioned previously, so she was not included in
the analyses. There was no reported injury.
Statistical Package for Social Sciences (SPSS for Windows, Version Paired-sample t-test (Table 2) showed that the GDS score in the
15.0; IBM Corporation, New York, NY) was used to analyze data. In- intervention group significantly improved (P ¼ .005) after the 3
dependent samples t-test or chi-square tests were used to test dif- months of dance therapy, indicating positive effect of the intervention
ferences between control and intervention groups before the dance on depression. On the other hand, participants in the control group
program. The paired samples t-test was used to test differences experienced further worsening of depressive symptoms, although the
within single groups (control and intervention) at pre- and posttests. difference was not statistically significant (P ¼ .081). The same trend
In addition, general linear model for repeated measures (GLM) was was observed even when the sample was divided according to anti-
used to support the results provided by paired sample t-test. This depressant intake, as shown in Figure 1. Participants taking antide-
procedure allows a direct comparison of pretest with posttest change pressants (n ¼ 11 in the intervention and n ¼ 18 in the control group)
in performance across the groups by yielding a group  test inter- were more depressed than those without the medication (n ¼ 68 in
action. The 2 factors (group: control vs intervention)  2 factors (test: the intervention and n ¼ 65 in the control group) but both subgroups
pretest vs posttest) design was applied while controlling for antide- showed similar trends of improvements after the dance therapy, sig-
pressant intake and NH location at baseline. Statistical significance for nificant only in subjects without antidepressants (P ¼ .006) because of
all used statistical tests was assessed at a 2-tailed .05 level. the low number of participants with antidepressants.
The results of the paired-sample t-test were supported by the
GLM model, which was highly significant for dance therapy (Wilks
Results
lambda F ¼ 10.97; P ¼ .001). Similar GLM results were obtained when
controlling for antidepressants at baseline, suggesting that the
Statistical Analysis of Participants With MMSE of 15 or Higher
change in depressive symptoms was significantly associated only
with the dance intervention (Wilks lambda F ¼ 10.58; P ¼ .001) and
Baseline characteristics of the study sample for statistical analyses
not with the antidepressant intake (Wilks lambda F ¼ 0.107; P ¼ .744).
are presented in Table 1. Independent sample t-tests or chi-square tests
GLM controlled for NH sites revealed that the results were not
found no statistically significant differences between control and
associated with specific NHs (Wilks lambda F ¼ 0.258, P ¼ .612) but
intervention groups. Mean age of the whole sample was 83 years and
with the dance intervention (Wilks lambda F ¼ 10.75; P ¼ .001).
included mostly women (92%). Almost half of the participants reported
The most frequently reduced symptoms after the dance inter-
10 to 11 years of school. Most of the participants experienced diffi-
vention among the 15 that make up the GDS scale included questions
culties in both ADLs and IADLs and had minor mobility limitations
12 and 10: “Do you feel pretty worthless the way you are now?” and
Table 1
“Do you believe that you have more memory problems than the
Baseline Characteristics of Study Participants with MMSE 15 others?” (reduced from 46.8% to 36.7% depressive answers, respec-
tively, from 32.9 % to 22.8%). In 9 cases, the GDS score was reduced
All, n ¼ 162 Experimental Control Group, P Value
Group, n ¼ 79 n ¼ 83
below the threshold for depressive symptoms and, in an additional 6
cases, the reduction was just on the threshold including reductions
Age, mean (SD), y 83.11 (7.98) 83.38 (8.23) 82.85 (7.87) .811
Female gender, n (%) 149 (92) 76 (91.6) 73 (92.4) .844 from 12, 10, or 9 points to 6.
Self-rated health, 2.90 (1.05) 2.96 (1.17) 2.86 (0.94) .622
1e5, mean (SD) Results in Participants With Low MMSE and/or Changes in
Education, y, n (%) .659
Antidepressant Medication
5e9 53 (32.7) 24 (45.3) 29 (54.7)
10e11 70 (43.2) 37 (52.9) 33 (47.1)
12 39 (24.1) 18 (46.2) 21 (53.8) Participants with MMSE score between 10 and 14 points also were
MMSE, 0e30, 24.79 (3.92) 24.78 (4.08) 24.80 (3.78) .983 followed and described despite their exclusion from the statistical
mean (SD)
ADL (Barthel Index), 88.40 (14.74) 87.12 (15.86) 89.63 (13.55) .284 Table 2
0e100, mean (SD) Changes in Geriatric Depression Scale Scores
IADL (Lawton), 0e8, 4.50 (2.19) 4.61 (2.29) 4.40 (2.12) .578
mean (SD) Intervention Control
Get up and go test, 8.33 (2.63) 8.2 (2.99) 8.46 (2.25) .534 Group, n ¼ 79 Group, n ¼ 83
0e12, mean (SD) Geriatric depression scale, GDS 15
Anti-depression 29 (17.9) 11 (13.9) 18 (21.7) .198 Pretest, mean (SD) 5.71 (3.84) 4.86 (3.15)
medication, yes, Posttest, mean (SD) 5.00 (3.29) 5.27 (3.27)
n (%) P value, paired sample t test .005 .081
GDS 15, 0e15, 5.28 (3.55) 5.71 (3.84) 4.86 (3.15) .123 P value, GLM .001
mean (SD)
Paired sample t-test statistic was used to calculate pretest to posttest differences in
ADL, activities of daily living; IADL, instrumental ADL; GDS, Geriatric Depression performance.
Scale; MMSE, Mini-Mental State Examination. Generalized linear model (GLM), the 2 factors (group: control vs intervention)  2
Independent samples t test (or chi-square test respectively) was used to examine factors (test: pretest vs posttest) design was used to directly compare changes in
possible between-group differences. both groups.
4 H. Vankova et al. / JAMDA xxx (2014) 1e6
Fig. 1. Effect of dance therapy on GDS. Inter, intervention group; cont, control group;
AD, antidepressant medication.
analysis because the follow-up was considered important from the
clinical point of view. Their GDS score results indicated the same
tendencies as found in the analyzed sample: GDS score of the 9 in-
dividuals in the intervention group improved (5.0 to 4.5), whereas the
GDS score of the 6 individuals in the control group further worsened
(from 8.8 to 9.5). Average GDS of this subgroup of controls with lower
MMSE was influenced by one person with a GDS score of 15, who is
described in the Discussion section.
Examination of participants with the change of antidepressant
medication revealed that new antidepressants were more often
prescribed to participants in the control group as compared with the
intervention group (5 vs 4 cases) and were more often stopped in the
participants in the intervention group as compared with the control
group (4 vs 2 cases).
Discussion
The purpose of this randomized control trial was to explore the
effect of dance intervention on depressive symptoms in NH residents.
Despite the extensive literature on the effect of physical activity on
depression, there is a notable lack of studies focused on dance. To our
best knowledge, no study to date was conducted to examine the
effect of dance in institutionalized older adults having difficulties
with ADL/IADL performance.
The results from our study indicate that dance intervention can
decrease depressive symptoms among typical NH residents. To our
knowledge, only 4 studies36e39 focused on the effect of dance on
depression among older adults, but all of them included community-
dwelling individuals. In agreement with our study, the results of 2 of
them were positive, suggesting the beneficial effect of dance on
depression.38,39 But Alpert et al36 did not find statistically significant
improvements in GDS after the intervention based on modified jazz
dance, which might be because of the type of dance used. The dance
has to be familiar to older adults so they can fully benefit and remi-
nisce.63 Also, Eyigor et al37 did not find significant improvement in
GDS score, but his sample consisted of active older adults mostly
without depressive symptoms. However, participants in Eyigor
et al’s37 study verbally expressed that they felt happier after the
dance sessions. Furthermore, positive effect of dance on depression
also was described in younger populations.34,35
Research focused on the effect of physical activity on depression in
the population of frail or even dependent NH residents is sparse and it
lacks evidence about interventions based on dance. Therefore, it is
interesting to consider a broader range of studies examining effects of
any physical activity on depression in this subpopulation. Although
recent reviews20e22 described positive effect for the general population
of older adults, a cluster randomized controlled trial of moderately
intense exercise program (the OPERA study) for NH residents
reported negative results and recommended alternative strategies to
manage psychological symptoms in this population.23 Also the
authors concluded that the exercise program used in the OPERA study
might be more suitable for fitter older adults without cognitive
impairment.
One of the alternative strategies suitable for ADL/IADL-dependent
NH residents could be a dance therapy because of the nature of this
particular exercise. Dance therapy is not only about physical perfor-
mance but rather social interaction, with strong emotional aspects.
Familiar movements accompanied by music that elderly participants
used to listen to while they were young might also provide a unique
contribution. We believe that the characteristics of the traditional
dance and reminiscence, effects of both movements and music,63,64
can result in positive changes in GDS, especially in a population with
cognitive limitations. The positive changes in the GDS also may be
mediated by the positive effect of EXDASE dance therapy on mobility
described in a previous report46 because of the proven relationship
between depressive symptoms and functional status.49,65 However, in
our opinion, there are also other important components responsible
for our findings. For instance, this kind of group intervention provides
participants with the opportunity to do something together and share
the experience, often realizing they can do something they never
thought would be possible again. We believe that interaction with
peers could have led to increased self-confidence and feeling of com-
petency reflected by improvement in GDS items 10 and 12 “Do you
believe that you have more memory problems than the others?” and
“Do you feel pretty worthless the way you are now?”
Regarding the cognitive impairment of participants, we respected
the recommended cutoff score for GDS use in mild cognitive impair-
ment.50 Participants with an MMSE between 10 and 14 points were
excluded from the analysis but not from the intervention that they
enjoyed. They participated regularly and verbally expressed satisfac-
tion with the intervention. Their GDS scores were monitored and re-
vealed the same tendencies as found in the study sample. Thus, it is
possible that GDS scale could be useful for mapping longitudinal
changes in depressive symptoms even among elderly with moderate
cognitive limitations. The practical usability of GDS in cognitively
impaired individuals also was supported by one case from our study,
which was excluded from the analysis because of a lower MMSE. A
cognitively impaired participant (MMSE of 14) randomly assigned to
the control group scored 15 in the GDS. This person was the only one
with such a high GDS score and also the only one with suicidal
behavior during the trial.
It is important to note that because of the exclusion of participants
with advanced cognitive deficit from analysis of GDS score, the
average MMSE score for the study sample might seem rather high for
typical NH residents. This fact also contributed to higher average ADL
score because of the known link between cognitive impairment and
ADL disability.49 In addition, those more physically impaired tended
to refuse participation in the study because they considered testing or
intervention (or both) too demanding for their actual health status,
which was reflected in the response rate of 85%.
In contrast to the OPERA study,23 we excluded individuals whose
antidepressant intake changed during the study. Although the long-
term intake can be controlled for statistically, changes of prescriptions
during the trial could interfere with results and the only way to avoid
this bias was to exclude those participants from the study. However, it is
clinically interesting to have a closer look at those participants. Their
physicians were not informed about the study so they responded to the
 H. Vankova et al. / JAMDA xxx (2014) 1e6
actual status of their patients influenced by the intervention. More
frequent withdrawal of antidepressant medication in the intervention
group and more frequent new prescriptions in the control group offer
additional indications of the positive effect of the dance therapy and
further decline of depressive status among those without intervention.
For long-term antidepressant intake, possible interference was
controlled twice: by GLM analysis and by regrouping the study sample
according to antidepressant intake as the only intervention. Paired-
sample t-test did not show statistically significant changes between
pre- and posttests in groups with or without long-term antidepressant
intake. GLM analysis controlling for antidepressant administration pro-
vided evidence that the change in depressive symptoms was signifi-
cantly associated only with the dance intervention.
The findings presented in Figure 1 are interesting also from the
prevention point of view. Worsening of depressive symptoms was
observed in all controls, with or without antidepressants. The
improvement in the whole intervention group was highly significant,
the subgroup with antidepressants was too small for separate analysis,
but the tendency was the same as in the non-antidepressants sub-
group. The findings suggest that dance is beneficial for both subgroups:
those with antidepressants as an additional nonpharmacological
treatment, which is in accordance with Lavretsky et al,31 and for those
without antidepressants as a successful prevention of further decline
observed in controls.
Our findings also confirmed underdiagnosis and inadequate treat-
ment of depression often observed in the long-term care environment
in the Czech Republic49 as well as other countries.2,4,15 Fewer than 18%
of all participants were taking antidepressants at baseline, whereas
more than 43% of them had a high level of depressive symptoms (GDS
score 6).
Our results are not only important from the statistical point of view
but also from a clinical point of view, especially considering the
changes from the more complex perspective. The fact that the dete-
rioration of depressive symptoms typical for older adults living in NHs
can be stopped and replaced by the improvement by a simple non-
pharmacological treatment is very important. On the individual level,
very clinically significant changes were observed in 15 cases in which
the GDS score was reduced by several points or below the threshold for
depressive symptoms.
Several limitations should be mentioned. First, most of our partic-
ipants were women, limiting the interpretation of results for both
genders. However, the sample reflects the gender distribution in long-
term care settings. Second, it could be interesting to include delayed
follow-up in future research to examine whether the benefits of the
intervention can be maintained over time. Third, the selection of
participating NHs was not random. However, GLM controlling for the
NH as covariate revealed that results were similar in all NHs. Finally,
the use of GDS scale forced us to exclude participants with a low MMSE
from analysis, although they actively participated in the intervention.
Because cognitive impairment is typical for NH residents, future
research should focus on these residents and use instruments vali-
dated specifically for this population.
Conclusion
In conclusion, this study provides evidence that dance-based ex-
ercise can reduce the amount of depressive symptoms in NH residents.
This type of intervention seems to be especially suitable for ADL/IADL-
dependent older adults, including those with cognitive impairment.
This issue deserves further attention in the future, as this form of ex-
ercise holds much promise in helping these older adults to improve
their quality of life.
5
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