Dementia is one of the most significant healthcare problems globally. It is a collective term for neurodegenerative symptoms that include memory loss, communication and comprehension difficulty, impaired judgment, personality change and difficulty with activities of daily living, caused by loss and injury of neurons. There is progressive deterioration of cognitive ability that affects each individual uniquely and as a consequence there is now research suggesting that there is a move towards a personalised approach in management (Crisp, Taylor, Douglas & Ribeiro 2013; Kitwood 1997). There are also associated non-cognitive symptoms including mood disorders, agitation and aggression that are collectively referred to as “behavioural and psychological symptoms of dementia” by the International Psychogeriatric Association (Finkel et al 1996).
Dementia affects 413,106 people in Australia and it is estimated that by 2056, over one million people will be affected with a cost of $36.8 billion dollars (NATSEM 2016). More than 50 per cent of residents in government-subsidised aged care facilities have dementia. It is the single greatest cause of disability over the age of 65 years, the third leading cause of disability burden overall (Australian Institute of Health and Welfare 2012) and the second leading cause of death (Australian Bureau of Statistics 2015).
The most common type of dementia is Alzheimer’s disease (AD). Alzheimer’s Disease International state that 35.6 million people are affected globally. Dementia can also be associated with other chronic conditions including Parkinson’s disease. There is no cure for dementia and the drugs that are available are not clinically effective. It is both complex and multifactorial. Dr Dale Bredesen from the Buck Institute for Research into Aging has recently classified AD into groups according to their cause, although they are not necessarily mutually exclusive – inflammatory, atrophic, glycotoxic, toxic, vascular and traumatic. This work evolved from previous research where three subtypes were identified (Bredesen DE 2015).
Management therefore involves addressing the potential underlying causes. Lifestyle factors particularly regular exercise and meditation have been shown to improve dementia in numerous studies with some evidence for other factors such as diet, reduction of toxin load and supplementation. This has significant implications for the role of lifestyle in both prevention and improving symptoms of this global burden. Aerobic exercise has been shown to be of benefit with much supporting evidence which will be discussed below followed by a consideration of studies that have specifically looked at dance and music, with a review of the underlying neurological mechanisms thought to be involved.
The benefits of aerobic exercise in dementia
A significant study undertaken was a thorough meta-analysis of 1,603 studies of exercise and dementia (Ahlskog et al 2011) which showed that participants with dementia had better cognitive scores after 6 -12 months of exercise compared with sedentary controls. There were significant improvements with respect to the prevention of dementia in normal participants as well. Many studies showed that the hippocampus and gray matter volumes increased with corresponding clinical observations including improved memory and cognition. Magnetic resonance imaging (MRI) imaging also demonstrated improved neural connectivity.
Another breakthrough study conducted in the United Kingdom (Elwood 2013) followed 2,235 men in Wales, aged 49 – 59 and observed the impact of five factors on their health over a thirty-year period – exercise, healthy diet, normal weight, low alcohol intake and non- smoking. This study showed that exercise was the most powerful contributor, with a reduction of cognitive decline and dementia risk for following four of the five risk factors of 60 per cent. As Dr Norman Doidge reflects regarding exercise, “If any drug could do that, it would the most popular, talked about treatment in medicine” (Doidge 2015 p96).
One of the most significant mediators of neuroplasticity is brain derived neurotrophic factor (BDNF) (Floel et al 2010). Many studies have suggested the role of BDNF in neurogenesis and synaptic connections (Huang and Reichardt 2001; Lessmann and Brigadski 2009; Edelmann et al 2014). BDNF is known to be increased with factors that include physical activity and social interaction (Mattson 2008).
Animal studies suggest that coordination and not endurance training induces synaptogenesis (nerve connections) and glial changes (Black et al 1990) – hence the relevance of the type of activity. Dance involves more coordination than other physical activities.
The benefits of dance in dementia
Dance is a form of aerobic exercise different to other forms of exercise because it combines physical activity with sensory stimulation (sensorimotor) and also has cognitive, social and affective components. Despite animal studies having shown that this combination has the strongest effect on neurogenesis, human studies to date are relatively scarce (Kempermann et al 1997; van Praag et al 2005).
Verghese et al (2003) compared six cognitive activities (eg crossword puzzles, reading, playing musical instrument) and eleven physical activities (eg dancing, walking, swimming) in a 21-year prospective study in elderly participants. Although cognitive activity reduced dementia, physical activity generally did not – the only exception however was dance, which lowered the dementia risk by a staggering 76 per cent. Risk reduction was also generally related to the frequency of the activity.
Muller et al (2017) studied two groups of healthy seniors over an 18-month period – one on a standard fitness program involving repetitive movements and the other in a dance program that involved constantly changing, new movements. MRI, BDNF and neuropsychological tests were performed at baseline, 6 and 18 months. Dancers had higher levels of BDNF compared to the standard group. After six months, the dancers showed a significant increase in the gray matter volume (left pre-central gyrus which controls voluntary motor function) and at 18 months, an increase in the para hippocampal gyrus volume. Attention and verbal memory in both groups improved at 6 and 18 months. The increase in pre-central gyrus volume may have been due to different movements (polycentric) with varying music (polyrhythmic). The authors concluded that participation in a long-term dance program is superior in inducing neuroplasticity and that “dance is highly promising in its potential to counteract age-related gray matter decline”. They also commented that this is related to the multimodal nature of dance – combining the physical, cognitive and coordinative challenges.
Porat et al ( 2016 ) studied the effect of dance, music and song in groups with no and mild cognitive impairment They were given a detailed questionnaire relating to their lifetime experience in music and dance. The participants had MRI scans and neuropsychological assessments. The results concluded that those who had been dancers performed better in cognitive tasks that involved memory and learning suggesting that music, song and dance could potentially avert or delay mild cognitive impairment.
Lifestyle factors that help in preventing dementia were studied by Muller et al (2017) who yet again reported that a promising approach lies within dance programs because this incorporates both cognitive and physical activity to improve neuroprotection.
Guzman et al (2017) used their 12-week dance program with patients with mild to moderate dementia in three care homes. Collaborating data from 10 residents, 35 carers and 3 family members, they found there was a significant improvement in mood and socialisation. The residents wanted to continue with the program and the authors expressed that their dance program be disseminated further in care homes.
The power of music in dementia
Music is known to activate specific brain pathways related to emotion – including the hippocampus, amygdala, prefrontal cortex, insular and cingulate cortex and hypothalamus. There are thought to be several mechanisms as to how music influences the brain. Gomez et al (2016) state that there are four main theories – 1. neuroplasticity 2. neurogenesis, regeneration and repair 3. neuroendocrine and 4. neuropsychiatric. The biochemical changes involved include the release of several neurotransmitters, neuropeptides and other biochemical mediators such as endorphins, endocannabinoids, dopamine and nitric oxide. (Boso et al 2006).
A recent systematic review (Abraha et al 2017) looked at different non –pharmacological interventions for behavioural and psychological symptoms in dementia and found that music and behavioural management were effective in reducing these dementia symptoms.
Rong Fang et al (2017) reviewed literature on the use of music therapy (MT) in dementia. There have been several previous studies confirming this. They looked at music therapy, singing, background music and combining it with a physical activity which all had positive effects. The authors reported that music therapy should be ideally started early in dementia onset and to consider combining it with other physical modalities – such as dance. This combined therapy of music and dance was also suggested by Gomez et al (2016) following from their 6-week study of music therapy in Alzheimer’s where significant improvements were recorded in memory orientation and mood (anxiety and depression).
Another study of residents with mild to moderate cognitive impairment at care homes had a combined dance (as a form of participation based physical exercise) and relaxation intervention. They found the participants had reduced levels of anxiety and depression, improved cognitive function and improved quality of life (QOL). Dance as a form of participation-based physical exercise was found to reduce anxiety and depression levels and improve QOL and cognitive function among the studied sample of cognitively impaired elderly subjects in Malaysia (Adam et al 2016).
As we can see, the benefits of dance include improved cognition (through increasing neurogenesis and neural pathways via many mediators including BDNF), memory, mood, stress relief, self-confidence, social and psychological well-being. Dance integrates several brain functions simultaneously including kinaesthetic, musical and emotional which enhances neuronal connectivity.
There has been substantial research into the effects of dance therapy and music in patients with dementia as well as normal controls. Preventative strategies are more imperative than ever, given the alarmingly increasing rate of cognitive impairment and dementia. The combined power of dance and music is irrefutable and provides a proven and cost-effective way to help overcome the burden of dementia in the general population and care homes.
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