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Aging Clinical and Experimental Research

https://doi.org/10.1007/s40520-019-01159-w

REVIEW

Effects of dance intervention on global cognition, executive function


and memory of older adults: a meta-analysis and systematic review
Xiangfei Meng1 · Guichen Li1 · Yong Jia1 · Yufei Liu1 · Binghan Shang1 · Peng Liu2 · Xueying Bao3 · Li Chen1,4

Received: 1 December 2018 / Accepted: 21 February 2019


© Springer Nature Switzerland AG 2019

Abstract
Objective To summarize and assess the effects of dance intervention on global cognition, executive function and memory
in older adults.
Methods We searched the databases PubMed, Web of Science, Cochrane Library, EMBASE, Clinical Trials.Gov and four
Chinese databases (CNKI, CBM, Wan Fang Data and VIP) to identify articles written in English or Chinese and published
until April 2018. Randomized controlled trials and quasi-experiment were included if they evaluated the impact of dance on
cognition, and individuals aged 60 and over.
Results Thirteen studies with a total of 1605 participants met the inclusions criteria. Our primary outcomes of interest are
cognitive functions and are categorized into three cognitive domains: (1)Global cognition: meta-analyses for outcome related
to global cognition indicated a large effect size. In the subgroup of using MMSE, results indicated a significant effect for
dance on cognition [MD = 1.57, 95% CI (0.53, 2.61), p = 0.003; I2 = 62%], in the subgroup of using SCEF, effect sizes was
statically significant and no heterogeneity between studies [MD = 33.25, 95% CI (30.94, 35.56), p < 0.00001; I2 = 0%]. (2)
Executive functioning domain: meta-analyses revealed that there were no significant differences between the two groups
in measures of executive function after the one study with a low-quality score was excluded [SMD = 0.13, 95% CI (− 0.02,
0.27), p = 0.09; I2 = 0%]. (3)Memory domain: quantitative analysis showed that dance may benefit memory function in older
adults. However, in our review, dance was more effective for elderly cognitions than exercise may be not support.
Conclusions Our meta-analysis and systematic review suggest that dance may be a safe and effective approach to improve
cognitive function in older adults.

Keywords Dance interventions · Cognitive function · Older adults · Meta-analysis

Introduction
Xiangfei Meng and Guichen Li contributed equally to this work.
According to Alzheimer’s disease International (ADI 2016)
* Peng Liu
liupeng@jlu.edu.cn [1], as a result of the demographic aging, by 2030 there will
be 65.7 million people suffering from dementia worldwide
* Xueying Bao
baoxy9358@126.com and by 2050 there will be 115.4 million. In this sense, cogni-
tive decline has emerged as one of the most common age-
* Li Chen
chen_care@126.com related health problems for older adults [2] and is associated
with increased risk for progression to dementia [3], increased
1
School of Nursing, Jilin University, 965 XinJiang Road, physical disabilities [4], and also increased health care costs
Changchun 130021, China [5]. The high prevalence of cognitive impairment underlines
2
School of Mechanical and Aerospace Engineering, Jilin the need for effective interventions to improve cognition in
University, No.5988 Renmin Street, Changchun 130025, older adults. Fratiglioni et al. [6] propose three lifestyle factors
Jilin, China
play a significant role in slowing the rate of cognitive decline
3
The 208th Hospital of the Chinese People’s Liberation Army, and preventing dementia: social network, cognitive leisure
Changchun 130062, Jilin, China
activity, and regular physical activity. Interestingly, dancing
4
Department of Pharmacology, College of Basic Medical
Sciences, Jilin University, Changchun, China

13
Vol.:(0123456789)
Aging Clinical and Experimental Research

is analogous to such an intervention, which involves all of the Methods


factors mentioned above.
Dance, as a novel multicomponent interventional approach, Search strategy
has sparked increasing interest of gerontology researchers. A
number of randomized controlled trials have shown that dance We searched the databases PubMed, Web of Science,
can support physical function [7], improve cognitive perfor- Cochrane Library, EMBASE, Clinical Trails.Gov and four
mance [8], reduce the amount of depressive symptoms [9], and Chinese databases (CNKI, CBM, Wan Fang Data and VIP)
promote life satisfaction [10] in older adults. Dance is not only to identify articles written in English or Chinese and pub-
an ideal physical activity but also an engaging social activ- lished until April 2018. The search terms were “Dance”,
ity that improves fitness levels and promotes healthy activ- “Dancing”, “Dance therapy”, AND “Cognitions”, “Cog-
ity, which are important for successful aging [11]. Dance can nitive function”, “Brain function”, “Memory”, AND
be performed in relaxed and pleasant environments and has a “Elderly”, “Aging”, “Older adults”, “Senescence”, “Bio-
great natural appeal to older adults compared to other conven- logical Aging” (Appendix). In addition, the reference lists
tional exercises. Many studies identified dance as a motivator of identified studies were checked manually to include other
for the older adults to adhere to a physical activity program potentially eligible trials.
[12, 13].
Dance maybe a potentially superior activity for maintain-
ing or improving cognitive ability [14]. Verghese et al. [15] Eligibility criteria
examined the influence of in cognitive and physical leisure
activities on the risk of developing dementia in a prospective Eligible studies were included if they met all of the follow-
study follow-up period of 5.1 years. The results of studies have ing criteria:
indicated that dancing was the only physical activity associated
with a markedly reduced risk of dementia. Dance is a com- 1. Study design The designs were randomized controlled
plex sensorimotor rhythmic activity comprising balance, social trials (RCT) or/and quasi-experiment (Q).
interaction, emotions, acoustic stimulation and musical experi- 2. Study population The participants were older adults
ence, all of which have the potential to ameliorate cognitive (≥ 60 years).
decline risk factors. In addition, dance is a physical activity 3. Intervention Participated in dance sessions longer than
requiring different cognitive functions including perception, 4 weeks were included. Studies assessed for eligibility
attention, executive function, procedural memory, visuomotor could include dance intervention of any style, such as
integration, and motor skills [16]. For example, participants traditional folk dance or ballroom dance (salsa, tango,
are required to pay attention and follow the music to perform waltz). We assumed that all dance styles would be
complex motor sequences and smoothly switch between these equally effective because they share similar principles;
patterns throughout the dance. Therefore, dance may stimulate movements are synchronized to music and organized
and improve cognitive function. into spatial patterns, which tend to be modular in organi-
Previous reviews have reported research evidence concern- zation. We excluded studies in combined intervention
ing the effects of dance for older adults on the risk of fall [17], (e.g., combined with pharmacological intervention or
cardiovascular risk [18], depressive symptoms [19], and physi- relaxation intervention).
cal benefits [20]. A review protocol [21] will determine the 4. Control groups The control group interventions were
efficacy of dance on cognitive function among older adults. not restricted, with no intervention, health education,
However, the primary outcome of interest for the protocol is exercise, or other types of interventions were eligible.
executive function, such as task switching and response inhibi- 5. Outcome The studies were required to report cognitive
tion. To our knowledge, there has not been a comprehensive function as the primary or secondary outcome was eli-
evaluation of dance interventions on global cognition, execu- gible.
tive function and memory in older adults. Therefore, aim of
this meta-analysis and systematic review is to assess the effects
of dance interventions on global cognition, executive function Data extraction
and memory in older adults.
All data were reviewed and extracted by two independent
investigators in a standardized manner. The following data
were extracted from the studies and summarized in Table 1:
first author, study design, study population (number, age),
intervention characteristics (dance style, duration, frequency,
and control group), all cognition-related outcomes measured

13
Table 1  Main characteristics of included studies
Study Country Study design Participants Measures/outcomes Results

Alves [26] Portugal RCT​ 65 older adults (60–80 years) Executive function: TMT-A&B, Flanker, Four-month ballroom dance intervention
Dance group = 23 Digit Span, SRT, SPWM, Go–No-Go, improves the cognition of healthy older
Walking group = 8 Task Switching, Dot Comparison, Manual adults
Control group = 24 Sequence, Raven’s Matrices
Memory: Memory Span test
Coubard et al. [27] France Q 110 older adults (59–89 years) Executive function: Arithmetic word prob- Contemporary dance improved switching
Dance group = 16 lems, Stroop test, Rule shift cards test but not setting or suppressing attention. In
Fall prevention = 67 contrast, neither fall prevention nor Tai Chi
Tai Chi chuan = 27 Chuan showed any effect
Aging Clinical and Experimental Research

Doi et al. [8] Japan RCT​ 201 older adults with MCI (≥ 70 years) Global cognition: MMSE Long-term cognitive leisure activity programs
Dance group = 67 Executive function: TMT-A&B involving dance or playing musical instru-
Music group = 67 Memory: Story memory, Word list memory ments resulted in improvements in memory
Education group = 67 and general cognitive function compared
with a health education program in older
adults with MCI
Hackney et al. [34] United Q 74 older adults (59–95 years) Global cognition: MoCA Cognitive function did not improve but main-
States of Dance group = 62 Executive function: TMT-B tained throughout the 6 months of adapted
America Education group = 12 Other: the Reverse Corsi Blocks, the Brooks tango intervention
Spatial Task
Kattenstroth et al. [24] Germany RCT​ 35 older adults (60–90 years) Cognition: RBANS Dance can in combination with many features
Dance group = 25 Attention: AKT, FAIR have beneficial effects on cognition, atten-
Control group = 10 tion, posture and balance, and sensorimotor
performance, as well as subjective well-
being
Kim et al. [31] South Korea Q 44 elderly syndrome patients (> 60 years) Global cognition: MMSE-KC Dance exercise may reduce the risk for
Dance group = 32 Executive function: TMT-A&B cognitive disorders in elderly people with
Control group = 12 Memory: Modified Boston Naming Test, metabolic syndrome
Word List Memory, Word List Delayed
Recall, Word List Recognition, Construc-
tion Recall
Other: Verbal Fluency Test, Construction
Praxis
Kosmat and Vranic [25] Croatia RCT​ 24 older adults with no cognitive impair- Executive function: WSCT-64 Training procedures, based on dance, could
ments (69–88 years) Memory: AVLT improve cognitive functioning in old-old
Dance group = 12
Education group = 12
Lazarou et al. [28] Greece RCT​ 154 older adults with MCI (60–80 years) Global cognition: MMSE, MoCA Dance may be an important non-pharmaco-
Dance group = 89 Executive function: TMT-B,ROCFT logical approach that can benefit cognitive
Control group = 65 Memory: RBMT functions
Attention: TEA
Merom et al. [32] Australia RCT​ 115 older adults (≥ 60 years) Executive function: TMT-A&B, SCWT, The superior potential of dance over walking
Dance group = 60 DSB on executive functions of cognitively healthy
Control group = 55 Learning and Memory: RAVLT, BVMT and active older adults was not supported

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Aging Clinical and Experimental Research

and results. If the studies used different time points for

nation, RBANS Repeatable Battery of Neuropsychological Status, AKT paper-and-pencil non-verbal geriatric concentration test, FAIR Frankfurt Attention Inventory, WSCT-64 Wisconsin Card
BVMT Brief Visuospatial Memory Test, VLMT an adapted German version of the “Rey Auditory Verbal Learning Test”, TAP Test of Attentional Performance, MMSE Mini-Mental State Exami-
MoCA Montreal Cognitive Assessment, TMT-A&B Trail Making Tests Parts A and B, SCWT​Stroop Color-Word Test, DSB Digits Span Backwards, RAVLT Rey Auditory Verbal Learning Test,

Sorting Test, AVLT Modified Auditory Verbal Learning Test, ROCFT Rey–Osterrieth Complex Figure Test, RBMT Rivermead Behavioral Memory Test, TEA Test of Everyday Attention, SRT
Square dancing can significant improve cogni-
Square dancing exercise can improve the cog-
Dance intervention did not lead to significant

Dance significant improve cognitive function


measurement, we chose the time point closest to the end

nitive function and the depression, anxiety

Simple Reaction Time, SPWM Spatial Working Memory, SECF Scale of Elderly Cognitive Function, Q quasi-experimented, RCT​randomized controlled trial, MCI mid cognitive Impairment
in both dance and exercise groups, but no
improvements in cognitive risk factors as
of the intervention. Extracted data were checked by a third
reviewer and any disagreements were resolved by discus-
sion and consensus. In case when various tests measured
the same outcome in one study, we only selected the most

tive function in older adults


groups differences emerged
measured with the TMT-B

common measures for synthesizing. In case where the out-


come measures used were very different from one study to

status for the aged


another, we used quantitative synthesis to report on addi-
tional studies.

Study quality assessment


Results

Study quality was assessed using the Downs and Black crite-
ria [22] by two reviewers independently. The scales with the
27-item instrument are designed to assess the methodologi-
cal quality of randomized and non-randomized studies. The
instrument includes five quality domains: (1) reporting (10
Executive function: TMT-A&B

items, 11 points), (2) external validity (3 items, 3 points), (3)


bias (7 items, 7 points), (4) confounding (6 items, 6 points),
Global cognition: SECF

Global cognition: SECF

and (5) power (1 item, 5 points). The maximum total score


Measures/outcomes

is 32 points. The quality was divided into four categories:


Memory: VLMT
Attention: TAP

poor (< 18), moderate (18–23), good (24–29) and, excellent


(≥ 30). The Downs and Black criteria have a high internal
consistency (Kuder–Richardson Formula 20:0.89), good
inter-rater reliability (r = 0.75), and high test–retest reliabil-
ity (r = 0.88).
530 older adults (39% age > 80 years)

Data analysis
125 older adults (61–82 years)
52 older adults (63–80 years)

76 older adults (60–70 years)

The statistical analyses were performed using Review


Manager, version5.0. All trials reported outcomes as con-
tinuous data, when studies used the same outcome scales,
Control group = 251
Dance group = 279

Control group = 37

Control group = 60

we calculated the mean difference (MD) with 95% CI.


Dance group = 26

Dance group = 39

Dance group = 65
Sport group = 26

When studies used different scales to measure the same


Study design Participants

outcome, we used the standardized mean difference (SMD)


with 95% CI in analyses. In all cases, we regard endpoint
data as a superior method over change scores. This is pre-
ferred since data can be skewed in favor of the treatment
or the control group where randomization is inadequate.
If the endpoint data were not provided, they were calcu-
RCT​

RCT​

RCT​

RCT​

lated using baseline and change mean. Calculations were


performed using a random effects model to accommodate
for heterogeneity across studies. Under the random effects
Germany
Australia
Country

model, the individual study weights are more balanced,


China

China

thus the summary effect is more conservative. Heterogene-


ity was assessed using the I2 statistic, which is a quantita-
tive measure of inconsistency across studies. Studies with
Table 1  (continued)

an I2 statistic of > 75% were regarded as high heterogene-


Merom et al. [33]

Muller et al. [23]

Zhang et al. [30]

ity. When the heterogeneity identified across studies was


high, we further performed subgroup analyses to explore
Chen [29]

possible explanations for heterogeneity, including study


Study

design (RCT/Q), study quality (low/high), and method

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Aging Clinical and Experimental Research

used to evaluate cognitive function (MMSE/other). We Characteristic of studies


also conducted sensitivity analyses to confirm consistency
of the funding by omitting one study in each turn. A p The characteristics of the eligible studies are summarized
value < 0.05 was considered statistically significant. in Tables 1 and 2. The overall analysis of 13 studies inves-
tigating 1605 participants. Six studies [23–27] were con-
ducted in the Europe (Germany [23, 24], Croatia [25], Por-
tugal [26], France [27], Greece [28]), four in Asia (China
Results [29, 30], Japan [8], South Korea [31]), two in Oceania
(Australia [32, 33]), one in America (USA) [34]. The age
Study research of participants ranged from 59 [27] to 95 [34] years old.
Ten studies assessed the elderly without any associated
573 studies were identified from electronic database health condition, two studies [8, 28] examined the effect
search and two additional studies were identified by hand of dance on cognition in participants with MCI, and one
searching. 182 articles were excluded because of duplicate study [31] evaluated the elderly patients with metabolic
records. 328 studies were excluded based on the titles and syndrome. The frequency of dance intervention varied
abstracts. 65 full-text articles were then reviewed, from from 45 [25] to 300 min [29, 30] per week, with the total
which 52 were excluded. Finally, 13 studies including 10 training programs varied from 10 weeks [25] to 72 weeks
RCTs and 3 quasi-experiment that met our inclusion cri- [23]. Dance style varied across studies. Nine [8, 23, 25, 26,
teria were included in the systematic review and 9 studies 28, 31–34] interventions were described as ballroom dance
underwent in the meta-analysis (Fig. 1). (eg., tango, waltz, Latin, jazz, salsa, cha-cha), two studies
[29, 30] were used square dance, the other studies used

Fig. 1  Flow diagram for


searching and selection of the
included studies

13
Table 2  Characteristics of dance intervention and control groups

13
Study Dance group characteristics Dance Frequency (times/week) Dance session Control group characteristics
length duration (min)
(weeks)

Alves [26] Ballroom dance (with different rhythms, e.g., 16 2 120 Walking group (participants walked together led by a
samba, bolero) professional exercise trainer)
Control group (no intervention)
Coubard et al. [27] Contemporary dance (based on specific theoretical, 20–28 1 60 Fall prevention (emphasizes the development of bal-
technical, and education principles with a focus on ance and of lower limbs)
improvisation) Tai chi chuan (emphasizes the development of inter-
nal energy and of dynamic force)
Doi et al. [8] Ballroom dance (including salsa, rumba, waltz, cha- 40 1 60 Music group (playing musical instruments)
cha, blues, jitterbug, and tango) Education group (attend three health education
classes)
Hackney et al. [34] Tango (each session consist of practicing steps and 12 2 90 Education group (highly diverse health-related topics
partnering and rhythm enhancement exercises) were discussed in a session)
Kattenstroth et al. [24] Agilando™ (a special dance program developed for 24 1 60 Control group (no intervention)
elderly people)
Kim et al. [31] Latin (cha-cha consists of three fast steps and two 24 2 60 Control group (no intervention)
slow steps with forward–backward and backward–
forward weight transfer)
Kosmat and Vranic [25] Waltz (each session consists of learning choreogra- 10 1 45 Education group (each session met with experimenter
phy and dancing slow waltz) and discussed various topics about older adults)
Lazarou et al. [28] Ballroom dances (such as tango, waltz, Viennese 40 2 60 Control group (no intervention)
waltz, fox trot, rumba, cha-cha, swing, salsa,
merengue, disco-hustle, as well as with Greek
traditional ballroom dancing)
Merom et al. [32] Ballroom dances (including rock and roll, foxtrot, 32 2 60 Walking group (a home-based self-help walking
waltz, and some Latin, e.g., salsa and rumba) program)
Merom et al. [33] Folk dances (including dances from the United 48 2 60 Control group (no intervention)
Kingdom, United States, France, Italy, Israel, and
Greece); ballroom dances (including rock and roll,
foxtrot, waltz, salsa, and rumba)
Muller et al. [23] Different genres dance (including line dance, jazz 72 First period (24 weeks) 2 90 Sport group (a conventional strength-endurance train-
dance, rock ‘‘n’’ roll and square dance) Second period (48 weeks) 1 ing program)
Zhang et al. [30] Square dancing (a popular open-air fitness exercise 48 4–5 30–60 Control group (no intervention)
throughout China)
Chen [29] Square dancing (a popular open-air fitness exercise 48 4–5 30–60 Control group (no intervention)
throughout China)
Aging Clinical and Experimental Research
Aging Clinical and Experimental Research

contemporary dance [27] and Agilando [24]. Agilando is Seven [8, 26, 28, 31–34] studies used the TMT, and three
a special dance program developed for elderly people and [8, 28, 31] studies used the MMSE.
can be performed alone without a partner. Three [23, 27,
32] studies used exercise control groups included walking, Study quality assessment
strength-endurance and fall prevention, ten studies com-
pared to no-exercising control groups included educational Thirteen studies evaluated the quality and each domain
programs [8, 25, 34] and no intervention control groups scores across studies are shown in Table 3. The poorest
[24, 26, 28–31, 33]. scores were 18 points, while the best ones were 29, out of
Our primary outcomes of interest are cognitive functions 32 total points. Seven were moderate quality and six were
and are categorized into three cognitive domains: (1)Global good quality. The average score for all studies was 23.15
cognition: there were eight [8, 23, 24, 28–31, 34] studies that (Table 3).
evaluated global cognition using Mini-Mental State Exami-
nation (MMSE), Montreal Cognitive Assessment (MoCA), Global cognition
Repeatable Battery of Neuropsychological Status (RBANS),
Scale of Elderly Cognitive Function(SECF). (2)Executive Meta-analyses for outcome related to global cognition indi-
functioning domain: nine [8, 25–28, 31–34] studies reported cated a large effect size, but high heterogeneity compared to
performance on the executive measures of Trail Making no-exercising [SMD = 1.65, 95% CI (0.55, 2.75), p = 0.003;
Tests Parts A and B (TMT-A&B), Digit Span, Wisconsin I2 = 96%]. Therefore, we further conducted subgroup analy-
Card Sorting Test (WSCT-64), Digits Span Backwards ses to explore possible explanations for heterogeneity. Three
(DSB), Rey–Osterrieth Complex Figure Test (ROCFT), [8, 28, 31] of the seven studies employed MMSE as a meas-
Simple Reaction Time(SRT), Spatial Working Memory ure of global cognitive function, two [29, 30] studies used
(SPWM), Stroop test, Flanker, Go–No-Go, Task Switch- SCEF. In the subgroup of using MMSE, results indicated a
ing, Dot Comparison, Manual Sequence, Raven’s Matrices, significant effect for dance on cognition [MD = 1.57, 95% CI
Arithmetic word problems, Rule shift cards test. (3)Memory (0.53, 2.61), p = 0.003; I2 = 62%] (Fig. 2), in the subgroup of
domain: five [8, 25, 28, 31, 32] studies assessed performance using SCEF, effect sizes were statically significant and no
on the memory measures of Rey Auditory Verbal Learning heterogeneity between studies [MD = 33.25, 95% CI (30.94,
Test (RAVLT), Brief Visuospatial Memory Test (BVMT), 35.56), p < 0.00001; I2 = 0%] (Fig. 3).
Rivermead Behavioral Memory Test (RBMT), Rey Auditory Only one German study [23] assessed the benefits of
Verbal Learning Test (VLMT), Story memory, Word list newly designed dance program as compared to conventional
memory, Modified Boston Naming Test, Word List Memory, strength-endurance training, while in cognitive ability data,
Word List Delayed Recall, Word List Recognition, Construc- group differences emerged with regard to the use of Verbal
tion Recall, Memory Span test. The two most widely used Memory Test. The authors discussed that the intervention
assessment tools across studies were MMSE and TMT. might be insufficient.

Table 3  Quality of included studies


Study Reporting (11 External validity Bias (7 Confounding (6 Power (5 Total (32 Quality as
points) (3 points) points) points) points) points) per cutoff
described

Alves [26] 8 2 4 4 0 18 Moderate


Coubard et al. [27] 7 1 4 2 5 19 Moderate
Doi et al. [8] 10 3 6 5 5 29 Good
Hackney et al. [34] 10 2 6 5 0 23 Moderate
Kattenstroth et al. [24] 9 2 5 5 5 26 Good
Kim et al. [31] 7 2 6 3 5 23 Moderate
Kosmat and Vranic [25] 9 2 6 3 5 25 Good
Lazarou et al. [28] 7 3 5 4 5 24 Good
Merom et al. [32] 9 3 7 6 0 25 Good
Merom et al. [33] 10 3 6 6 0 25 Good
Muller et al. [23] 9 2 5 5 0 21 Moderate
Zhang et al. [30] 7 2 5 3 5 22 Moderate
Chen [29] 7 2 5 2 5 21 Moderate

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Aging Clinical and Experimental Research

Fig. 2  Result of meta-analyses evaluating global cognition between dance and control

Fig. 3  The effects of dance on global cognitive function was measured by MMSE and SCEF

Executive function not found because the participants, particularly the walk-
ing group, appeared to be highly active at baseline. Another
The effects of dance on executive function were evaluated explanation could be the nature of intervention, which lacked
in seven [8, 25, 26, 28, 31, 33, 34] studies that compared sufficient physical and mental challenges. Future research
to no-exercising controls using the TMT-B. Meta-analyses requires high intensity and higher dosage of intervention.
revealed no significant differences between the two groups Olivier [27] examined the impact of contemporary dance
in measures of executive function [SMD = 0.17, 95% CI improvisation on attention control (a dimension of executive
(− 0.07, 0.42), p = 0.17; I2 = 42%] (Fig. 4a). Sensitivity function) of older adults, as compared to two other motor
analysis of executive function showed no heterogeneity but training programs, fall prevention, and Tai Chi Chuan. After
remained with no statistically significant differences when 5.7-month training, the results indicated that CD improved
one study [26] with a low-quality score indicating bias was switching but not setting or suppressing attention, while nei-
excluded [SMD = 0.13, 95% CI (− 0.02, 0.27), p = 0.09; ther fall prevention nor Tai Chi Chuan showed any effect.
I2 = 0%] (Fig. 4b).
Dafna [32] 2016 determined whether dance benefits Memory function
executive function more than walking. The finding from 115
participants did not support the superior potential of dance We found four studies [8, 25, 28, 31] that compared with
over walking on executive functions of cognitively health non-exercising controls were conducted to evaluate the
and active older adults. The authors argued that significant effectiveness of dance intervention on memory with a total
differences between the dance and the walking group were 423 older adults. Assessment tools for memory function

13
Aging Clinical and Experimental Research

Fig. 4  The effects of dance on executive function in older adults

varied substantially, these outcomes on memory were not the efficacy of dance intervention of moderate length (10-
employed consistently across studies precluding quantitative weeks, 45 min/week) on cognitions in 24 older adults with
synthesis. Therefore, our study only qualitatively describes no cognitive impairments. In this study, a modified AVLT
the memory domain. All four studies reported significant procedure was used to tap short-term memory. The authors
improvements in memory for the dance intervention. Two found an improvement in short-term auditory-verbal mem-
studies [8, 28] evaluated the effect of dance intervention for ory in dance group.
older adults with mild cognitive impairment (MCI). One Only one study [32] investigated the memory perfor-
study [8] of 201 Japanese adults with MCI was determined mance of social dance among community-dwelling older
to compare a 40-weeks dance to health education. Memory adults as compared to walking. Dance participants per-
function measured using the story memory and world list formed better on visuospatial immediate and delayed recall
memory tests from the National Center for Geriatrics and were measured by RAVLT and BVMT.The authors dis-
Gerontology Functional Assessment Tool study cognitive cussed the most likely explanation is that spatial learning
assessment battery. The results indicated that dance inter- and memory are useful for learning dance, and that partici-
ventions resulted in improvements in memory function com- pants doing the dance intervention may have practiced this
pared with control group. However, dance was beneficial skill to help remember dance steps leading to improvement.
for story recall but not for world list recall in this trial. The
authors discussed that story recall might be more sensitive
than word recall to the early memory changes of Alzheimer Discussion
disease. The other [28] study explored the effects of Interna-
tional Ballroom Dancing on cognitive function in elders with This is the first meta-analysis and systematic review to
amnestic mild cognitive impairment (aMCI). Short-term and evaluate the efficacy of dance intervention on global cogni-
long-term memories were measured by Rivermead Behav- tion, executive function and memory in older adults. The
ioral Memory Test story direct and delayed recall (RBMT). present meta-analysis showed a positive effect of dance on
Significant differences between groups were found in benefit global cognition, while there were no significant differences
of the dance group, while the control group showed worse of dance on executive function in elderly. The present quan-
performance in the memory function. Se-Hong2011 [31] titative analysis showed that dance may benefit memory
reported on finding from 44 elderly metabolic syndrome function in older adults. However, in our review, dance was
patients with normal cognitive function. Statistically signifi- more effective for elderly cognitions than exercise may be
cant improvement on memory domain was found in dance not support.
group with regard to word list delayed recall (p = 0.038) and Seven studies evaluated the effect of dance intervention
word list recognition (p = 0.007). Kosmat [25] investigated on global cognition in older adults when compared with

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Aging Clinical and Experimental Research

no-exercising controls [8, 24, 28–31, 34]. In these individual evaluated Tango for older adults in independent living on the
studies, five out of seven reported significant improvement cognition measure of the Montreal Cognitive Assessment
for dance groups. Meta-analysis results revealed that dance (MoCA). The results indicated that cognitive function did
significantly improve global cognition in elderly. Four stud- not improve but was maintained in dance group compared
ies [8, 25, 28, 31] that compared with non-exercising con- to control groups. The authors discussed that several partici-
trols were conducted to evaluate the effectiveness of dance pants in this study performed difficulty with ADLs at base-
intervention on memory. Quantitative analysis showed that line, and the speed of cognitive decline greatly increase for
dance may benefit memory function in older adults. Several many older adults after ADL performance difficulty begins
explanations for the impact of dance cognitive function have [34]. Se-Hong Kim concluded that a 6 month of dance exer-
been suggested. First, dance is classified as a moderately cise did not significant improve cognitive function measured
aerobic exercise. This intensity dancing and exercise have by the MMSE-KC. The authors explained this finding by the
been shown to have positive effects on cognition [35] and lack of sensitivity of MMSE. Additionally, both studies [31,
brain structure [36, 37]. Cognitive decline may be partially 34] are small sample size and quasi-experimental design that
caused through cerebrovascular insufficiency, which tends subjects were neither randomized nor blinded. It is possible
to increase with age. However, exercises maintain cerebro- that experiments’ potential bias might have affected finding.
vascular integrity by sustaining blood flow and the supply Executive function, the management of cognitive process,
of oxygen and nutrients to the brain [38]. Exercise affects has been conceptualized as four components; the abilities to
cognition by increasing brain-derived neurotrophic factor formulate goals, plan how to achieve them, carry out goal-
(BDNF) and synapses, and promoting neuronal growth oriented plans, and perform effectively [45]. Previous stud-
and survival [39, 40]. Second, dance is a combination of ies imply that an activity that engages attention and mem-
music and exercise that may add further benefits on cogni- ory progress would improve executive cognitive function
tion. More generally, music employs numerous emotional [46]. Dancing is analogous to such activity, which requires
and cognitive activities and provides acoustic stimulation. executive function including focus of attention, remember
“Neurologic music therapy” (NMT) has been developed as instructions, and juggle multiple tasks successfully. How-
a systematic treatment method to improve sensorimotor, ever, the present meta-analysis showed that no significant
and cognitive domains of functioning via music [41]. From improvements of dance on executive cognition. Some pos-
animal research, music exposure can enhance brain-derived sible reasons are discussed below. First of all, previous
neurotrophic factor (BDNF) expression level in dorsal hip- research has shown that the effect of exercise on executive
pocampus (DH) and thus enhance spatial cognition ability function is inconsistent and depends on the characteristics
[42]. Third, another possible benefit of dance on cognition of the subjects [47] and exercise duration [48]. Therefore,
is the effective education and learning associated with danc- the heterogeneity of participants in term of cognition at
ing. Participants are required to follow the instructor’s lead baseline may influence the finding. In several participants
to learn dance steps and directions, and complex motor with ADL impairment at baseline, the speed of cognitive
sequences during dance class. Verghese et al. [15] argued decline increased significantly [34]. So, it’s hard to main-
that participation in leisure activities, similar to education, tain or improve their executive function. Other subjects were
may increase cognitive reserve, reducing the incidence cognitively active at the start of the dance group. Engaging
and delaying the onset of dementia. Similarly, the learning older adults who are generally fit and active may leave lit-
therapy was reported as an effective cognitive rehabilitation tle room for improvement if, as a consequence, the brain
for the dementia patients by improving prefrontal function already exhibits efficient processing [31, 33]. No improve-
[43]. Learning of new and complex dance-related move- ment in executive function may be due to inadequate train-
ment induces changes in multiple brain regions in unfamil- ing does, such as short intervention period and low dance
iar dance situations [14]. Cross [44] found that learning to intensity. On the other hand, no significant differences in
dance by effective observation appeals to be closely related executive function between groups may have been the result
to learning by physical practice, both in the level of achieve- of active controls. Social interaction that experienced in the
ment and also the neural substrates that support the organiza- education group can affect cognition [49].
tion of complex actions. Finally, dance is a multicomponent Compared with traditional exercise, dance is a com-
training with physical, cognitive, and social dimensions, all plex sensorimotor rhythmic activity integrating multiple
of which may be synergetic benefits when delivered in com- physical, cognitive, and social elements [50] and provides
bination. Animal research showed that combining physical multisensory stimulation in an enriched environment [51].
activity with sensory enrichment has stronger and longer- Consistent evidence demonstrates that a multimodal exer-
lasting effects on the brain than either treatment alone [23]. cise intervention can achieve superior effects on cognitive
There were two studies [31, 34] with no significant function as opposed to single modality interventions [52,
improvements of global cognition in older adults. Madeleine 53]. In our review, two RCTs [23, 32] did not find that

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Aging Clinical and Experimental Research

dance intervention was more effective for elderly cogni- Compliance with ethical standards
tive functions than exercise. The third study by Coubard
OA suggests that dance improve cognition as compared to Conflict of interest The authors declared no conflicts of interest rel-
other motor training programs. However, the quality of this evant to this article.
study was too poor to draw any useful conclusions. The Ethical approval This article does not contain any studies with human
present quantitative synthesis shows that improvements participants or animals performed by any of the authors.
in cognition were observable in both dance and exercise
Informed consent For this type of study, formal consent is not required.
groups, but no group differences emerged. One explana-
tion could be the nature of dance intervention, which is a
moderate-intensity physical activity. Prolonged interven-
tion time and increased intervention dosage might have Appendix
greater cognitive benefits.
There are several limitations to this meta-analysis and PubMed search strategy
systematic review. First, there is too few studies that focus
on the effects of dance on cognitive function in older adults, ((((((“dance therapy”[MeSH Terms] OR (“dance”[All
so a limited number of studies are included in this study. Fields] AND “therapy”[All Fields]) OR “dance therapy”[All
Moreover, the analysis of global cognition showed high Fields] OR (“dance”[All Fields] AND “therapies”[All
heterogeneity across the included studies, and we explored Fields]) OR “dance therapies”[All Fields]) OR (“dance
that heterogeneity comes from the variation in cognitive therapy”[MeSH Terms] OR (“dance”[All Fields] AND
measures by subgroup. Because of the heterogeneity of the “therapy”[All Fields]) OR “dance therapy”[All Fields] OR
measures, we have to limit our meta-analyses to only the (“therapy”[All Fields] AND “dance”[All Fields]))) OR
most commonly measured outcomes. In addition, our review (“dance therapy”[MeSH Terms] OR (“dance”[All Fields]
was limited to published studies in the English and Chinese AND “therapy”[All Fields]) OR “dance therapy”[All Fields]
language, which may increase the risk of publication bias. OR (“therapies”[All Fields] AND “dance”[All Fields])))
Further research in this area should pay attention to the OR (“dancing”[MeSH Terms] OR “dancing”[All Fields]
following points. To date, most of the studies focus on the OR “dance”[All Fields])) OR (“dancing”[MeSH Terms]
effects of dance on cognition in older adults with normal OR “dancing”[All Fields])) AND (((((((“cognition”[MeSH
cognition. Further studies should pay more attention to the Terms] OR “cognition”[All Fields] OR “cognitions”[All
elderly with cognitive impairment such as MCI and demen- Fields]) OR (“cognition”[MeSH Terms] OR “cognition”[All
tia; to improve and maintain the effect of intervention, the Fields] OR (“cognitive”[All Fields] AND “function”[All
duration of dance intervention should be extended appro- Fields]) OR “cognitive function”[All Fields])) OR
priately and conduct a long-term follow-up. There is a need (“cognition”[MeSH Terms] OR “cognition”[All Fields]
for further standardized cognitive outcome measures allow- OR (“cognitive”[All Fields] AND “functions”[All
ing for more pooling of homogenous data; larger and well- Fields]) OR “cognitive functions”[All Fields])) OR
designed RCTs are required to evaluate the effects of dance (“cognition”[MeSH Terms] OR “cognition”[All Fields] OR
on cognition with aging. (“function”[All Fields] AND “cognitive”[All Fields]) OR
“function, cognitive”[All Fields])) OR (“cognition”[MeSH
Terms] OR “cognition”[All Fields] OR (“functions”[All
Fields] AND “cognitive”[All Fields]) OR “functions,
Conclusion cognitive”[All Fields])) OR ((“brain”[MeSH Terms] OR
“brain”[All Fields]) AND (“physiology”[Subheading] OR
Our meta-analysis and systematic review suggest that dance “physiology”[All Fields] OR “function”[All Fields] OR
may be a safe and effective approach to improve cognitive “physiology”[MeSH Terms] OR “function”[All Fields])))
function in older adults. However, studies with larger, high OR (“memory”[MeSH Terms] OR “memory”[All Fields])))
quality, and homogeneous are required to determine the AND ((((((((“aged”[MeSH Terms] OR “aged”[All Fields]
effects of dance on executive function and memory function. OR “elderly”[All Fields]) OR (“aging”[MeSH Terms]
OR “aging”[All Fields])) OR (“aging”[MeSH Terms]
OR “aging”[All Fields] OR “ageing”[All Fields])) OR
Author contributions The authors have contributed to this review (“aged”[MeSH Terms] OR “aged”[All Fields])) OR
equally and approved the final version of the manuscript and attest
that it has not been previously published. (“aging”[MeSH Terms] OR “aging”[All Fields] OR
“senescence”[All Fields])) OR (“aging”[MeSH Terms]
Funding This study did not receive any specific grant from funding OR “aging”[All Fields] OR (“biological”[All Fields]
agencies in the public, commercial, or not-for-profit sectors. AND “aging”[All Fields]) OR “biological aging”[All

13
Aging Clinical and Experimental Research

Fields])) OR older[All Fields]) OR (older[All Fields] 20. Keogh JW, Kilding A, Pidgeon P et al (2009) Physical benefits
AND (“adult”[MeSH Terms] OR “adult”[All Fields] OR of dancing for healthy older adults: a review. J Aging Phys Act
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review and meta-analysis. Syst Rev 7:24
22. Downs SH, Black N (1998) The feasibility of creating a check-
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