AIMS/OBJECTIVES The overall aim of this project is to evaluate the usefulness of Wu Tao dance therapy for people with dementia living in low care facilities, and assessing the impact of agitation. The aim would be to include care staff at a low care facility, within the dance group and monitor carer stress in relation to working with clients whom experience high levels of agitation. The key objectives are to:

•  Lift mood.
• Create a therapeutic bond between staff and resident.
• Create a fun environment.
• Reduce carer stress and increase carer confidence.
• Examine and measure changes in client agitation.
• Encourage friendships to form between residents.
• To up skill staff within Wu Tao dance therapy
• To continue dance therapy within the facility

INTRODUCTION The Dementia Behaviour Management Advisory Service (DBMAS) under the auspice of Alzheimer’s Australia WA, is a service that supports carers of people with dementia. This program provides a range of services including clinical support, assessment, care planning, education and training. Within this team network I am the senior behaviour consultant. Given the difficulties that people living with dementia encounter daily, bringing a new psycho social intervention/ non pharmacological treatment into the lives of people living with dementia in the form of dance was an initiative that the DBMAS team believed could be introduced in to dementia care facilities, to alleviate agitation/anxiety and promote a bond between carer and the person with dementia. DBMAS has for the last 12 months implemented many other psych social interventions in to its strategy planning, such as aromatherapy, music therapy, of which we have received very positive feedback. Therefore introducing dance therapy was a natural progression for DBMAS to incorporate social stimulation and exercise. The proposed plan was therefore to introduce Wu Tao dance in to a facility and try to measure any changes within the group and individuals. This would initially need to be a small sample size to trial Wu Tao dance (as no funding was available at this point). Whilst hoping subjectively, to witness some positive impact, staff were also aware that this experience may have little or no impact on those people living with dementia. Staff expressed their scepticism about the value of this type of therapy before it commenced Researching other articles on dance it was evident that exercise alone improved physical ability and improved sleep (Burgener S 2008). There is however limited research in the area surrounding dance, yet the literature  sourced, suggests that we can meet and cross all barriers through dance and that direct language of the body and movement (Greenland P (2009), yet no one had ever tried Wu Tao with this specific group of people. Aged care facility staff report when referring a resident to DBMAS that they find the effects of agitated behaviour, often being the most challenging. NATURE OF AGITATION Within the DBMAS team many referrals received are relating to agitation and the difficulties surrounding this area. People with severe dementia can be a neglected group with respect to their treatment needs (Boller, Verny, Hugonot-Diener, & Saxton, 2002). One particular concern is for those individuals whom experience agitation. Agitated behaviours are particularly common for some people with a dementia- type illness, and may be reported most frequently in those living in residential care (Boller, Verny, Hugonot-Diener, & Saxton, 2002). Agitation is not a diagnostic term; rather it is used to describe a group of symptoms, which include aggression, wandering, calling out, screaming and verbal abuse (Cohen-Mansfield et al 1989). These behaviours can pose a challenge for nursing staff; however there has been a gradual introduction of non-pharmacological therapies over recent years (Douglas et al 2004). Non pharmacological interventions aim to address the unmet needs of the resident, which it is suggested may be causing these difficulties (Camp, Cohen-Mansfield, & Capezuti, 2002). Therefore a more insightful approach to meeting these needs could decrease the feelings of loneliness, boredom and sensory deprivation. Whilst medication does have a role to play in the treatment of agitation and for people with Dementia, it has been shown that antipsychotics have only moderately improved symptoms of agitation and psychological disturbances (Sultzer, 2003).There is some concern from health care professionals about their propensity for side effects. “Wu Tao” (The Dancing Way) Wu Tao (pronounced woo dow) is otherwise known as “The Dancing Way”: the way being “Tao”. This dance was developed by Michelle Locke from Perth Western Australia. A former ballet dancer, Michelle was forced into early retirement due to a back injury in 1983. After many years she found the only pain relief effective was Japanese Shiatsu. Combining her interest in people and their emotions, and her new found love of Japanese Shiatsu, she was able to marry the two, therefore creating Wu Tao. This therapy combines gentle movement, music and meditation which have been designed to harmonize the flow of energy, and is suitable for all walks of life and ages.  It also has origins in oriental medicine. Wu Tao consists of five dances that balance the body by activating the meridians (energy channels). This results in a feeling of great harmony. Wu Tao has been described as allowing the body to be a vehicle for the soul to speak, allowing those to express themselves through movement however small (Chou, Boldy & Lee, 2002). This dance has dietary, psychological and spiritual aspects which are incorporated into its teaching. Wu Tao is both movement and stillness. Doing and being. It can bring participants to a place that is free from chatter and experience the stillness of their own being (Locke, 2008). The Wu Tao dance has been described as finding the ability to go with the flow of life, feeling still and ending the struggle, and has recently been launched internationally (Locke, 2008). CARER INVOLVEMENT Dance has been used as part of the creative art therapies in the western world since the 1950s (Nystrom, Lauritzen, 2005). Through the experience of dance it has been suggested that we can get to know each other and engage in the symbolic expression of movement. The creative arts have been shown to have a critical role, since people with dementia often lose their ability to converse in a straightforward way (Marshall & Archibald, 1998). Through the use of movement and dance, people with dementia can communicate their experience, and the positive role of the relatives and carers can be enhanced. Within the governments agenda for life long involvement in physical activity and person centered conversation, skills using movement can bond and unify without any prompting. Greenland P (2009) suggests that this allows carers/relatives the ability to unlock the innate yearning all human beings have to communicate directly with each other. Working within a dementia specific unit can be challenging for many staff, and can result in carer burden stress (Brodaty, 2003). The stressful nature of providing personal care can be easily underestimated. This can strongly impact on both the staff member and the care recipient. It has been recognized that caring for people with a dementia type illness is simply a very difficult task to achieve (Benner & Wrubel, 1989) (Smith, 1992).  Research has shown that encompassing dance as an activity can blur the boundary between carer and cared for (Coaten, 2001). Dance can allow a forum of celebration and richness into the lives of everyone taking part. It has also become more evident that enjoyment and involvement between carer and client has been shown to increase job satisfaction (Chou, Boldy & Lee, 2002). Hokkanen et al (2003) found that staff observed a change in the behaviour of residents, when a pilot study of their dance and movement group was conducted.  Residents appeared to interact more socially both with each other and care staff. DELIVERING THE THERAPY In February 2009, 6 residents from a low care facility were identified as having symptoms of agitation as per the Cohen Mansfield Agitation Inventory (CMAI). Pre session scores were taken, thus giving us a clearer indication of the level of agitation. The average score was 66.83, (inclusion criteria >39). This cohort consisted of five females and one male, between the ages of 81 years and 92 years, giving the mean age of 85.1. All participants had a diagnosis of Dementia. Using the Global Deterioration Scale (GDS) Reisberg B, (1982), participants were assessed by the Senior Behaviour Consultant from DBMAS, ratings were identified  between moderate to severe in degrees of cognitive loss. Each client consented to join the Wu Tao Dance sessions and had the option to withdraw from the sessions at any time. Relatives were informed of the sessions, and consent was given by family members for those clients whom were unable to consent verbally. All clients were observed through participation by the senior behaviour consultant, any non- verbal/verbal indications that the clients did not wish to attend the sessions was therefore acted upon. However it became apparent by verbal indications from clients, observations and comments form staff that they enjoyed Wu Tao.  These sessions would occur weekly over a period of three weeks. A Therapy room was established within the facility, which was quiet, relaxing and spacious enough to encompass movement. Chairs surrounded the dance area enabling residents to be seated during the session if they so wished. Those residents whom were not able to stand for long periods of time were then provided with the option of being seated. The environmental factor plays an important part; not only to encourage participation, eliminate risk, but also to enhance spiritual well being. Dance sessions can be modified accordingly to account for the needs of the client group; for example breaking the steps down to be simple and concise, and allowing directions to be followed more easily. Although the dance session was slightly modified the instructor stated, “I thought that we did it (the dance) quite differently, but when I think back we actually didn’t, it was only the stretches at the beginning that really changed. It was no different to the general public.” It was important to include a midway break into the dance session, which allowed residents and the instructor opportunity for drinks and refreshments. For residents to participate comfortably it is important to choose suitable attire. Many of the residents that participated were unable to express themselves verbally, and therefore were given the opportunity to use Wu Tao dance as a tool for expression. Coaten (2001) suggests that dance can be enlightening, however small the reaction. The enlightening and opportunity for expression was evident through the communication and connection displayed between residents and staff. Assessors were participants in the ongoing dance sessions. This enabled visual assessment of non-verbal cues of the resident’s expressions during the dance. For example, smiling and interaction with staff members, residents who usually had disagreements tended to group and bond together. This was monitored via follow up phone calls each week to the facility and recorded in subjective evidence; see table 3 and the question relating to relationship changes and the staffs observations. Whilst low cost is seen as a positive factor for Wu Tao as a treatment of agitation in dementia, it needs to be considered when planning budgets and projected costs. The dance trial indicated a number of positive and negative factors impacting on the results obtained, these included;

Positive Aspects	Negative Aspects
Non Pharmacological	Resident Participation
Easily integrated in to daily routine	Sourcing instructors
Lowers agitation	Understanding Wu Tao
Reduces Carer Stress	Time constraint for staff
Encourages carer/resident interaction	Short trial
Physical activity/no limitations apply	May only be appropriate for low to moderate levels of dementia (further research will need to be conducted)
Low cost	Staff reluctance and motivation

RESULTS  A post CMAI measure was used following the final Wu Tao session, to identify any changes. The result showed that the average score was now 60.67, presenting a decline in agitation of 6.16 (See table 1 for all CMAI scores). Table 1: Cohen-Mansfield Agitation Inventory (CMAI) – Results

Client	Initial score (05.02.09)	Follow-up score (date)
1	50	55
2	83	62
3	89	79
4	55	70
5	69	49
6	55	49
Total	401	364
Average	66.83	60.67

A reduction of 6.16 between pre and post scores

As indicated from the table above 4 out of the 6 participants scores reduced, indicating that some reduction in agitation was noted, 2 participants scores however increased. Both residents with increased scores had medication changes throughout the trial period; this may have contributed to their increase in scores. Questionnaires were also collected over the 4 week trial to monitor the responses of residents and staff to the intervention. The table below represents the changes observed and described by both residents and staff from the initial and subsequent Wu Tao sessions. All of the participants in the dance group, which included residents and staff, indicated that Wu Tao was a pleasurable and enjoyable therapy. Many felt that this could be incorporated in to their weekly activity programme, and given the correct training could be an activity where both staff and residents could benefit. As anticipated, some residents did have difficulty orienting themselves adequately to the instructions. This was mainly left and right side orientation, which is however a minor difficulty as the dance is still able to be completed. The aims of the sessions were met as follows:

• Wu Tao was noted to lift the spirits of both residents and staff, through the increase in communication and social laughter present during and after each session.
• Staff were observed to interact with one another more easily and a greater level of relaxation was noted.
• A therapeutic bond between staff and residents developed. One resident when asked “what did you think about the staff joining your group?” replied “It teaches them to be like us”. It was noted from participants that much laughter and verbal interaction was evident.
• It was indicated by staff that this form of therapy would be beneficial to their own well being. One member of staff stated that it provides a “lighter side of the work”; this was also indicated by the number of requests from staff to attend out of work classes.
• Agitation, through the results of the CMAI was shown to be reduced for 4 of the residents.
• The facility aims to continue the dance therapy, provided funding constraints enable.

Table 2: Resident’s responses to questionnaires

Question	Yes	No	Further comments
Did you enjoy the dance session	100%	0%	Enjoyed movement Relaxed me ‘Gave me a big lift’ ‘Very pleasant’
Do you feel the dance group has improved your mood, i.e. made you happier?	83.3%	16.7%	Wanted to join in Felt on top of the world Brighter Made me feel happy It didn’t make any difference to me
Do you feel the dance has helped you? How?	83.3%	16.7%	No just the same Made me think more deeply Not so stiff Together and interaction Enjoyed the music and being happy I’m not mobile enough
Would you like to attend a group like this each week?	83.3%	16.7%	Once per fortnight Would love to I think it will be very beneficial It will keep me out of mischief
Did you think it was good about the staff joining in your group?	100%		Good, teach them to be like us You follow the people you know Really like the staff joining in Good idea
Did the dance group make you feel differently?	91%	9%	Take me a while to digest Gives me a lift Something different to think about Just let it come out Happy, relaxed

Table 3: Staff responses to question

Question	Yes	No	Further comments
Do you feel that the Wu Tao dance group was beneficial to residents and staff? If so how?	100%		Very relaxing and easy to follow Residents and staff smiling and happy It could be graded to suit varying abilities – allows those who can’t verbally express themselves the opportunity to express themselves physically Provides excellent forum for group participation and increase of social interaction A lot of fun and good exercise
Do you feel it has increased your job satisfaction?	91.7%	8.3%	Not immediately It is nice to do group activities A lighter side of the work, enjoyable Felt happy to see the residents enjoying themselves Relaxing
Have you noticed any relationship changes in the group?	58.3%	41.6%	First session – encouraging to see the interaction between various residents I worked 3-7.30pm last Thurs and the residents were very relaxed throughout the evening All had a laugh and no negativity More interaction Not yet Residents chatting and laughing more
Did you notice any changes in resident’s behaviours throughout or following the sessions, if so what did you notice?	83.3%	16.7%	Enjoyed, very relaxed, focused Not yet Saw a remarkable increase in movement and ability to follow instruction from one resident in particular Looked happy, laughing and talking Feedback from afternoon staff – they were more settled after the session
Do you feel these groups could be introduced into your facility by staff? And if so would it be useful to continue?	100%		Would reduce anxiety Good for all residents Depends how well it translates to people in wheelchairs Definitely – could be done in large/ small groups
Did you attend the dance session?	100%
Do you feel that relationships between residents in the group may have changed? In what ways?	75%	25%	More communication and interaction N/A, not as yet A non-threatening environment where the residents can interact, along with being a new challenge Brings residents and staff much closer Remained after the session and chatted – improving communication and general well-being
Have you noticed changes in the way that residents who participated in Wu Tao react differently to those who didn’t?	50%	50%	Many were unsure and hadn’t noticed changes as yet. 1 resident just watched and didn’t appear as happy as the rest of the group Looked a lot more relaxed
Do you feel that a weekly dance group involving staff and residents could increase your own well being? If so how?	100%		All staff seemed more relaxed Reduce agitation Involvement and interaction in a relaxed space Exercise/ movement and fun (interaction and brain stimulation) Could release all the stresses of work A great session to interact with staff and residents.

CONCLUSION Initially many of the residential staff were hesitant towards Wu Tao as a therapy. Many did not believe that this could reduce agitation in residents whom have had a long standing history of dementia behavioral disturbances. However following education sessions surrounding dance therapy and its positive impact, staff were willing to be involved in the Wu Tao trial. Many of the staff stated they were pleasantly surprised by the relaxing and enjoyable experience. By the conclusion of the first session, Wu Tao was considered to be very well received by both staff and residents. Many staff reported that they were eager to continue the dance sessions outside of their work environment. Staff at the facility noted that the group dynamics had changed significantly, becoming more positive amongst both residents and staff. A positive working environment is critical in working in dementia care, and this highlights the value of Wu Tao and dance in enabling expression both verbally and non-verbally. To enable dance sessions to be conducted within a facility environment, education and support form care staff is of paramount importance, the positive approach from staff helps to promote a relaxed and social environment for all involved allowing the group to form a therapeutic bond. It is important to anticipate negative reactions to such alternative therapies when commencing such sessions.  Negative reactions could be due to a lack of existing or research relating to dance therapy within the daily practices of residential facilities, along with stereotypic views towards alternative forms of treatment (Norman H 1999) Symptoms of agitation make living with dementia more difficult for both clients and those who support them. From a subjective point of view it seems that Wu Tao has possibly improved the lives of those living with dementia. u Tao may provide a non-pharmacological way to aid treatment and prevention of agitation in dementia, this may not only help integrate staff and residents but also lift the spirits of those involved. In conclusion Wu Tao is an experience for all, and it is possible that “Wu Tao” can reduce agitation and bring life and fun to any residential facility. ACKNOWLEDGEMENTS I would like to acknowledge the facility of Brightwater care group in Joondalup for taking part in this trial, and for their dedication and support of older adults with Dementia. Without this facility and their involvement, this project would not have been possible. Also thank you to Kaye and Michelle, the Wu Tao dance instructors, for their patience and enthusiasm in this trial. Further information regarding Wu Tao in dementia (Wu Tao Wisdom) can be found at www.wutaodance.com References