The Effectiveness of Dance as an Intervention on the Engagement in Occupation by Frail Older Adults: A Systematic Review

According to the 2020 United States Census, 55 million adults are aged 65 and above [1]. As Americans age, an increasing number of individuals are vulnerable to frailty. Frailty in older adults is a condition in which aging is associated with a decline in independence due to deficits in strength, functional mobility, physical performance factors, socioemotional components, and cognition [2]. It has been defined as the presence of three or more of five indicators: weakness (reduced grip strength), slowness (gait speed), weight loss, low physical activity, and exhaustion [3]. People with one or two of the indicators are classified as pre-frail. Approximately one-fourth to one-half of people over age 85 are considered frail [4]. Frailty limits participation in occupations, which decreases health, wellness, and overall quality of life [2]. Frail individuals are vulnerable to hospitalization because of injuries related to falls, which cost the American hospital system approximately $50 billion per year for non-fatal falls [5]. Interventions that encourage this growing population to continue their engagement in meaningful activities are vital to support physical well-being and reduce health care costs. The aim of this review is to answer the following clinical question: “What is the evidence for the effectiveness of dance interventions to enable factors of occupational engagement in frail older adults?”

Occupational therapists utilize client-centered and motivating interventions to assist clients in reaching desired outcomes of positive physical health and social well-being [6]. According to the Occupational Therapy Practice Framework, dance is a fundamental functional activity used in leisure, social participation, and health management [6]. Dance is defined as the use of rhythmic movements to promote emotional, social, cognitive, and physical performance [7]. Cross-sectional studies have found that older adults who dance on a regular basis have greater flexibility, postural control and balance, quicker reflexes, and better cognitive function than those who do not [8]. Many adults over the age of 60 live sedentary lifestyles, leading to physical limitations, early onset of medical conditions, and low self-efficacy. Dance is a form of physical activity that can be adapted for all skill levels to enable participation in desired occupations . Dance is an intervention useful for occupational therapists because it may contain cultural significance or be highly motivating, encouraging participation [9,10]. 

Limited research has examined how dance can enable the frail adult population to engage in desired occupations. We currently know that dance is an enjoyable and motivating form of exercise; however, this systematic review explores research that examines how dance impacts occupational engagement. This systematic review will help to clarify the potential value of using dance as an intervention for Frail and Prefrail (FPF) older adults. 

• Search Strategy 

An electronic database search of CINAHL, Scopus, Cochrane Trial, and PsychInfo Results was completed. The reference librarian developed search strategies with feedback from the systematic review team. The search was done on 07/15/2022. The search strategy used keyword synonyms with frail older adults and dance movement therapy interventions. The search string in each database was conducted by using a combination of keywords, subject headings, and truncation. No limiters were used. Four team members first conducted a title and abstract review for inclusion criteria through Rayyan software. Following the title and abstract review, the first six authors reviewed each full article to determine eligibility for inclusion in the review. Disagreements regarding inclusion were discussed among the group. Final decisions were made through a thorough investigation of the study’s inclusion/exclusion criteria and a unanimous decision among researchers for each study. Researchers included articles that did not state “frail,” if the participants met the criteria for pre frail. The inclusion/exclusion criteria are listed in table 2. Initial outcome criteria for the impact on occupational performance did not directly relate to occupation, so inclusion criteria were broadened to factors relating to occupational engagement. Factors included are not directly related to occupational performance but are strong indicators of occupational performance. Twelve articles were retrieved for full-text review and met the inclusion criteria. The search strategies were translated to each database using specific subject headings. The full search string terms are listed in table 1. 

Table 1: Search Terms. 

A total of 501 records were discovered through database searches, with an additional 5 discovered through Pubmed, WorldCat, OTseeker, PEDro, and Google Scholar. Following the removal of 213 duplicates, 288 articles were screened by four researchers for inclusion and exclusion criteria. Studies were excluded during the initial title and abstract screening utilizing Rayyan software. Studies were excluded if the study did not meet FPF criteria, included MT, BMT, CIMT, LSVT/LSVT-BIG, mentioned dance’s impact only for a specific diagnosis, and did not include dance as an intervention. A total of 77 full-text articles were reviewed for eligibility, with 12 meeting all the criteria. A total of 3 qualitative studies were excluded from the results. 

The title of this systematic review was amended from the title originally submitted to PROSPERO, “The Effectiveness of Dance on Engagement in Occupations in Frail Older Adults.” This title was amended to “The Effectiveness of Dance as an Intervention to Enable Occupational Engagement in Frail Older Adults: A Systematic Review” because we added factors that contribute to occupational engagement in addition to actual engagement in those occupations. We believe this to be a more comprehensive review. 

• Selection criteria 

Decisions on included and excluded research were based on preliminary factors stated in table 2, which permitted the search to be concise yet thorough to assess the impact of dance on the population of frail older adults. Evidence from method designs of quantitative methods was included. Frail older adults were characterized as individuals who were deemed ‘pre frail’ or ‘frail’ based on their current health status. Studies were included if they did not specify the participants as ‘frail’ or ‘pre frail’ but were deemed appropriate for this research based on the review of participants' health status by meeting Fried’s defined areas of frailty. The presence of three of the five factors: weakness (reduced grip strength), slowness (gait speed), weight loss, low physical activity, and exhaustion are considered frailty and two of the five factors are considered pre frail [3]. Included articles were required to discuss the participant’s changes in occupational engagement or factors that influenced occupational engagement. The participant must meet table 2 inclusion criteria in conjunction with frailty’s three main areas of decline. This process was necessary because limited research has addressed the frail older adult population. Systematic reviews and meta-analyses were excluded from this review. Non-empirical sources such as opinion-based studies were also excluded. 

Table 2: Selection Criteria.

Note. DMT= dance movement therapy. RMT=rhythmic movement training. MT=music therapy, BMT=bilateral movement therapy. CIMT=constraint-induced movement therapy. LSVT=Lee Silverman Voice Treatment 

When assessing the impact of dance intervention on occupational engagement, functional mobility, ADLs, physical performance factors that contribute to occupation, cognition and socioemotional impacts were included. The impact on occupational engagement is defined for areas of physical performance factors, cognition, and socioemotional components, as the impact on occupational engagement is less clear than in ADLs and functional mobility. Cognition poses a significant impact on occupational engagement as lower levels of cognition are associated with decreased participation in occupation [11]. To fully assess dance intervention’s impact on the factors of occupational engagement, the impact on cognition needs to be assessed. Social participation was included in socioemotional components as a measure of occupational participation as it is defined as an occupation in the Occupational Therapy Practice Framework [6]. Physical performance factors contributing to occupation, such as improved postural balance and reduced falls, are prerequisites to occupational engagement as stability and mobility are needed for numerous occupations [12].

An exhaustive search was completed based on the inclusion criteria (Table 2), and the completed research resulted in 12 articles. Four level 1B studies, two level 2B studies, and six level 3B studies were included. Four randomized control trials, five one-group pre-post studies, two quasi-experimental studies, and one mixed methods study that examined a total of 895 frail older adults aged 55 years to 89 years old were included in the review. The majority of participants were females, aged 65 to 86 years with declining physical and cognitive function. All 12 articles used dance as the experimental variable, but the most common style of dance intervention was ballroom dancing, which includes foxtrot, waltz, cha cha, rumba, bolero, swing, and samba [12-14]. The risk of bias for all 12 articles is described below (Tables 3&4). The impact of dance on each participant was assessed through several standardized assessments. The most common evidence-based outcome measures consisted of self-reported and clinician-administered examinations. The self-reported measures included the International Physical Activity Questionnaire short form (IPAQ-SF), Borg Perceived Exertion scale, Self-Evaluation of Life Function (SELF), and a depression scale [12,15-17]. The common clinician-administered assessments that were focused on analyzing participants' physical capacities, psychosocial state, and functional status included the Timed Up & Go (TUG), Montreal Cognitive Assessment (MOCA), Mini-Mental State Exam (MMSE), Range of Motion (ROM), and Barthel Index [13,14,17,18]. 

• Risk of bias 

Risk of bias at both the study level and outcome levels were evaluated and reported as “low” [16,19-21], “moderate” [12-15,18,22,23] or “high” [17] for the quantitative studies [24]. A risk of bias table was completed for quasi-experimental trials and randomized controlled trials (Table 3). A separate risk of bias table was completed for pre-post studies with no control group (Table 4). Each paper was then evaluated and rated individually per AOTA guidelines for systematic reviews [24]. The bias results revealed with four low risk of bias, six with moderate risk of bias, and two articles with a high risk of bias. 

Table 3: Risk of Bias Table: Non-randomized controlled Trial (Quasi-Experimental Study) and Randomized Controlled Trial (RCT). 

Note: Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (–). Scoring for overall risk of bias assessment is as follows: 0–3 minuses, low risk of bias (L); 4–6 minuses, moderate risk of bias (M); 7–9 minuses, high risk of bias (H). 

Table 4: Risk of Bias for Before-After (Pre-Post) Studies with No Control Group. 

Note. Y = yes; N = no; NR = not reported. Scoring for overall risk of bias assessment is as follows: 0–3 N, Low risk of bias (L); 4–8 N, Moderate risk of bias (M); 9–11 N, High risk of bias (H).

• Levels of evidence 

The levels of evidence were determined through the AOTA guidelines for systematic reviews [24,25]. Four Level 1B [12-14,19], two Level 2B [15,17], and six Level 3B [16,18,20-23] were included in the review. The four Level 1B quantitative studies utilized a randomized controlled trial of high-quality evidence. The Level 2B studies were both quasi-experimental designs. None of the Level 3B studies included a control group but included a pretest and a posttest to compare the intervention implementation to baseline.

• Occupational engagement outcomes 

Several of the articles indicated a linkage between dance/movement-based therapy increasing the level of full body functionality within the frail population. The studies examined 895 frail older adults aged 55 years to 89 years old, with females being the majority of participants. FPF older adults participated in various types of dance, such as line dance, Iranian dance, waltz, cha cha, fox-trot, and ballroom dance. Dance interventions were implemented in a variety of settings, such as inner-city neighborhoods, nursing homes, residential care facilities, YMCAs, table 5 displays details for each study reviewed. Below are the study occupational engagement outcomes.

Table 5: Evidence Table.

Note: Abbreviations are as follows. Mini Mental State Examination (MMSE). Young Christian Men’s Association (YMCA). Late Life Function and Disability Instrument (LLFDI). Physical Working Capacity 130 Test (PWC 130). Beck Depression Inventory (BDI-II). Verbal Short- and Long-term Memory Test (VLMT). Test of Attentional Performance (TAP). Voxel-based morphometry (VBM). Self-Evaluation of Life Function Scale (SELF). International Physical Activity Questionnaire Short Form (IPAQ-SF). Center for Epidemiologic Studies on Depression Scale (CES-D). Durable medical equipment (DME). Timed Up and Go Test (TUG). Senior Fitness Test (SFT). Trail Making Test (TMT). The Montreal Cognitive Assessment (MOCA).

Activities of Daily Living (ADLs) 

Two Level 1B, one Level 2B, and one Level 3B study examined the impact of various dance programs on frail older adults' overall physical capabilities to function in ADL independence. Three studies found benefits of aerobic, ballroom, or cultured dance, indicating improvement in participants' ability to perform everyday activities [12,14,16]. One Level 2B study found no significant improvement in ADL independence [17]. One Level 1B article examined prerequisite skills needed to perform occupations rather than occupation-based outcomes, so it was included in this category [12]. 

One Level 1B study conducted 1-hr graded general dance and ballroom dance, which consisted of cha cha, waltz, and foxtrot, once a week for three months for 211 nursing home residents in the Czech Republic [14]. The participants were assessed at baseline, and after three months of intervention using standardized outcome measures such as Lawton Instrumental Activities of Daily Living (IADL) Scale, Timed Get up and Go Test (TUG), and Barthel Index. The results from the dance intervention indicated it had contrasting effects on the participants’ physical capabilities in those who received the intervention versus controls [14]. A Level 2B randomized control trial found that the intervention group had significant improvements in IADLs and mobility [17]. Moreover, the control group from the Level 1B study had a statistically significant decrease in mobility compared to the intervention group. No statistical significance was found in the change in ADLs between the two groups of the studies. However, the impact of decreased mobility was less severe in the experimental group [14]. An additional Level 1B study with a high risk of bias examined 17 participants in a 4-week range of motion (ROM) dance program and found only statistical improvements in the frequency of exercise in the ROM dance program. The outcome measures relied heavily on clinician reasoning due to observations of ROM and client self-reporting on ADLs using the SELF Assessment [17]. 

A Level 3B study showed improved postural balance and reduced risk of falls after participating in a ballroom dancing program among sedentary frail older adult populations with cognitive impairment residing in long-term institutions. Over a 12-week period of three 50-minute weekly sessions, the experimental group (n=30) of 59 total participants showed a significant difference in the distribution of limb weight-enhancing motor performance in ADLs. The Level 3B study found that line dance intervention twice a week for 12 weeks resulted in improved movements related to upper extremity ADLs (showering, dressing, feeding, etc.) among low socioeconomic status (SES) African American women. The effects of the study were sustained after an 18- week re-assessment. Late-Life Function & Disability Instrument (LLFDI) outcomes showed increased motor performance after participating in the dance intervention [16]. 

• Functional mobility 

Four studies examined the outcomes of dance on lower extremity function and performance in frail older adults [12,19-21]. Each study shows a positive impact of dance on aspects of functional mobility. The four studies examined aspects of mobility and gait that impact an individual's participation in their desired occupations using the TUG, the BORG Rate of Perceived Exertion (BORG), measurements of walking speed, stride length, and cadence, and through analyzing participant’s reports of their perceptions of their performance. 

Two studies, a Level 1B and Level 3B, utilized the TUG to observe the effects dance movement therapy has on the patient’s ability to ambulate [19,21]. Results of both studies showed a decrease in falls, improved balance, and improved mobility following the interventions. An additional Level 1B study measured patients' perceived exertion with the BORG Scale, which showed improved balance and decreased falls after intervention [12]. In a Level 3B study, cadence, walking speed, and stride length were measured before and after an Iranian dance intervention group and showed an increase in gait performance and gait quality after the intervention [20]. 

• Physical Performance Factors that contribute to Occupation 

Physical performance factors include factors that contribute to reduced participation in several occupations. In this systematic review, factors in this category included slowness, weakness, physical activity, exhaustion, and decreased range of motion (ROM) [15,16,18]. These performance factors can limit engagement in occupations, as they are skills that contribute to successful motor performance skills. Slowness, weakness, physical activity, and exhaustion directly affect occupations of physical activity, safety, and functional mobility. These performance factors may also affect any occupations requiring mobility or standing, such as showering, dressing, food preparation, and home maintenance [6] Limitations in these areas would decrease the quality and quantity of occupational engagement. 

Slowness, weakness, physical activity, and exhaustion were measured in a Level 2B study before and after participation in dance sessions [15]. Slowness was assessed using a 6-meter gait speed test, weakness was measured by handgrip strength using a hand-held dynamometer, and physical activity was evaluated according to the International Physical Activity Questionnaire Short Form (IPAQ-SF). These three physical performance factors significantly decreased, but there were no differences in exhaustion as measured by two questions derived from the Center for Epidemiologic Studies on Depression (CES-D) scale. 

Lower extremity ROM assists with a client’s mobility. Among four studies conducted by Meng et al., on dance therapy’s impact on upper extremity ROM, improvement was seen in only one of the studies [15]. Dance’s impact on physical function and physical working capacity was measured in two Level 3B studies [16,18]. Physical working capacity, the ability to perform maximum physical work, was measured with the Late Life Function and Disability Instrument (LLFDI), and the physical working capacity was measured with the Physical Working Capacity 130 Test (PWC 130). Both studies showed that therapeutic dance participants increased physical function and working capacity. The performance factors shown to improve were slowness, weakness, and physical activity, while those that did not improve with a dance intervention were exhaustion and ROM. Improvement of physical performance factors through dance intervention suggests improvement in occupational engagement, impacting frail older adults’ daily participation in desired activities. 

• Socioemotional factors 

Although some articles did not use social participation in their outcome measures or intervention, they used it as a form of motivation and support participation in the intervention. Study results indicated that participants were entertained during the dancing sessions [13-16,21-23]. One Level 3B study evaluated the effectiveness of therapeutic dancing for social interaction and how this intervention is a source of emotional support. The participants used the intervention as an opportunity to share stories and reflect on the music and dance. The NIH loneliness questionnaire was used to measure the outcome of dance. The pre-intervention score was 7+/-7 (5,15), and the post-intervention score was 5+/-8 (5,13), reporting that there was an improvement in feeling less alone [22]. A Level 3B study used a depression scale as an outcome measure, which contained 20 items to be scored on a 4-point Likert scale, with 0 being rarely depressed and 3 being depressed most of the time [16]. At pre-test patients reported severe depression (M =20.0, SD = 12.4), while post-test results showed that dance intervention significantly decreased depression (t = 6.11, p < .001). The same article defined disability as the inability to perform socially defined life tasks, such as personal maintenance, social community activities, and participation in economic activities and utilized the disability instrument to assess the impact of disability in community-dwelling older adults. They rated 16 major life tasks on a Likert scale ranging from 1 (completely limited) to 5 (not at all). The participant’s level of disability improved from (M = 65.7, SD = 14.9) to significantly increased physical function (, t = -2.74, p = .013) after completing the dance intervention for 12-weeks [16]. 

• Cognition 

One Level 3B study administered the Verbal Short- and Long-term Memory Test (VLMT) and the Attention Test Battery-Test of Attentional Performance (TAP). The results showed significant improvements in the post hoc test comparison from baseline to 18 months and 6 to 18 months in all three VLMT subcategories in both groups. The TAP group also significantly improved compared to the baseline to the 18-month data in both groups [18]. One Level 2B study used intervention in which cognitive skills were needed. Although previous research showed that gait performance was improved using cognitive activities, further research still needs to be done on the cognitive effects on older adults’ performance [20]. 

One Level 1B studies examined the effects of cognitive function in therapeutic dancing and administered the Montreal cognitive assessment (MoCA) to 60 participants [19]. This study utilized the MoCA as an outcome measure for the dance intervention and the results failed to show a statistically significant difference between groups for both measures of cognitive function. The study additionally administered the Trail-Making Test to test cognitive levels, but the test failed to show any cognitive improvement.

Findings indicate that dance is a beneficial intervention to increase occupational participation in FPF older adults. The performance factors improved through dance that led to an increase in occupational participation in the FPF older adult population were speed and quality of gait, cadence, balance, range of motion, and reduced fall risk [12,19,20]. In addition to increasing performance factors, dance increases motivation, social connectivity with others, the overall enhancement of quality of life, and decreases depression [13,16,22]. Additional findings indicate a potential for increased brain activity in areas related to spatial memory and motor skills through participation in a dance intervention [20]. The data concludes that dance programming has multifaceted benefits as it impacts general physical performance, cognition functioning, and social behaviors. 

As seen by Clifford et al., [22], participants found the dance intervention beneficial as an opportunity to share stories and reflect on the music and dance. The participants found dance intervention was not exclusively beneficial for their physical health, but for their feelings of social connectivity. 

Valentine-Garzon et al., [17] found no significant difference in ADL independence, ROM, or self-esteem following dance intervention when compared to the control group. Reasons for this could potentially be the small sample size of 17 participants, but it was found to have high quality and a low level of bias. Although the participants did not demonstrate a difference when compared to the control group, the experimental group reported finding the ROM dance program as beneficial, enjoyable, and performed with greater frequency than the control group. This study reveals a limitation of a short time period, two, 30 minute dance sessions per week, for four weeks, and stated that most exercise programs yield results after months to years of implementation. The short time period could be an explanation as to why no significant difference was shown between the two groups. 

Franco et al., [19] examined the impact of dance intervention on balance, safety for falls, overall mobility, and cognitive levels in 82 older individuals. The participants’ cognition did not improve in the experimental group after participation in a folk music dance intervention. This study was determined to have a low level of bias but had a small sample size of 41 participants in the experimental group. There was no difference between the experimental and control groups. In the cognitive tests, baseline cognition was measured through the MMSE, MOCA, or the Trail Making Test and participants’ baseline scores were within the average for normal cognitive function. There was no significant difference between the experimental and control groups in these cognitive tests. 

• Strength of evidence 

Strong evidence supports improved overall factors that enable occupational engagement from dance as an intervention for FPF older adults [24]. Strong evidence supports dance as an effective intervention to improve ADLs, functional mobility, and socioemotional factors, while moderate evidence supports cognition and physical performance factors that contribute to occupation. Two level 1B, one level 2B, and one level 3B study of overall strong evidence addressed ADLs [12,14,16,17]. Two level 1B and two level 3B publications of strong overall evidence were examined for functional mobility [12,19-21]. One level 2B and two level 3B articles of moderate overall strength of evidence examined physical performance factors that contribute to occupation [15,16,18]. The research regarding socioemotional utilized four level 3B and two level 1B articles of strong overall evidence [13-16,21-23]. The research regarding cognition used one level 1B and two level 3B articles showing a moderate overall strength of evidence [18-20]. 

• Strengths and Weaknesses of the Studies 

Limitations of the research include limited gender diversity, limited demographic data, low participant numbers, a high risk of bias, and many environmental barriers. Many of the studies had a high rate of female participation [20,21,23]. Frailty was shown in 5.4% of males and 8.8% of females revealing that the population assessed was not representative of the true population due to the limited male participation in dance interventions [26]. The most current research did not include specific demographics of dance participants. Only one study included socioeconomic status [16]. The lack of demographic information limits the ability of the researcher to generalize the results of the studies to the full American population. Additionally, the sample sizes were small, and a few studies had high attrition rates, negatively affecting the quality of the studies [22,21,17]. The risk of bias was assessed for each article. Outcome measures for multiple articles did not include a pre and post-test indicative of measurement bias [22,19]. All the studies required voluntary participation from older adults and nonrandomized bias of participation could have affected the selection bias of the populations participating in the studies. Only participants who were willing to complete dance intervention were included in the studies, which could lead to selection bias. 

• Strengths and weaknesses of review 

Weaknesses of this review were the omission of articles not written or translated into English and articles that exclusively addressed specific conditions such as cancer and cardiovascular disease. In addition, unpublished or private studies were excluded, which limits the exhaustiveness of our review.

Strengths of our review included the wide variety of data on dance's overall effect on occupational performance among the studies. Each study examined different aspects of an occupation, such as physical factors, ADL factors, psychosocial factors, and cognitive abilities. The studies took place in multiple geographic locations providing many perspectives and cultural motivations for the therapeutic intervention. Various forms of dance were used as an intervention, such as the cha-cha, aerobic dance, line-dance, and Iranian dance [13,16,20]. Having several dance genres strengthened the systematic review by investigating the impact of dance as a whole rather than the impact of one form of dance. The impact of dance as an intervention was assessed using various standardized assessments, which increased the validity of the results and studies [12,15-17]. In addition to the strengths of the research, a strength of this review was that the assistance of a reference librarian was used to obtain data from 10 databases to find articles relevant to our topic. Another strength was Rayyan, an online resource for rating research articles, which was utilized to streamline the article selection process and reduce rater bias. 

• Recommendations for future research 

The emergence of using dance as an intervention to address occupational engagement is an area that needs to be more thoroughly researched for clinical relevance. Most of the research studies assessed performance factors rather than specifying their impact on ADL performance, revealing a need for more research on how the functional or performance-based outcome measures relate to ADLs. Additionally, research on the effects of dance on functional cognition and potentially exploring what parts of the brain are activated and maintained post-intervention would be beneficial for the future of cognitive therapeutic interventions. More evidence is needed to evaluate the effect of dance on an individual’s cognition [20]. One of the articles mentioned that there was no improvement in cognition when using dance as an intervention for frail older adults) [19]. Future studies will need to target the diverse experiences of different groups, including socioeconomically disadvantaged individuals and sexual and gender minority groups to ensure a broad representation of the diversity of the population. Finally, it is recommended that research comparing specific styles of dance, such as ballroom, cultural dance, or aerobic dance, should be conducted to identify which dance style shows the most improvement in FPF older adult participants.

The results of the studies have the following implications for occupational therapy practice:

• Occupational therapists can utilize dance as an intervention to promote ADLs/IADLs by improving upper and lower extremity function, all while incorporating cognitive skills required to complete the tasks.
• Dance is a motivating intervention that can be used in practice to encourage social participation and decrease isolation.
• Current research reveals that dance as an intervention has promising results in reducing physical and cognitive symptoms associated with frailty. Further studies from occupational practitioners are needed to investigate the impact of engagement in occupations.

Evidence suggests that occupational therapists and other health professions can implement dance as a valid and reliable intervention to assist frail and prefrail older adults in occupational performance. Our review indicates that dance as a beneficial intervention for older adults with cognitive deficits, limited physical performance and mobility, and ADLs. Therefore, dance can be used as an intervention to increase participation in occupation by frail and prefrail older adults.

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