The effect of dance movement therapy and walking interventions on loneliness and self-neglect in older people aged 65 and over: a randomized controlled trial

Abstract

Background

Loneliness and self-neglect of older people are significant public health concerns, often accompanied by recluseness, which can impaired psychological health by preventing living together with society. Therefore, the aim was to evaluate the effect of dance movement therapy (DMT) and walking interventions on the loneliness and self-neglect levels of older people.

Methods

This study was carried out with older people aged 65 and over registered at a family health center. In total, 48 people were randomized into the DMT (n = 16), walking (n = 16), or control (n = 16) groups. At the beginning and end of the study, all three groups completed a survey including the Participant Information Form, the Elder Self-Neglect Scale (ESNS), and the Loneliness Scale for the Elderly (LSE). The DMT group received the intervention twice a week, for a total of six sessions, while the walking group participated in a walking program for the same duration.

Results

After the interventions, both DMT and walking groups showed significant improvements in emotional loneliness, social loneliness, total ESNS, and LSE compared to the control group. Compared to walking, DMT led to greater improvements in ESNS (aMD = -15.421; 95% CI: -23.915 to -6.927; p < 0.001), LSE (aMD = -1.939; 95% CI: -3.312 to -0.566; p = 0.003), physical health (aMD = -3.545; 95% CI: -6.958 to -0.132; p = 0.039), environmental health (aMD = -6.488; 95% CI: -12.333 to -0.642; p = 0.025), and mental health (aMD = -4.052; 95% CI: -6.835 to -1.268; p = 0.002). Differences in social loneliness (aMD = -0.650; p = 0.049) and social network (aMD = -1.530; p = 0.018) were smaller but significant, while emotional loneliness showed no significant difference (aMD = -0.926; p = 0.056).

Conclusions

This study showed that DMT and walking interventions effectively reduced loneliness and self-neglect in older people, with the DMT group producing greater improvements than the walking group across most subdimensions.

Trial registration

The randomised controlled trial study was registered on the Clinical Trial Register (Registration number: NCT05655455). Date of registration: 12/09/2022 https://register.clinicaltrials.gov/.

Background

Loneliness and self-neglect are common and serious public health problems that affect older people’s health and quality of life [1, 2]. Loneliness is negatively affects psychosocial well-being, can be seen in many segments of society, so it an undesirable subjective experience, arising from unfulfilled intimate and social needs [3–5]. The lowest prevalence of loneliness in older people range from 4.2% to 6.5% in northern European countries, and the highest range from 18.7% to 24.2% in eastern European countries [6]. In a study by Zhang et al. it was reported that 59.3% of 634 older people over the age of 65 experienced moderately lonely, 21.3% experienced severely lonely and 10.9% experienced very severely lonely [7]. Advanced age, female gender, being separated or single, social stress, and difficulty in daily activities can all affect loneliness levels [4, 8, 9]. Self-neglect in the older people is defined as the failure or refusal to meet the self-care needs that enable independent living due to their reduced capacity and failure to take action necessary to live in a healthy and safe environment [10, 11]. The literature shows that self-neglect is accompanied by serious conditions such as death [10, 12], impaired health [12], frequent hospitalizations [11], abuse of older people, or caregiver neglect [13]. According to a systematic review of self-neglect in older people the prevalence rates of self-neglect range from 18.4% to 29.1% [14]. A study with Chinese older people conducted by Xu et al. found that the prevalence of self-neglect was at a high level of 72.7% [15]. To mitigate the feelings of loneliness and self-neglect experienced by older people, it is important to implement effective health promotion programs and evidence-based interventions that will allow them to cope with these feelings. In the literature several interventions such as animal-assisted therapy, music therapy, reminiscence therapy and technological guided strategies have been carried out to reduce loneliness and social isolation in older people [16–20]. Evidence-based studies have not been found in the literature on self-neglect intervention, it is recommended that holistic interventions should be performed for such as social support, cooperation, communication, and a multidisciplinary team approach [5].

DMT helps older people to live more active, healthy, enjoyable lives, especially in them [21]. According to the American Dance Therapy Association DMT is defined as the psychotherapeutic use of movement to maintain the emotional, social, cognitive and physical integrity of the individual and in order to increase health and well-being [22]. The most important feature that distinguishes DMT from general dance is that its purpose does not require a performance or high-level dancing skills [23]. The basic principle on which DMT is based is that there is a relationship between movement and emotion. A systematic review and meta-analysis found that DMT was effective in promoting mental health amongst older people without dementia, suggesting that the multimodal enrichment tool is a potential strategy for health promotion and prevention of Alzheimer’s disease [24]. Similar to DMT, health professionals often recommend walking intervention as a dominant, low-cost, and low-risk exercise that older people can easily perform in their free time to prevent chronic health problems and improve psychological well-being [25, 26]. A study conducted by Yu et al. with Chinese older people reported that walking was associated with better life satisfaction, happiness, and less loneliness in older people [26].

A wide range of interventions have been developed to tackle social isolation and loneliness among older people [5]. No study has been found in which the effects of DMT or walking interventions where done with groups were evaluated together on the loneliness and self-neglect of older people aged 65 and over. To address this gap in the literature, it is thought that these two interventions to reduce the level of loneliness and self-neglect in older people, combined with community-based approaches will be more effective in reducing these situations. It is thought that the results of this study will improve the physical and mental health and life satisfaction of older people and provide basic data for health promotion programs that will support them spiritually, socially, psychologically, and culturally. In this context, this study aimed to evaluate effect of DMT and walking interventions on the loneliness and self-neglect levels of older people.

Methods

Study design and participants

This study was conducted at ‘family health centers, which are part of the primary health-care system in Amasya, Türkiye between September 2022 and June 2023. The study sample consisted solely of older people aged 65 and over registered at the family health centers. A family health center provides personalized preventive health services (such as pregnancy care, maternity and baby care, child follow-up, vaccination services) as well as primary diagnosis, treatment, rehabilitation and consultancy services, health-promoting and preventive services, maternal and child health [27, 28]. This center provides referral services to a full-service hospital for older people experiencing loneliness, self-neglect, chronic illnesses, or mental health issues. Participants included in this study were older people, aged 65 and over, registered at a family health center, and willing to participate. Individuals excluded from the study were having vision and/or hearing problems, a chronic disease that would prevent participation in the study, a condition that would prevent physical exercise, and a diagnosed mental health problem. Participants who met al.l inclusion criteria were randomized into DMT, walking, and control groups. All participants were informed about the study’s purpose and scope, the content of the training program, and their legal rights and responsibilities.

Research hypotheses:

• H1: Older people who participate in the DMT program will exhibit significantly reduced levels of loneliness and self-neglect compared to those in the control group.

• H2: Older people who participate in the walking program will exhibit significantly reduced levels of loneliness and self-neglect compared to those in the control group.

Randomization method and sample size

A total of 264 older people aged 65 years and over who were registered at family health centers were initially screened for trial participation. Of these, 113 participants were assessed for eligibility. A total of 65 participants were excluded, fully consistent with the CONSORT flowchart: Not meeting inclusion criteria (n = 32) (e.g., severe mobility limitations or cognitive impairments), declined to participate (n = 22), other reasons (n = 11), and the study was completed with the remaining 48 participants (Fig. 1). Based on previous studies, the sample size for the primary outcome (LSE and ESNS total score) was calculated using G Power 3.1 software, assuming a medium effect size (Cohen’s f = 0.25; ηp² = 0.06) [29, 30]. A one-way ANCOVA was planned for the three-group design, controlling for baseline scores, with α = 0.05 and 95% power, and adjustments for multiple comparisons were made using Bonferroni correction. Based on these parameters, 42 participants were required to detect a meaningful difference, and the final sample of 48 participants ensured adequate power for both primary outcomes and the secondary outcomes [31]. Since the sample size met the calculated value, 48 participants were randomized according to their survey form number (via a randomizer program) and subsequently assigned to three groups of 16 participants each (the DMT group, the walking group, and the control group), randomized by a researcher who was not involved in the study (Fig. 1).

Fig. 1.

CONSORT (2025) flow diagram

Allocation concealment was achieved using sequentially numbered, opaque, sealed envelopes. A single-blind approach was applied for the statistician, who performed data analyses blinded to group assignments. Participant and assessor blinding was not feasible because the researchers delivering the DMT and walking sessions were actively involved in the interventions. To prevent intervention contamination, the DMT and walking sessions were conducted at different times and in separate locations. The control group received usual care only, without additional health education or social contact, allowing the interventions to be compared with standard practice. Interventional contamination was monitored by scheduling sessions separately. A detailed questionnaire was administered to all participants at the beginning and end of the study. This study adheres CONSORT guidelines. The CONSORT (2025) flow diagram is presented in Fig. 1.

Interventions

After randomization, the DMT (60 min, 2 sessions per week for 6 weeks) and walking groups (60 min, 2 sessions per week for 6 weeks) participated in a 12-session intervention, whereas the control group received no intervention. Reminder messages sent to the participants from an application of social networking services, including the researchers, to participate in the intervention on time and in full. Researcher taught the DMT techniques to participants in a school gym twice a week for one hour per day for six weeks. The DMT intervention was led by a researcher trained in DMT techniques as a psychotherapeutic intervention and holding a PhD in psychiatric nursing. The facilitator developed the session content-including goals, core skills, group choreography, music/rhythm, intensity/load, social interaction, and feedback methods-based on established DMT frameworks and relevant literature [23, 24, 29–32] (Table 1). The facilitator completed three days of formal DMT training. Weekly supervision sessions were conducted to ensure adherence to the protocol, and fidelity checks, including observation and review of session recordings, were performed regularly to ensure consistent delivery of the program. Each session followed a three-phase structure: warm-up, sustaining, and closure. Warm-up activities included forming a circle, breathing, and muscle relaxation. The sustaining phase implemented weekly goals and techniques such as body awareness, directional movements, centering, grounding, opposites, Laban and Gestalt techniques, and walking with rhythm, adapted to group needs and interactions [23, 32]. Closure involved forming a circle to share experiences and provide feedback.

Table 1.

Content breakdown of the 12-session DMT program

Session	Goals	Core Skills	Group Choreography	Music/ Rhythm	Intensity/ Load	Social Interaction Elements	Feedback Methods
1.week	Meeting and group rules	Warm-up exercises, initiating communication	Circle	Calm instrumental music	Low	Meeting, eye contact, building a connection	Verbal sharing
2.week	Spatial awareness	Independent movement	Free space usage	Calm instrumental music	Low	Shared space, sense of belonging	Verbal sharing
3.week	Trust and harmony	Confidence dance, rhythmic walking	Pair and group work	Lively music	Moderate	Group interaction	Verbal sharing
4.week	Movement in daily life	Purposeful movement	Mutual matching	Calm and lively music with varying tempos	Low- Moderate	Dual interaction	Emotional sharing
5.week	Body awareness	Recognizing the three levels of the body (trunk, lower and upper)	Circle	Calm instrumental music	Low	Group harmony	Verbal sharing
6.week	Body awareness	Using the up-down, front-back, inside-outside directions of the body	Free space usage	Rhythmic music	Low-Moderate	Group harmony	Verbal sharing
7.week	Balance and movement	Centering, grounding	Circle	Calm instrumental music	Low	Group harmony	Physical feedback
8.week	Contrasts and harmony	Laban movements	Pair and group work	Calm and lively music with varying tempos	Low-Moderate	Group interaction	Emotional sharing
9.week	Communication and empathy	Gestalt movements	Mutual matching	Lively music	Low- Moderate	Dual interaction	Emotional sharing
10.week	Expression of emotions	Using body language	Circle	Calm instrumental music	Low	Group harmony	Emotional sharing
11.week	Group work	Creating group choreography with emotion, movement and rhythm	Free space usage	Cultural music	Moderate	Group interaction	Physical and emotional sharing
12.week	Closure and evaluation	Self-assessment	Circle	None	Low	Strengthening group bonds	General evaluation

Sessions progressed thematically as shown in Table 1: Early weeks emphasized meeting and group rules, spatial awareness, and trust; middle weeks focused on body awareness, balance, and contrasts; and later weeks included communication, empathy, emotional expression, and group choreography, concluding with self-assessment and strengthening group bonds. Music and rhythm varied from calm instrumental to lively or cultural music, intensity/load ranged from low to moderate, and social interaction and feedback methods included verbal, emotional, and physical sharing, depending on the session. All 16 participants completed all 12 sessions, and Table 1 presents the content breakdown of the 12-session DMT program to ensure reproducibility and fidelity.

Participants in the walking group participated in 60-minute sessions twice a week for 6 weeks in an open area in the province where the study was conducted. Sessions were held on the same day each week, with the group walking together to promote social interaction, facilitating comparison with the social exposure of DMT sessions. Before starting the study, participants were instructed on safety considerations, including avoiding excessive sweating, maintaining normal breathing, and monitoring for any discomfort or palpitations [33, 34]. Exercise intensity was monitored using facilitator observation, participant feedback, step cadence, and movement pace, ensuring that participants could maintain comfortable conversation without breathlessness. DMT sessions were delivered at low-moderate to moderate intensity, while walking sessions were maintained at moderate intensity. Safety and participant comfort were systematically monitored using a standardized adverse event checklist, which included dizziness, palpitations, musculoskeletal pain, or falls. No adverse events were reported, indicating that both interventions were delivered safely and at appropriate intensities. Reminder messages were sent via a social networking application to support adherence, and all participants in the walking group (n = 16) completed the 12-session interventions. Walking intensity was tracked using observation, participant feedback, and step cadence, and safety and participant comfort were systematically monitored using a standardized checklist. A zero-dropout rate was achieved across all three groups through a combination of strategies designed to maintain participant engagement and adherence. The research team maintained regular communication with participants and adapted interventions to individual physical abilities. Ongoing motivation and support were provided to encourage adherence. Furthermore, the walking and DMT sessions were directly administered by the researchers, and the combination of flexible scheduling with structured, socially engaging group sessions fostered high adherence, resulting in complete follow-up throughout the study. Exercise intensity during both DMT and walking interventions was maintained at a level suitable for older people, based on facilitator observation and participant feedback. Sessions were conducted in safe, accessible environments, including a school gym and an outdoor area. Indoor spaces were cleared of obstacles, well-lit, and ventilated, while outdoor areas were selected to minimize uneven terrain and environmental hazards. Two trained facilitators were present throughout each session to monitor participants for signs of fatigue, imbalance, or discomfort. Safety was systematically tracked using a standardized adverse event checklist, including indicators such as falls, dizziness, musculoskeletal strain, and general participant discomfort. No adverse events were reported, indicating that the interventions were delivered safely and at an appropriate intensity.

Data collection tools and methods

Two primary outcomes were assessed over a 6-month follow-up, in accordance with the registered clinical trial protocol (ClinicalTrials.gov identifier: NCT05655455): loneliness, measured by the LSE total score (0–22), with higher scores indicating greater loneliness, and self-neglect, measured by the ESNS total score (60–300), with higher scores indicating greater risk. Secondary outcomes included the LSE two-way scores, reflecting the two core subdimensions of loneliness, and the ESNS subdomain scores, representing the four predefined domains of self-neglect (social network, physical health, environmental health, and mental health). All outcomes were measured at baseline and at 6 months, and their selection, measurement schedule, and statistical analyses were fully aligned with the pre-specified endpoints and analysis protocol of the registered clinical trial. Data collection was conducted between September 2022 and June 2023. Participants were interviewed face-to-face and informed about the data collection procedures. An information meeting was held to explain how to complete the data forms, which were administered to participants at the family health centres where they were registered. All participants completed the data collection tools themselves at both pre-test and post-test.

Data collection tools

Participant Information Form: This form was prepared by the researchers utilizing the literature. It included 10 questions about the age, gender, marital status, place of residence, type of house, educational level, employment status, occupation, social security, and economic status of the participants [30, 35, 36].

Loneliness Scale for the Elderly (LSE): The LSE developed by De Jong Gierveld and Kamphuis and revised in 1999 [37, 38], is designed to measure social and emotional loneliness in older people. The Turkish validity and reliability study was conducted by Akgül and Yeşilyaprak in 2015 [3]. The LSE consists of 11 items rated on a 3-point Likert scale. Five items are forward-scored, and six items are reverse-scored. The social loneliness subscale (items 1, 4, 7, 8, and 11) includes positive statements scored as ‘0 = yes,’ ‘1 = maybe,’ and ‘2 = no.’ The emotional loneliness subscale (items 2, 3, 5, 6, 9, and 10) includes negative statements and is reverse-scored using the same scale. Subscale scores are summed to calculate the total loneliness score, which ranges from 0 (lowest loneliness) to 22 (highest loneliness). Higher scores indicate higher levels of loneliness. The Cronbach’s alpha values were 0.79 for emotional loneliness, 0.80 for social loneliness, and 0.82 for the total score, indicating good internal consistency. As no standardized cut-off scores exist for the LSE, formal clinical interpretation of scores is limited; only relative levels of loneliness can be discussed.

Elder Self-Neglect Scale (ESNS): The ESNS was developed by Iris et al. for professionals who work with older people [39]. Özmete et al. conducted the Turkish validity and reliability study of the ESNS [36]. The original scale is used for older people aged 65 and over and includes 73 items and 6 factors [39]. The Turkish version of the scale includes 60 items and four main factors: social network, physical health, environmental health, and mental health. The scale which uses a 5-point Likert-type rating system is scored as “very much” 1 point and“none” 5 points. The highest and lowest scores possible from the ESNS are 300 and 60, respectively. Higher scores indicate a higher risk of self-neglect in older people [36]. The cut-off score of the scale has not been determined. The cut-off score of the scale has not been determined. A higher score indicates a higher risk of self-neglect in the older people [36]. In the Turkish validity and reliability study, Cronbach’s Alpha value was 0.96. The Cronbach’s alpha internal consistency coefficient for the whole scale was 0.964 [36]. In this study, Cronbach’s Alpha was found to be 0.964.

Statistical analysis

The study data were analyzed using the SPSS software package, version 21.0 (IBM Corp., Armonk, NY) and R version 2.15.3 (R Core Team, 2013). Mean, standard deviation, frequency, and percentage were used to report the data. The conformity of quantitative data to normal distribution was assessed using the Shapiro-Wilk test and graphical analysis. To compare baseline characteristics (demographic variables and pre-test scale scores) across the three groups, one-way ANOVA was applied for continuous variables and chi-square tests for categorical variables. To compare scale scores across the three groups while controlling for baseline values, Analysis of covariance (ANCOVA) was conducted with pre-test scores included as covariates, followed by post hoc pairwise comparisons among the three groups, with Bonferroni correction applied to adjust for multiple comparisons. This approach controlled for Type I error while evaluating differences in loneliness and self-neglect outcomes between groups. All randomized participants completed the study; therefore, analyses were conducted on a complete-case basis, equivalent to an intention-to-treat (ITT) analysis. No per-protocol sensitivity analysis was performed. A p-value of < 0.05 was accepted as the statistical significance level. All data recorded in the database were analyzed by a statistician independent of the researchers to minimize analysis bias.

Results

Demographic characteristics

Forty-eight older people were enrolled in this study. The study found no statistically significant difference initially between the groups in terms of socio-demographic characteristics (p > 0.05) (Table 2).

Table 2.

Distribution of demographic characteristics and scale scores of the participants

	Control group	Walking group	DMT group	p
Age
65–69	9 (56.3)	12 (75)	13 (81.3)	a0.597
70–74	3 (18.8)	2 (12.5)	2 (12.5)
75–79	2 (12.5)	0 (0)	1 (6.3)
80 and over	2 (12.5)	2 (12.5)	0 (0)
Gender
Female	14 (87.5)	13 (81.2)	14 (87.5)	a0.339
Male	2 (12.5)	3 (18.8)	2 (12.5)
Marital status
Married	16 (100)	16 (100)	16 (100)	-
Single	0 (0)	0 (0)	0 (0)
Place of residence
City	15 (93.8)	13 (81.3)	13 (81.3)	a0.814
District	0 (0)	1 (6.3)	1 (6.3)
Village	1 (6.3)	2 (12.5)	2 (12.5)
House type
Flat	14 (87.5)	13 (81.3)	12 (75)	a0.894
Separate house	2 (12.5)	3 (18.8)	4 (25)
Educational level
Illiterate	0 (0)	1 (6.3)	2 (12.5)	a0.585
Literate	1 (6.3)	4 (25)	4 (25)
Primary school	7 (43.8)	3 (18.8)	4 (25)
Middle school	2 (12.5)	1 (6.3)	0 (0)
Secondary school	3 (18.8)	4 (25)	2 (12.5)
University	3 (18.8)	3 (18.8)	4 (25)
Employment status	0 (0)	2 (12.5)	1 (6.3)	a0.762
Occupation
Housewife	4 (25)	5 (31.3)	6 (37.5)	a0.906
Worker	0 (0)	1 (6.3)	1 (6.3)
Officer	1 (6.3)	1 (6.3)	0 (0)
Retired	11 (68.8)	9 (56.3)	9 (56.3)
Social security	14 (87.5)	15 (93.8)	15 (93.8)	a0.999
Economic status
Income < expenses	2 (12.5)	1 (6.3)	1 (6.3)	a0.380
Income = expenses	11 (68.8)	14 (87.5)	15 (93.8)
Income > expenses	3 (18.8)	1 (6.3)	0 (0)
LSE emotional loneliness	3.87 ± 1.96	3.56 ± 1.36	4.12 ± 1.82	c0.658
LSE social loneliness	2.50 ± 1.50	2.75 ± 1.18	2.56 ± 0.73	c0.825
LSE total	6.38 ± 2.96	6.31 ± 2.33	6.69 ± 1.89	c0.897
ESNS social network	11.75 ± 4.23	10.94 ± 3.89	12.56 ± 2.50	c0.453
ESNS physical health	27.81 ± 9.35	30.69 ± 6.51	29.69 ± 6.54	c0.557
ESNS environmental health	49.31 ± 7.42	48.19 ± 7.55	50.75 ± 6.64	c0.605
ESNS mental health	25.38 ± 5.55	25.56 ± 8.25	26.44 ± 4.65	c0.880
ESNS total	114.25 ± 21.88	115.38 ± 18.30	119.44 ± 11.68	c0.689

Three-group paired comparison, Bonferroni corrected

^aFisher-Freeman-Halton exact test^bPearson’s chi-square test^cOne-way ANOVA

*p < 0.05

Sixteen participants were randomly assigned to each group. No participants withdrew from the study, and all analyses were performed on all 48 older people. None of the participants reported any adverse effects. The periods of recruitment and follow-up were completed between in September 2022 and June 2023. The CONSORT (2025) flow diagram is shown in Fig. 1.

There was also no statistically significant difference between the groups before the intervention in terms of the LSE total score, emotional loneliness, social loneliness subdimension scores, ESNS total score, social network, physical health, environmental health, and mental health subdimension scores (p > 0.05) (Table 2).

Loneliness

In terms of the post-intervention scores, the study found that for emotional loneliness, the adjusted mean difference (aMD) was − 1.153 points between the walking group and the control group (95% CI: -1.948, -0.359; p = 0.006; ηp² = 0.233; Hedges’s g = -0.942), -2.212 points between the DMT group and the control group (95% CI: -3.114, -1.309; p < 0.001; ηp² = 0.464; Hedges’s g = -0.884), and − 0.926 points between the DMT group and the walking group (95% CI: -1.875, 0.024; p = 0.056; ηp² = 0.121; Hedges’s g = 0.058). For social loneliness, the aMD was − 0.919 points for walking vs. control (95% CI: -1.513, -0.325; p = 0.004; ηp² = 0.257; Hedges’s g = -1.196), -1.402 points for DMT vs. control (95% CI: -2.215, -0.589; p = 0.001; ηp² = 0.300; Hedges’s g = -1.113), and − 0.650 points for DMT vs. walking (95% CI: -1.296, -0.004; p = 0.049; ηp² = 0.128; Hedges’s g = 0.017). For LSE total scores, the aMD was − 2.156 points for walking vs. control (95% CI: -3.528, -0.784; p = 0.001; ηp² = 0.304; Hedges’s g = -0.942), -4.095 points for DMT vs. control (95% CI: -5.468, -2.723; p < 0.001; ηp² = 0.621; Hedges’s g = -0.884), and − 1.939 points for DMT vs. walking (95% CI: -3.312, -0.566; ηp² = 0.402; Hedges’s g = 0.058; p = 0.003) (Table 3). Figure 2 shows the change in the total scores of the LSE and its subdimensions in the groups over time.

Table 3.

Comparison of mean scores of LSE, LSE subdimensions, ESNS, and ESNS subdimensions among groups after interventions

	Walking group/Control group				DMT group/Control group				DMTgroup/Walking group
	aMD [SE] (95% CI)	p	Effect size (ηp2)	Hedges’s g	aMD[SE] (95% CI)	p	Effect size (ηp2)	Hedges’s g	aMD [SE] (95% CI)	p	Effect size (ηp2)	Hedges’s g
Emotional loneliness	-1.153 [0.821] (-1.948, -0.359)	0.006*	0.233	-0.942	-2.212 [0.708] (-3.114, -1.309)	< 0.001*	0.464	-0.884	-0.926 (-1.875, 0.024)	0.056	0.121	0.058
Social loneliness	-0.919 [0.460] (-1.513, -0.325)	0.004*	0.257	-1.196	-1.402 [0.465] (-2.215, -0.589)	0.001*	0.300	-1.113	-0.650 (-1.296, -0.004)	0.049*	0.128	0.017
LSE	-2.156 [1.172] (-3.528, -0.784)	0.001*	0.304	-0.942	-4.095 [1.035] (-5.468, -2.723)	< 0.001*	0.621	-0.884	-1.939 (-3.312, -0.566)	0.003*	0.402	0.058
Social network	-1.673 [1.266] (-2.972, -0.373)	0.008*	0.215	-0.089	-3.202 [1.276] (-4.502, -1.903)	< 0.001*	0.631	-0.125	-1.530 (-2.846, -0.213)	0.018*	0.190	-0.035
Physical health	-3.684 [0.685] (-7.134, -0.233)	0.033*	0.229	-0.596	-7.228 [0.650] (-10.654, -3.802)	< 0.001*	0.473	-0.631	-3.545 (-6.958, -0.132)	0.039*	0.406	-0.035
Environmental health	-7.213 [0.350] (-13.006, -1.419)	0.010*	0.351	-0.596	-13.700 [0.347] (-19.502, -7.899)	< 0.001*	0.533	-0.631	-6.488 (-12.333, -0.642)	0.025*	0.156	-0.034
Mental health	-2.833 [0.132] (-5.611, -0.054)	0.044*	0.279	-0.254	-6.884 [0.132] (-9.570, -4.098)	< 0.001*	0.607	0.260	-4.052 (-6.835, -1.268)	0.002*	0.243	0.003
ESNS	-16.447 [1.560] (24.905, -7.990)	< 0.001*	0.598	-0.466	-31.869 [1.526] (-40.387, -23.350)	< 0.001*	0.730	-0.460	-15.421 [1.522] (-23.915, -6.927)	< 0.001*	0.350	0.006

aMD: Adjusted Mean DifferenceANCOVA: pre-test values were included in the analysis as covariatesThree-group paired comparison, Bonferroni corrected

*p < 0.05

Fig. 2.

Changes in group LSE subdimensions and total scores over time

Self-neglect

Post-intervention ESNS scores showed that the walking group had lower scores compared to the control group: social network (-1.673, 95% CI: -2.972, -0.373; p = 0.008), physical health (-3.684, 95% CI: -7.134, -0.233; p = 0.033), environmental health (-7.213, 95% CI: -13.006, -1.419; p = 0.010), mental health (-2.833, 95% CI: -5.611, -0.054; p = 0.044), and ESNS total (-16.447, 95% CI: -24.905, -7.990; p < 0.001). The DMT group showed even larger reductions compared to control: social network (-3.202, 95% CI: -4.502, -1.903; p < 0.001), physical health (-7.228, 95% CI: -10.654, -3.802; p < 0.001), environmental health (-13.700, 95% CI: -19.502, -7.899; p < 0.001), mental health (-6.884, 95% CI: -9.570, -4.098; p < 0.001), and ESNS total (-31.869, 95% CI: -40.387, -23.350; p < 0.001). Comparisons between DMT and walking groups also favored DMT for all subscales: social network (-1.530, 95% CI: -2.846, -0.213; p = 0.018), physical health (-3.545, 95% CI: -6.958, -0.132; p = 0.039), environmental health (-6.488, 95% CI: -12.333, -0.642; p = 0.025), mental health (-4.052, 95% CI: -6.835, -1.268; p = 0.002), and ESNS total (-15.421, 95% CI: -23.915, -6.927; p < 0.001) (Table 3). Figure 3 shows the change in ESNS and subdimension total scores in the groups over time. Figure 4 shows the ESNS, LSE, and subdimension scores by group.

Fig. 4.

ESNS, LSE, and subdimension scores by group

Fig. 3.

Changes in group ESNS subdimensions and total scores over time

When the pre- and post-intervention mean scores of the walking and DMT groups were compared, decreases were observed across most variables in both groups. Emotional loneliness scores decreased by 37.76% in the DMT group and by 16.44% in the walking group. Social loneliness scores decreased by 1.11% in the DMT group and by 3.23% in the walking group. Total LSE scores decreased by 26.13% in the DMT group and by 11.30% in the walking group. Social network scores increased by 6.40% in the walking group but decreased by 3.47% in the DMT group. Physical health scores decreased by 33.87% in the DMT group and by 50.86% in the walking group. Environmental health scores decreased by 51.19% in the DMT group and by 53.25% in the walking group. Mental health scores decreased by 39.48% in the DMT group and by 40.01% in the walking group. Finally, total ESNS scores decreased by 40.37% in the DMT group and by 45.41% in the walking group (Table 4).

Table 4.

Comparison of mean scores and percentage changes from before to after by group

	Control group			Walking group			DMT group
	Before mean	After mean	Diffrence %	Before mean	After mean	Diffrence %	Before mean	After mean	Diffrence %
Emotional loneliness	12.313	9.063	-3.250 - % 26.40	9.125	7.625	-1.5 - % 16.44	12.250	7.625	-4.625 - % 37.76
Social loneliness	7.938	6.563	-1.375 - % 17.32	5.813	5.625	-0.188 - % 3.23	5.688	5.625	-0.063 - % 1.11
LSE	20.250	15.625	-4.625 - % 22.84	14.938	13.250	-1.688 - % 11.30	17.938	13.250	-4.688 - % 26.13
Social network	9.750	10.750	1.0 % 10.26	9.813	10.438	0.625 % 6.4	10.813	10.438	-0.375 -% 3.47
Physical health	26.250	19.0	-7.250 - % 27.62	36.500	17.938	-18.563 - % 50.86	27.125	17.938	-9.187 - % 33.87
Environmental health	50.188	27.688	-22.500 - % 44.83	57.750	27.0	-30.750 - % 53.25	55.313	27.0	-28.313 - % 51.19
Mental health	20.688	15.875	-4.813 - % 23.27	26.688	16.0	-10.688 - %40.01	26.438	16.0	-10.438 - % 39.48
ESNS	106.875	73.312	-33.563 - % 31.40	130.750	71.375	-59.375 - %45.41	119.688	71.375	-48.313 - % 40.37

Discussion

The aim of this randomised controlled trial was to evaluate the effect of DMT and walking interventions on the loneliness and self-neglect levels of older people. Although loneliness and self-neglect are widely recognised as important determinants of physical, psychological, and social well-being in later life, intervention-based studies addressing both outcomes simultaneously remain limited. In the existing literature, loneliness and self-neglect have often been examined separately, and most intervention studies have focused on a single type of physical activity, which has restricted understanding of the comparative effectiveness of different movement-based interventions. This study addresses this gap by employing a randomised controlled design, including a DMT group, a walking group, and a control group, enabling both between-group comparisons and the evaluation of intervention-specific effects. To the best of our knowledge, no randomised controlled study conducted in Türkiye has simultaneously evaluated loneliness and self-neglect while comparing two different movement-based interventions with a control condition. By directly comparing an expressive movement-based intervention (DMT) with a conventional physical activity (walking), this study clarifies whether different intervention modalities provide distinct or complementary benefits, thereby strengthening the evidence base for targeted intervention strategies aimed at reducing loneliness and self-neglect among older people.

The study results indicate that both DMT and walking interventions were effective in reducing emotional and social loneliness, as well as improving self-neglect–related outcomes in older people. Both interventions also positively affected social networks, physical, environmental, and mental health, although the improvements were generally larger in the DMT group compared to the walking group. Overall, DMT produced greater improvements than walking in most psychosocial and health-related subdimensions, highlighting its potential to enhance well-being in older people. DMT represents a structured, expressive movement-based approach combining physical activity with emotional expression, body awareness, and social interaction, whereas walking is a conventional, non-expressive form of physical activity focused primarily on movement and accessibility. The effectiveness of both interventions suggests that movement-based programs can positively influence psychosocial and health outcomes through complementary pathways. Implementation under expert supervision further strengthened participant engagement and ensured that the needs of this sensitive population were appropriately addressed. Overall, this study contributes to the literature by demonstrating that both expressive and non-expressive movement-based interventions can be feasible and effective strategies for addressing these psychosocial challenges in older people. By addressing two interrelated psychosocial problems within a single intervention framework, the study responds to an unmet public health need in Türkiye. It also offers practical evidence that may inform geriatric care practices, community-based programs, and preventive mental health services. In this respect, the study provides a clear contribution to both national and international literature by positioning movement-based interventions as viable approaches to psychosocial challenges that are often examined in isolation.

Considering the positive effects of physical activity on self-confidence and emotional well-being, planned dance and walking activities are expected to have beneficial effects on older people. Regular physical activity, which is especially common in Asian societies and maintained despite advancing age, has been shown to reduce declines in physical and cognitive performance [29, 40]. In this study, DMT and walking interventions were implemented to examine their effects on loneliness and self-neglect in older people. As all interventions were conducted under the guidance of experts, the participation motivation and social expectations of this sensitive and vulnerable population were addressed in a professional manner.

In this study, pre-intervention loneliness and self-neglect levels were similar across groups. After the interventions, both DMT and walking groups showed significant improvements in LSE and ESNS compared to the control group, with DMT showing greater improvements than walking in most subdimensions. These findings are consistent with Esmail et al., who conducted a three-armed randomized controlled trial to investigate the effect of 12 weeks (3x/wk, 1 h/session) of dance movement and aerobic exercise training on cognitive functioning, physical fitness, and health-related quality of life in healthy older people. They found that the cognitive and physical functioning levels of participants in both experimental groups were positively affected after the training [41]. These results highlight the importance of addressing loneliness and self-neglect, as these factors affect physical and mental health and increase their prevalence and severity [33, 42]. In this study, the walking group showed reductions of 11.30% in LSE and 45.41% in ESNS relative to baseline values, whereas the DMT group showed reductions of 26.13% in LSE and 40.37% in ESNS. Some modest changes were also observed in the control group, likely reflecting natural fluctuations over time, maturation-related factors, repeated testing, or observation (Hawthorne) and placebo effects. Specifically, decreases in the control group were observed due to the observation effect, placebo effect, time and maturation, and testing effect. Nevertheless, the magnitude of these changes was small compared to the intervention groups, highlighting that the improvements in the DMT and walking groups are attributable to the interventions themselves. These findings also highlight the importance of including a control group in psychosocial intervention studies to account for such non-specific effects. However, studies in the literature that compare interventions such as DMT, walking, or physical exercise in older people are limited, highlighting the need for more research to investigate the effectiveness of these interventions.

Loneliness

One of the most important causes of regression in old age is loneliness. Socialization and an active life are the most important remedies against the destructive effects of time [43, 44]. This study found that the DMT intervention played a more significant role in the social loneliness, general loneliness and self-neglect levels compared to the control and walking groups. The results of this study are similar to studies emphasizing that DMT provides more robust results than physical exercise. A three-armed randomized controlled trial conducted by Ho et al. examined the psychophysiological effects of DMT and physical exercise interventions in older people with mild dementia and reported that the DMT group experienced significant reductions in depression, loneliness, and negative mood but increased daily functioning, and daily cortisol slope [29]. The same study’s results support the view that in older people with declining cognitive abilities, DMT is beneficial as a multifaceted intervention to improve various aspects of functioning. Pitluk Barash et al. examined the feasibility and efficacy of an intervention combining physical therapy exercise and DMT on the risk of falls in older women in a randomized pilot study [45]. They found more effective results for balance and muscle strength in the group in which both DMT and physical therapy exercises were implemented together compared to the control group in which only physical therapy was implemented. The relevant literature emphasizes that DMT protects physical health, reduces physical limitations, improves the emotional state and behavioral domains, increases social relations and participation, and improves psychological resilience and quality of life in older people [46, 47].

The results of the present study showed that the walking intervention was effective in reducing the loneliness level of older people aged 65 and over compared to the control group. Similarly, Mizuta et al. in a cross-sectional study examining the context of walking and loneliness in older people, found that walking with a companion could effectively prevent or reduce loneliness in older people and that there was no significant difference between walking alone and not walking at all [48]. Previous studies suggest that walking with someone or a community positively affects physical activity, motivation, self-efficacy, and social interaction, decreasing loneliness [49–52]. It is also reported that older people who engage in physical activity more days per week experience less loneliness [53]. Many studies have shown that walking benefits general mental [54, 55], physical, and social health in healthy older people at the onset of aging [56], and reduces the perception of fatigue [57], and regular walking is one of the appropriate and important activities to slow aging [57–60]. A review study conducted by Cohen-Mansfield and Perach found that interventions that focus on maintaining social networks and health promotion played a role in reducing loneliness in older people [61].

Self-neglect

The literature includes studies that examine the root causes, prevalence, and factors affecting self-neglect in older people [62–64]. However, no study examining the effect of DMT or walking intervention on self-neglect levels of older people was found. In this study, DMT and walking interventions effectively reduced the self-neglect levels of older people. Older people who self-neglect participate less in social activities and social support [65, 66]. Their decreased physical functioning is associated with an increased risk of self-neglect [67] and the more severe the depression of older people living alone, the higher the level of self-neglect [64]. It is thought that regular and group participation in the interventions evaluated in this study played an important role in reducing self-neglect levels by providing benefits such as motivating older people aged 65 and over by allowing them to socialize, increasing their independence or reintegrating into society, thereby reducing their feelings of depression and loneliness. As reported in the literature, both interventions can protect and improve physical, cognitive, and mental health in older people [36, 43, 68].

Mechanistic insights and comparison of DMT and walking

To clarify the mechanisms underlying the observed effects of DMT and social walking, the interventions were examined in terms of their psychosocial and physiological pathways. DMT appears to exert superior effects on loneliness and self-neglect among older people through its multimodal therapeutic mechanisms, including affective regulation, enhancement of body-image awareness, synchronized movement and mirror interactions, and interpersonal attunement [69]. These embodied mechanisms-rooted in rhythmic expression, full-body synchrony, and interpersonal attunement-facilitate emotional regulation, social connection, and improved self-care. When comparing these mechanisms with the literature on social walking in fitness, a parallel but less intensive pathway becomes evident. Social walking programs reduce loneliness primarily through social presence, shared activity, and peer interaction, engaging affective and bodily processes more implicitly. Evidence shows that walking with others is associated with lower loneliness [48, 53], and that structured group-walking interventions can enhance physical activity adherence and social engagement [70]. Although DMT engages deeper levels of embodied synchrony and emotional attunement, both approaches rely on relational movement experiences-co-presence, rhythm, mutual support, and group belonging-as mechanisms for improving psychosocial well-being. Thus, DMT represents an intensive therapeutic modality, whereas social walking offers a scalable, low-cost fitness-based alternative suitable for implementation in community health and day-care settings, together forming complementary movement-based strategies for reducing loneliness and enhancing quality of life in older people. Future research and interventions could leverage these overlapping mechanisms to design hybrid or complementary programs that maximize both psychosocial and physical benefits for older people.

Clinical and community implementation

The results of this study indicate that both DMT and walking interventions for older people can be feasibly adapted for use in community health centers and day-care facilities, and that the group-based format of these interventions can enhance motivation, foster social interaction, and provide psychosocial support, encouraging older people to participate consistently and engage actively in physical activity. While walking interventions can be implemented by community health personnel following brief training, DMT should be delivered by a practitioner who has received training in DMT techniques as a psychotherapeutic intervention and holds a PhD in psychiatric nursing. For implementation in community or day-care settings, community health personnel-such as nurses, physiotherapists, or activity coordinators-could deliver structured movement or walking programs following brief, targeted training on group facilitation, participant safety, basic movement activities, documentation, and psychosocial support. Staff would require approximately 2–3 h per week per session, including preparation, session delivery, documentation, and follow-up. Implementation procedures include assessing participants’ physical and mental status, conducting structured group sessions, monitoring attendance and adherence, and referring to healthcare professionals as needed. With low equipment needs, modest staffing, and minimal costs, these interventions are scalable and sustainable, allowing pilot programs to expand to multiple centers using standardized protocols and existing infrastructure. Overall, movement-based group interventions provide a practical, low-cost, scalable, and sustainable approach to promoting physical activity, reducing loneliness, and mitigating self-neglect among older people, while optimizing existing personnel and resources in community and day-care settings.

Conclusion

Based on the study results, DMT and walking interventions effectively reduce the loneliness and self-neglect levels of older people aged 65 and over, with DMT being more effective than walking in reducing these outcomes. When implemented as low-cost, feasible strategies within older people’s health promotion programs, DMT and walking interventions can protect both physical and psychosocial health, support active aging, and should be included in structured rehabilitation programs to provide early psychosocial support. Importantly, these programs can be practically applied beyond research settings. Such programs can be delivered by trained community health staff (e.g., nurses, physiotherapists, or activity coordinators) using existing facilities, without the need for specialized equipment. For example, weekly group sessions of DMT or structured walking programs can be incorporated into community centers, senior activity programs, and other relevant service sites to provide early psychosocial support, encourage social interaction, and foster self-care behaviors among older people. Incorporating DMT and walking interventions into structured rehabilitation or community-based programs offers accessible, scalable, and sustainable solutions to reduce loneliness and self-neglect. Further studies with larger samples are recommended to explore the broader physical, mental, and cognitive impacts of these interventions in older populations.

Limitations

The main limitation is that the interventions in the study required physical endurance and the techniques applied were reduced to a level that older people can physically do, as older people had difficulty completing all application techniques. Furthermore, the study was conducted with a limited number of older people in a specific area of the population, and its representativeness is limited. Because DMT intervention is not a common practice, the data obtained cannot be generalized. Although interventions were scheduled separately to minimize interventional contamination between groups, a small risk of contamination cannot be completely excluded. Due to the nature of the interventions, participant and assessor blinding was not feasible, potentially introducing performance or assessment bias. Nonetheless, single-blinding was maintained for the statistician who conducted the data analysis. Therefore, future studies with larger scales and higher participation rates are needed. Despite all these limitations, the fact that the study was conducted with an expert team on a vulnerable group such as older people and that each phase was completed added strength to the study. Conducting each intervention with researcher participation and observation, and integrating the feedback received are crucial for future studies.

Authors’ contributions

G.Y.D.G: Conceptualization, Methodology, Investigation, Software, Formal analysis, Writing-original draft preparation, Writing- Reviewing and Editing. G.U: Methodology, Investigation, Software, Writing- Original draft preparation, Writing- Reviewing. All authors read and approved the final manuscript.

Funding

This work was supported by the Research Fund of Amasya University (Project No.FMB-BAP 22–0535).

Data availability

The data is available from the corresponding author on a reasonable basis.

Declarations

Ethics approval and consent to participate

The study was approved by the Amasya University Ethics Committee. (date: 09.08.2022 and approval no: E- 30640013-050.01.04-83767). Then, the administrative permission was obtained from the Provincial Health Directorate of the province and the administration board of the hospital where the study was carried out. The study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki. Written and verbal informed consent form was obtained from all of the participants, outlining the study’s purpose and benefits, their role in the study, the confidentiality of their information, and the voluntary nature of their participation. Permission to use the scales was obtained from the experts who developed them.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.