Montessori principles work for Alzheimer's: what did Maria Montessori discover in her work with children that could be useful in the care of residents with Alzheimer's or other dementias? - Feature Article

Nursing Homes, June, 2003

Based on an interview with bill keane and kathleen ustick

In the early 1900s, Maria Montessori was the only female physician in Italy. Highly discriminated against, she was affiliated with a hospital that gave her a group of children they said were uneducable. Although her assignment was to merely maintain their health, Montessori discovered that by having their activities segmented and working in small groups, the children could build skills, gain self-esteem, and learn to focus on a task. The techniques Montessori pioneered are still used today to educate children around the world. Recognizing the potential of this methodology to connect with and care for people with Alzheimer's and other dementias, Cameron J. Camp, MA, PhD, of the Myers Research Institute in Beachwood, Ohio, pioneered a program that adapts Montessori principles for persons with dementia.

Mather Life Ways' Mather Institute on Aging's experience and continuing research support the belief that even after diagnosis, people with Alzheimer's or other dementias retain a personality, verbal skills, and even mobility and dexterity that can be supported in a creative way. Intrigued by Dr. Camp's research, Bill Keane, director of dementia services for Mather LifeWays' Mather Institute on Aging, contacted him for details. As a result of their conversations, Dr. Camp and his team arrived earlier this year at Mather Pavilion at Wagner, a 184-bed nursing home in Evanston, Illinois, for a two-day training session that involved 16 staff members (eight of whom were frontline workers). "This was a wonderful opportunity because CNAs, not just managers, learned the hands-on techniques for working with the residents of our Memory Care Program," says Kathleen Ustick, manager of dementia services at Mather Pavilion at Wagner.

Although Mather Pavilion at Wagner has only used the Montessori approach to Alzheimer's care since February, it has already influenced the culture of the Memory Care Program. Those who were trained by Dr. Camp are now mentoring other staff with positive results. They are dedicated to promoting independence and keeping residents positively engaged throughout the day.

Keane explains that the Memory Care Program operates on the fundamental premise that everything is an activity. Bolstering this approach, each staff member is permanently assigned to a group of residents and has built a relationship--a bond--with them and their families. "Our philosophy is that we want to focus on strengths and retained abilities, not just monitor and measure loss of function, particularly in the middle and late stages of the disease," he explains.

Staff from nursing to housekeeping are using Montessori techniques in their interactions with residents with dementia. "We're not creating 'universal workers,"' says Keane, "but rather we are ensuring that all staff have the tools to work with efficiency and compassion within this population. Nor do we want to mimic a 'homelike' atmosphere. For our residents, this is their home and, for many, their final home.

According to Keane there are five underlying guidelines for relating to people with dementia:

* An activity or experience should support a sense of self-worth.

* Residents should have an opportunity to express their thoughts and feelings.

* Residents must have a sense of accomplishment and success.

* Residents should experience a sense of belonging, being part of a group.

* Residents must have a sense of order, a big issue in dementia care. It is vital that residents feel comfortable and secure within established boundaries.

"We try to plan all our activities using familiar, real-life materials," says Ustick. "Beginning with simple, one-step activities, we use things like rice, chickpeas, or kidney beans in easy scooping activities and, over time, move to other activities that are more complex."

As the residents' skills develop, facilitators will begin to pursue another major Montessori principle, which is to move the activity from a concrete experience to something in the abstract. For example, Keane explains, a small group might be involved in flower arranging (a simple skill activity). In the course of the activity, the facilitator and residents move to a discussion about flowers (a reminiscence activity). The facilitator might say, "Mary, why do you keep choosing lilacs in your arrangement? What do they remind you of?" Then Mary might respond with a beautiful story of how they grew in her backyard and a memory related to the lilacs' heady scent.

For most residents with dementia, says Keane, it is important to communicate by demonstrating rather than by verbalizing. Best results come through providing an atmosphere that is more physical-expression-dominated than speech-dominated. Another important principle is to have actions move in a defined direction--from left to right, top to bottom--and to consistently use that approach with the group to reinforce natural patterns.

Ustick suggests that an activity should be broken down from a larger context to a smaller context, making it easier for the resident to comprehend. She cites the model of a treasure hunt--a simple container is filled with navy beans that a resident must dig through to retrieve hidden items. As self-esteem and confidence grow through success, this simple "hunt and find" activity can be adapted to a small group of three. "We set out a checkerboard," explains Ustick, "hiding the checkers in the bean-filled container. One resident digs through the beans, grabs a checker, and calls out the color. The second resident places it on the checkerboard, and the third lets the others know how many more checkers they need to find." Keane asserts that an activity such as this, broken down into individual steps performed by a small team, helps residents to develop and/or maintain motor skills helpful in other aspects of their lives, such as eating or dressing. "Life is an activity," says Ustick.