February 1, 2005 |

Activities for Dementia Care: Unlocking What Remains

As the rapidly falling snow swirls and blows around the courtyard outside the activities room at Menorah Park Center for Senior Living in Beachwood, Ohio, the atmosphere inside is warm and inviting on this cold December day. The weather outside might be frightful, but in here, there’s a party going on!

Rose is sorting small, colorful pom-poms and placing them into the painted compartments of an ice-cube tray that match them. Milton is hard at work with a screwdriver, concentrating on driving screws into four holes that have been drilled in a smooth piece of wood, while Sadie places pegs of graduated sizes into their respective holes in a long wooden block.

Madeline, the most verbally expressive member of this group of residents, is adeptly-and with noticeable pride-sorting a large container of brightly colored, plastic alphabet letters into piles. Besides being pleased by her accomplishment, she also enjoys the fact that she’s doing a mitzvah-an act of helping someone else. She is sorting the letters to be used in an activity other residents will enjoy later.

Another woman is putting together simple two-piece puzzles made from magazine photos that have been cut out and laminated, while the woman sitting beside her is using a plastic ice cream scoop to remove painted golf balls from a bowl and place them into the color-matched wells of a muffin tin. Rhea has several stacks of playing cards in front of her that she’s sorted according to the designs on the backs of the cards.

Someone else is searching through a large plastic tub of unpopped popcorn for coins that have been hidden there. She’s arranging the found coins by size on a paper template with circles drawn on it as visual cues to help with the sorting (figure 1). I learn later that digging through the corn for coins is not only a meaningful activity for her-meaningful because it employs familiar objects-but that it’s also therapeutic, because moving her hands through the cool, hard kernels provides pleasant sensory stimulation.

Presiding over this group of residents, all in advanced stages of Alzheimer’s disease or other forms of dementia, is Samantha Porter, one of Menorah Park’s eight activities coordinators (each residential unit has its own coordinator). She points out that these Montessori-based activities [see the sidebar, “So Simple, It’s Genius,” for a detailed discussion of this approach] are not meaningless exercises aimed at merely keeping residents occupied, but they’re effective tools for improving and maintaining residents’ cognition and fine-motor skills through the use of familiar, everyday objects.

“For example, the activity with the golf balls and the muffin tin allows residents to practice a motion similar to that of feeding oneself,” Porter explains. “And an activity like finding and grasping small objects such as coins can help maintain the fine-motor coordination involved in buttoning buttons while dressing oneself,” she adds.

Porter points out that these activities also give residents a feeling of success. The activities are designed to be failure-free; none of them can be done “wrong.” If a square peg doesn’t fit into a round hole, so be it. It’s enough that residents are engaged in the activities and enjoying themselves. “What’s important is the process, not the outcome,” Porter emphasizes.

Residents are permitted to choose which tasks they’re interested in on any given day, which gives them a feeling of independence and a sense of ownership. But because Porter, who has overseen activities at Menorah Park for three years now, is so familiar with the individual residents’ capabilities, she might gently guide them toward an activity that will give them the greatest feeling of accomplishment-preventing frustration with too difficult a task or boredom with one that is too simple. And she helps residents by giving them more complex projects once they’ve completed simpler ones. True to Montessori principles, they go at their own pace because rushing them would cause frustration and, perhaps, agitation.

An aspect of the Montessori-based approach to working with residents that helps with cognition is the repetition of activities. Porter shows residents once how to complete a task and then, if they need help, reminds them how to do it the next time and the next, until they can tackle it without her assistance. With repetition, the residents learn how to do the activity instinctively, even though they might not consciously remember all the steps in the process.

Some of the activities are useful for evoking memories, such as one in which laminated magazine photos of smiling or frowning people are matched with cards that say, in extra-large letters, “HAPPY” or “NOT HAPPY.” “For example, seeing a photo of a laughing baby during this activity can prompt residents to talk about their children when they were babies,” says Porter.

The photos being used in this activity were selected by Jim (figure 2), a resident from this unit who isn’t with the group today because he’s enjoying time with a visitor. Giving residents opportunities to help other residents is a key Montessori principle, Porter explains. Just as the older children in a Montessori classroom enjoy serving as mentors for younger children, the higher-functioning residents derive great satisfaction from assisting others. In fact, Porter says that when residents are reluctant to participate in activities, they often change their minds when she asks for their help, noting that they respond to this approach much more readily than if she were to simply give them a task and say, “Here, do this.”

Activities for the more cognitively intact residents can be more complex. One of these is called Question-Asking Reading, in which a resident can read to a group from a simple story or fact sheet-Montessori mentoring in action again. At the end of the story or fact sheet are questions about what was just read, designed to stimulate discussion and socialization.

Porter says, “Some people have the misconception that individuals with Alzheimer’s can’t read, but that’s often not the case. It’s the ‘first in, last out’ principle, meaning that the things people learned earliest in life are often those they retain the longest.” I notice this principle in action later, when Milton politely raises his hand to get Porter’s attention after he’s completed his task. It occurs to me that this is how he most likely learned to signal his teacher when he was a young boy in school.

Another of the more advanced activities is a game that combines the memory skills of the game Concentration with boards like those used in a game of bingo. The group leader, either a member of the activities staff or one of the residents, holds up a card that says, for example, “You are my __________.” All those who have the word “sunshine” in a square on their boards say the word and pull a tab to mark that square. This often leads to a spontaneous sing-along.

As Porter finishes explaining the memory game to me, I hear a tiny voice behind me saying, “Samantha, I have some Js and Rs. And, oh! I have lots of Es.” Madeline has continued her diligent sorting and has more stacks of letters ready to be put into bags for others to use in arts and crafts projects later. I compliment her on doing such a great job, and she grins and nods graciously.

Porter gives Madeline a hand with bagging the letters and then moves on to offer encouragement to other residents or, if asked, to help with a task. She moves among them comfortably, and it’s obvious that they’re comfortable with her, too. She knows when to offer help and when to hang back and allow residents to try to complete an activity on their own.

I’ve noticed during my visit to this Alzheimer’s unit at Menorah Park that, as is true of most parties, not all the “party goers” today are of the “dancing and wearing a crazy party hat” variety, but that that’s okay. Although most of the residents are involved in one of the activities, a few choose to simply sit and watch. And although they aren’t actively participating, it shows on their faces that they are engaged in their own way-in being with their peers and enjoying the buzz of activity surrounding them.

As I’m putting on my coat and preparing to leave, I smile at Jenny, a silent, sweet-faced woman whose eyes have connected with mine several times during my visit. She returns my smile with a twinkle in her eye and a little wave of her hand. Her expression seems to convey, “Yes, I’m in here. Thank you for noticing. I wish you well.”

While making my way across town through the slippery, slushy streets to return to my office, reflecting on all that I’ve just observed, I recall something that Dr. Cameron Camp, the director of Menorah Park’s Myers Research Institute [see sidebar], said to me a few days earlier. I had asked him if residents in the later stages of Alzheimer’s disease could still benefit from Montessori-based activities. He replied, “There’s always something we can do. Even if a person is comatose, we can still let her smell her favorite perfume, or we can let him feel the sensation of silk on his skin. We can talk in a soothing voice. If people are alive, we want to work with them. We always ask, “What remains?”

I’ve seen that “what remains” for one person might be the skill and diligence to sort pile after pile of red and blue and green and yellow letters; and “what remains” for another person might be the simple ability to derive pleasure from being with others in a safe, positive, comfortable environment.

I remember once again that the important thing is never to forget that each individual who has dementia-regardless of his or her cognitive ability and/or ability to communicate verbally-is, nonetheless, still a person. The Montessori approach acknowledges each resident’s uniqueness-and capitalizes on it-by allowing tasks to be individualized for those who engage in them.

I’ve seen that this no-pressure, failure-free, self-directed approach creates a peaceful, nurturing environment. Not one person in the group of about 15 people I’ve just observed-each of them in advanced stages of dementia-became agitated during my visit. No one appeared to be frightened or frustrated or anxious. The atmosphere was one of “emotional comfort.” I feel it, too. Being with this group of people has been like a warm, soothing cup of cocoa to my soul, a respite from the wintry storm outside.

Some days I wouldn’t trade jobs with anyone. This has been one of those days.

Menorah Park is a continuing care retirement community located in Beachwood, Ohio. For more information, e-mail Deborah Kulber, Director of Public Relations, at dkulber@menorahpark.org or visit www.menorahpark.org. To send your comments to the author and editors, please e-mail zinn0205@nursinghomesmagazine.com. To order reprints in quantities of 100 or more, call (866) 377-6454.

Before visiting Menorah Park to observe a session of its Montessori-based activities for residents with dementia, Editor Linda Zinn spoke with Cameron Camp, PhD, director of The Myers Research Institute, a division of Menorah Park. The Institute is one of only 11 geriatric research centers in the United States located in a long-term care environment. Dr. Camp and his colleagues pioneered the concept of using the Montessori-based activities for people with Alzheimer’s disease and related dementias.
The Myers Research Institute has trained activities staffs of more than 100 facilities in the United States, as well as staffs at facilities in Canada and Spain, in the use of these activities. A visiting scientist from Taiwan is also using this approach in her country.

The Institute’s manual, Montessori-Based Activities for Persons with Dementia, Volume I (available through Amazon.com), has been translated into Japanese, Spanish, and Mandarin Chinese. More translations are being planned, and Volume II is expected to be released shortly, along with a manual that will instruct family members in how to have better visits with their loved ones with dementia.

What inspired you to adapt the Montessori approach for use in activities for people with dementia?
Dr. Camp: I first saw the Montessori principles in action when I took my son to a Montessori school. The order, the use of materials to guide toward success, and the matching of activities with individuals’ abilities seemed to make a lot of sense for persons with Alzheimer’s and related dementias. Thus began our research in the early 1990s.

We continue to go back to classrooms and reread Maria Montessori’s work to see more ways to translate it into dementia care. For example, in the Montessori classroom, five-year-olds teach lessons to three-year-olds; based on that principle, we train people with early-stage dementia as group activity leaders for people with more advanced disease.

Are there some residents for whom these activities aren’t suitable?
Dr. Camp: We try to work with everyone, across all ranges of dementia, but not every resident is receptive at first. If a person is saying, “I don’t want to do anything,” we have to ask why this is happening. The answer cannot be because this person has dementia. That’s a circular argument: i.e., we know this person has dementia because he exhibits problem behavior, and he exhibits problem behavior because he has dementia.

Often the real reason persons with dementia don’t want to participate in these activities is fear of failure. They don’t want to display less-than-competent behavior, so they use their unwillingness as a defense mechanism-if they say, “Go away,” they won’t fail. We use the Tom Sawyer approach to overcome their reluctance. For example, I might sit beside a resident, start working at a task, and say, “Don’t mind me. I have to get this done. Pay no attention to me.” Then I make a mistake and see if they correct it. The idea is to help this person not to feel threatened or overwhelmed, and to give him or her the chance to just observe-observation is also a form of engagement.

What kind of results have you seen with this approach?
Dr. Camp: We’ve seen better results than those observed with standard activity programming. We’ve been able to get a significant increase in positive affect/emotion and a significant decrease in problem behavior. When people with dementia are engaged in an activity, they can’t be engaged with their social environment by exhibiting problem behavior; they’re focusing their attention on a meaningful activity.

This parallels Maria Montessori’s experience when she started her first school. She was asked to work with some children in a poor neighborhood in Italy who were getting into trouble and destroying property. She determined that she needed to educate them in order to make them productive members of society.

Sometimes people are skeptical as to whether Montessori-based activities will work, or they doubt that residents will want to participate. One activities director we had trained in the Montessori approach told me, “I had the training, but I didn’t necessarily believe the principles would work. I set up the room and the activities and got started. On the morning of the third day, residents were lining up to get in. That’s when I knew something was different about this.”

When Montessori-based activities are introduced to residents in early stages of dementia, do the benefits continue when their condition worsens?
Dr. Camp: Yes, they do. For example, we had a man with very early Alzheimer’s in one of our research projects who still lived in the community. We trained him to run a group activity (Question-Asking Reading) for other residents, and he came to our assisted living facility twice a week. As his disease progressed he became unable to drive, so he switched to taking a cab and continued for another 18 months. Even though his disability had increased, he could still remember enough procedures to run the activity. It was what he looked forward to. He had been a businessman all his life, and he said that this was the most meaningful work he’d ever done. And the other residents with dementia thanked him profusely for making the activity available.

Speaking of group activities, some activities staffs have rather large groups to work with. Do Montessori-based activities work in that setting?
Dr. Camp: You can work with small groups of 5 or 6, or you can work with larger groups. For example, we were training a facility’s activities staff, and we asked them what the typical size of their large group activities was. They had 30 people in their groups, for one-hour sessions. They were doing an activity with a beanbag and a rug with bull’s-eye rings painted on it. One resident would toss the beanbag, see where it landed, and hand it to the next person. During this game, everyone but the person throwing the beanbag just watched. I said to the staff, “Let me guess. Those tossing and those about to toss the beanbag are awake; the others are asleep.” That’s typical of group activities in which the entire group isn’t directly involved.

After the training, they adapted the activity. The staff flipped the rug over and drew a pie chart on it. In big, thick letters an instruction was written on each wedge of the pie: “Stomp your feet.” “Clap your hands.” Shout hallelujah.” Now they chose the beanbag tosser at random, instead of residents taking turns in a set order-no one sleeps when they don’t know who will be chosen next! They chose another resident to read the instruction written on the wedge where the beanbag landed. A staff member repeated the instruction loudly, so that everyone could hear it, and then everyone stomped their feet or clapped their hands, etc. No one was sleeping.

What other types of equipment and supplies can be used for Montessori-based activities?
Dr. Camp: That actually brings up another advantage of this approach. It’s a way of thinking, not a $500,000 program or even a $500 program. We start with the assumption that the money isn’t there to fund activities. I tell people to simply look at their shelves and think of ways to use everyday things differently.

I understand you’re using these activities in the assessment of people with Alzheimer’s and related dementias. How does that work?
Dr. Camp: We received a grant from the National Institute on Aging to develop an assessment tool based on Montessori activities, especially for use with restorative nursing and the MDS system. The existing mental status exams are usually intended for people with moderate to advanced disease, but they’re not a lot of help with developing a plan of care, and the MDS score doesn’t generally tell you what an individual can actually do.

Our assessment answers such questions as “Can this person read?” “What size print is necessary?” “Can this person categorize objects?” Does he think in a concrete or an abstract manner.” “Can he put things in order?” How many steps in sequence can he follow?” “Can he hold things and/or manipulate them?”

This is the sort of information that’s needed to develop restorative nursing programs. For instance, if a person has a range of motion beyond resting his hands in his lap, we can give him an activity based on what he’s interested in. For example, he can categorize operas by their composers or baseball cards by whether the players are in the National or American League. Practicing putting cards in stacks can help people maintain upper-body range of motion as a byproduct of being engaged in something, and we can get them to do it because it involves something they’re interested in.

Are you working on any other developments in dementia care?
Dr. Camp: We’ve been researching something called the “spaced retrieval” technique, which is aimed at helping people remember new information for clinically relevant periods. We have them practice successfully remembering information for the very short term, and then we expand the intervals incrementally. In other words, we ask them to say or do something immediately, then we wait 30 seconds and ask again, then 1 minute, 2 minutes, 4 minutes, etc. We’ve found that when we push their window of retention beyond 12 minutes or so, the information starts going into their long-term memory. They might not consciously remember the practice exercise or where it took place but, when asked, they remember how to respond.

For example, a nurse at a long-term care facility in Kansas had heard about this technique, so she practiced it with a resident who was a “low talker”-he only would mutter quietly. She would ask him, “When I talk, what should you do?” and had him respond, “Speak loudly!” She repeated the exercise at longer intervals, and he would answer correctly each time.

One day this resident was pacing, agitated, and muttering to himself. He looked like he was going to explode, and the more people asked him what was wrong, the more upset he became. The staff was discussing whether to give him a sedative orally or by injection when the nurse who had practiced spaced retrieval with him arrived. She asked him, “When I talk, what should you do?” He yelled, “Speak loudly!” Then she asked, “Do you have a problem?” And he said, “My feet hurt!” He had a bunion that was hurting him. The fix wasn’t a drug-it was to trim his bunion.

Spaced retrieval can also be used to promote safety. For example, you can have a resident practice so that she remembers to pick up her walker before she begins walking, or you can use the technique to help a resident remember to take a sip of beverage after eating a bite of food-whatever behavior you want. It’s an extremely flexible intervention, and you can train both staff and family members to use it.

We’re also using this method in a National Institute of Mental Health study in which we’re working with older HIV-positive adults, to help them remember to take their medications properly. Some of them are taking as many as 16 medications a day, and they often have memory deficits and difficulties with problem solving and many other functions. A 17th pill won’t help, but spaced retrieval will.

To contact Dr. Camp or learn more about the work of Myers Research Institute, visit www.myersresearch.org.

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