Montessori Principles Work for Alzheimer’s

What did Maria Montessori discover in her works with children that could be useful in the care of residents with Alzheimer’s or other dementias?

BASED ON AN INTERVIEW WITH BILL KEANE AND KATHLEEN USTICK

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 should experience a sense of belonging, being part of a group.
• Residents must have a sense of accomplishment and success.
• 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.

Consider, for example, the sequential activity involved in getting dressed. Together, the CNA and resident select the day’s clothing. With verbal cues such as, “First, put on your socks,” a resident, through daily repetition, will be better able to continue doing the task. “This process can be done with any of the ADLs to preserve or improve abilities; for some residents, the repetition can be helpful in relearning an ADL,” says Ustick.

Keane believes that although early in its implementation, the Montessori process can be beneficial for those in the late stages of Alzheimer’s. “A good assessment program lets you know what your resident’s life activities were. If ‘Gladys’ was a seamstress, a creative use of this knowledge might consist of gathering a variety of buttons in different shapes, sizes, and colors and having her arrange them as if she were preparing to do a sewing activity. When the task is completed, it is important to give her praise and acknowledge her achievement. Say, ‘Thank you. You did a wonderful job.’ You can invariably see the pleasure and validation on her face.”

Some Alzheimer’s professionals believe that the part of the brain that controls feelings and relationships is one of the last areas to be affected by the disease. Consequently, there are certain long-term relational memories that can still exist in late stages of the disease. “If you really know the person,” notes Keane, “you might be able to touch those memories and skills in a meaningful, experience-based program.”

One of the most validating developments of the Montessori approach is that residents in the early stages of Alzheimer’s can help those in the later stages of the disease. This gives them the opportunity to reinforce their own skills by using them, and they are pleased that they can help others.

“This program has received enthusiastic endorsement, not only from administration and staff, but also from residents’ families,” claims Keane. At Mather Pavilion at Wagner, families have expressed interest in what they can do to help. In each neighborhood of the Memory Care Program, staff holds regular family council meetings. When presented with the innovative Montessori approach-how it worked and what it hoped to accomplish-families responded. They wanted to know what they could do, what supplies were needed, and if they, too, could be mentored in the process so they could take an active part in their loved ones’ lives.

Nursing homes want to try new things, but often do not have the time or resources to acquire the necessary training. Drawing on its experiences using the Montessori application, Mather LifeWays would like to develop a “train the trainer” module in cooperation with Dr. Camp. “Because the materials used are generally inexpensive and easy to acquire, this is not a cost-prohibitive program,” says Keane. “Our biggest expense was the purchase of a laminator, which isn’t a very big expense at all. The laminator becomes valuable when devising new activities, such as sorting or matching-for example, when the subject of baseball is covered, we might cut out baseball pictures from magazines or newspapers. By laminating them, we now have a set of permanent materials for this subject and activity.”

Since Montessori principles were implemented, residents have filled their days with satisfying experiences and accomplishments at Mather Pavilion at Wagner. Incidents of aggressiveness, wandering, sundowning, and other negative behaviors have been reduced because residents are active, feel secure, and have a reinforced sense of purpose and self-esteem. Maria Montessori’s early childhood educational methods are just as appropriate for those who suffer from Alzheimer’s or other dementias. NH