Join the Revolution!  How Montessori for Aging and Dementia can Change Long-Term Care Culture by Bourgeois, Brush Elliot & Kelly


“The purpose of this article is to outline the findings of several systematic reviews of this literature, highlighting the areas of improvement needs, and to describe a new person-centered care model, DementiAbility Methods: The Montessori Way. This model focuses on the abilities, needs, interests, and strengths of the person and creating worthwhile and meaningful roles, routines, and activities for the person within a supportive physical environment. This is accomplished through gaining the commitment of the facility’s leaders, training staff, and monitoring program implementation. The potential for a culture change in long-term care environments is dependent on the development and rigorous evaluation of person-centered care approaches.”

Read more at https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0035-1554802

Reminiscence and Dementia

The power of reminiscence is a tool that should not be underestimated in dementia care.

Long-term memory involves the retrieval process and permanent storage of an unlimited amount of information and the ability to retrieve this information again at another time.  One type of storage system is called non-declarative memory. Non-declarative memory begins to develop in early childhood and includes habits and skills that are practiced with much repetition.  This involves unconscious and nonverbal recall of past experiences and is less impaired in many forms of cognitive impairment.  Because this memory system is usually less impaired, non-declarative memory-based tasks have the potential to generate positive effects for people with dementia. Reminiscence is the recall of memories and events from the past. Reminiscence activities can be part of a person-centered approach to caring that improves the wellbeing of people with dementia. By using stimuli such as music and pictures, reminiscence therapy leads to improvements in depression, loneliness, and overall mental well-being. In addition to these benefits, reminiscence therapy can also improve the care partner’s relationship with the person with dementia by connecting on a more personal level.

Here are some great programs and organizations that promote reminiscence as a tool:  

StoryCorps is an innovative organization with a program dedicated to record an individual interview session with a person with dementia. The ultimate goal of this is to preserve and store important and touching memories for both the family and the individual. The StoryCorps is unique in that the interview is stored in the United States Library of Congress for public access. Read more at http://storycorps.org/memory-loss/

The Timeslips program creates an improvisational storytelling workshop for people with dementia that is fueled more by imagination than facts or memories. New stories are formulated and told by participants that help them connect with staff, family, and friends in new ways. Read more at http://www.timeslips.org/

Music and Memory is an organization that strives to connect people with dementia and other mental/physical conditions to reconnect with themselves through the gift of personalized music. By having trained professionals set up distinctive playlists, music therapy is able to tap into deep memories. Read more at https://musicandmemory.org/

The Sporting Memories Network utilizes the power of reminiscence as a tool for people with dementia. By using sport icons, images, and conversations, this organization helps tackle, depression, social isolation, and dementia. Read more at http://www.sportingmemoriesnetwork.com/smn/

The “I CAN! I WILL!” project gathers hundreds of personal and informational stories from both people with dementia and their caregivers. This project has an expansive database of ideas for both support and awareness. Read more at http://www.alz.co.uk/icaniwill

The Memory Method is a program that assembles a group of people with dementia where they discuss memories amongst themselves. Volunteer coordinators sit in on this session and suggest new topics and subjects. The goal is to have the people with dementia talk without interruption and create a memory flow. Read more at http://www.globalaging.org/elderrights/world/2005/helping.htm

How can Task Breakdown help People with Dementia?

Task breakdown is the process of helping a person successfully participate in or complete an activity by making it a step-by-step process. People with dementia often become confused when there are many steps in a sequence. However, when we break an activity into its individual steps, and present each step one at a time, people with cognitive impairment are more likely to achieve success.

The best way to assist a person to complete a task is for you to demonstrate each step one at a time and then ask the person with dementia to follow before moving on to the next step. Task breakdown also helps people with dementia maintain control and dignity by ensuring they participate rather than having a caregiver do an activity for them.

For example, if someone with dementia was given a variety of ingredients at once and asked to “cook dinner,” the person might get started right away, or sit and stare, or leave, or say no.  A person in the later stages of dementia may find this request overwhelming. However, a person in the early stages may welcome the chance to cook a meal. That is why knowing the person is critical. Having an understanding of the person’s skills and abilities is essential in making any modifications they need to succeed. For example, if someone is having a hard time with the task of stirring cookie dough, for the first step, the care partner demonstrates picking up the wooden spoon. The care partner may then say to the person with dementia, “Now you try.”

 Successful Task Guiding Strategies  

1.     Tasks should be broken down into steps that are accessible for the person and the care partner should use a “demonstrate then follow” method. 

2.     Make sure the space you are working in is clutter-free.

3.     Only have the items needed for the task present.

4.     Lay supplies out in order of use from left to right and are to be used one step at a time.

5.     Two sets of supplies may be needed. For example, when setting the table, the care partner should place their items, one at a time, just like the person with dementia will do.

6.     Make sure the area you are working in is well lit, with no shadows.

7.     Contrast helps people see object more clearly.  Try placing all of the items needed for the task on a placemat that is a contrasting color from the work surface.

8.     Demonstrate the steps of a task- one at a time- for the person with dementia and then invite the person to follow after each step. This verbal invitation leads to the person following the guide, but often no words are even needed. Many people with dementia will follow the actions of their care partner when they are working on a task together. Often, following their care partner’s actions is easier than following written or verbal directions.

Focus on what Remains, not what is Missing

Some see their glass as half empty; others see their glass as half full.  So, which is it?  Well, it all depends on where you choose to focus your thoughts.  When we focus on negative things, we seem to see more negative things all around us. Living with dementia is not easy, and caring for someone with dementia is even harder; no disease is easy to live through.  If you know someone who has dementia, then you have watched what happens when he or she gets lost, forgets someone’s name, or can’t communicate an important piece of information.  It’s often humiliating for the person and it’s heartbreaking for family members to see this occurring.  These instances of memory loss tend to become our focus.  We notice every time our loved one forgets something.  But sometimes, we just need someone to point out the positives to us; to steer us in the right direction.

I would like to tell you a bit about a type of memory that isn't lost and point out some preserved abilities of people with dementia. Although the ability to learn and recall information is impaired by Alzheimer's disease, not all aspects of memory and learning are equally affected. Memory is not one thing, but a number of complex systems. As information enters through our five senses, It is translated into sensory memory and then stored in our working memory. Working memory involves short-term use of memory and attention. It holds sensory information temporarily until it is either used at that moment or processed into long-term storage for later access. 

Long-term memory has two components: nondeclarative and declarative, which are often used together.  Nondeclarative memory is knowing how or knowledge of skills and is reflected in how we do something. Once a skill is learned, it is recalled automatically. This type of memory is called procedural memory. Procedural or nondeclarative memory involves motor and perceptual skills and habits, such as brushing teeth, dressing, singing, reading, etc.

Much of procedural memory is a spared ability in dementia. For example, most people with dementia can read well into the stages of the illness, although type and size of font may need to be adjusted.

Declarative memory is knowing or knowledge of facts. This is the autobiographical memory of the events of our life, and our world knowledge. This type of memory is the first to be impaired in dementia. People with dementia become disoriented to time, forget people’s names, cannot retain information in conversation, and repeat stories or questions. A person with declarative memory impairment may forget the steps in a task or ask you to repeat the directions you just explained.

STRENGTH’S PEOPLE WITH DEMENTIA MAY RETAIN

·       Completing familiar tasks such as cooking or doing household chores

·       Using one’s imagination

·       Socializing with friends and family, helping others

·       Identifying numbers, shapes, colors

·       Reading

·       Appreciating or playing music

·       Engaging in artistic expression

·       Emotional connection

·       Knitting, sewing, painting, playing familiar games such as cards or dominoes

·       Understanding body language

·       Following directions with verbal or written cues

So, what does this mean for people with dementia?  It means that if we can help them to fill their day with all of the things they CAN do, such as familiar skills and hobbies, we will all be focusing our attention on the positive aspects of our lives.   When we have success, we feel good.  So, don’t ask someone with dementia to recall what they had for lunch or if they took their medicine, instead, read a book, play a card game, take a walk, paint a picture, listen to music, weed the garden, or just have fun spending time together.

Montessori for Aging and Dementia

Those of us who have children in Montessori school, as I do, have seen firsthand the joy of learning that takes place in a Montessori classroom.  We have watched our children be naturally drawn to the beautiful materials because they appeal to their instinctive drives.  Their work leads to a feeling of accomplishment and self-respect.  All of us, no matter our age, want to feel a sense of self efficacy and purpose.  So, could Montessori philosophies be successful for all of us, at any age?   Many of us are familiar with the term Montessori as it applies to education but only a few of us are familiar with the application of Montessori methods for Dementia.  Montessori for Aging and Dementia is a model of care which focuses on supporting the person in an environment that is adapted to support memory loss and independence.  The result is that people living with dementia are able to make meaningful contributions to their community, engage in meaningful activities in addition to having the opportunity to maintain, and even restore function. The approach is flexible, innovative and grounded in research.

Brush Development is very pleased to announce that Jennifer Brush has been appointed by the Executive Director of Association Montessori Internationale to serve as an inaugural member of the AMI Advisory Group for Montessori for Aging and Dementia.  Jennifer presented her research in the area of dementia at the first international conference for Montessori environments for dementia in Sydney last fall, and spoke at the AMI Annual Meeting in Amsterdam in April 2015.  She is one of two US dementia care experts participating in writing AMI standards for Montessori for Aging and Dementia with dementia care experts Gail Elliot from Canada and Anne Kelly from Australia.

New App Created for People with Dementia

My colleague Gail Elliot in Ontario, Canada has used her never ending creativity to develop a fun program for people with dementia.  Here’s what she has to say about it:

It is often a challenge to find things that people with dementia can do successfully that truly engage the person in the activity.  An iPad app has been developed for people with dementia, but in fact it could be used by anyone who loves guessing games, called "Best Guess".  I was sure that people who grew up before the age of computers and other progressive technology might be resistant to using the iPad.  However, when I introduced the game to someone who was very agitated, because he was frustrated with having little to do that would leave him feeling like the competent man he used to be, he reluctantly agreed to work with me on the first couple of questions and then completely took over the device and played the game until lunch was served 40 minutes later.  He laughed when he read the answers that were the incorrect answers and brilliantly lit up when he checked the correct answer. In fact, he beamed when the "Well Done" icon appeared on the screen.  Some questions were more difficult so he did not feel it was childish.  The successful answers outnumbered the two he got wrong.  

I have since used the Best Guess app with a number of people in various stages of dementia and have learned that once I get them started I can actually walk away and leave them to enjoy the game on their own.  Many read the questions out loud and laugh when they read the "silly" answer.  

What a pleasure to see people with dementia engaged in an activity that adds joy and feelings of competence.  Give it a try!  Since it is a new app it is hard to find if you go directly to iTunes.  Use the generic Google search bar.  When you bring up Google's home page type in "iTunes Best GuessDemenitiAbility" and you will see it come up.  OR go to www.dementiability.com and find the link on that website.

Enjoy the game!

Gail Elliot, BASc, MA

Gerontologist and Dementia Specialist

New Methods to Support Wayfinding for Persons with Dementia

I recently served as Principle Investigator on a National Institutes of Health Small Business Innovative Research grant in partnership with the Center for Applied Research in Dementia. The purpose of our recent research was to develop and implement a signage system for long-term care that supports wayfinding for persons with dementia. Recognizing where one is and where one is going are critical aspects enabling persons with dementia to be self-sufficient. In unfamiliar situations people rely on environmental cues to find their way. When these cues are not easily interpreted due to cognitive impairment, autonomy gives way to dependency. The search for information to aid orientation may cause frustration, anger or agitation (Zgola and Bordillon, 2001). Poor wayfinding abilities have been found to impact resident safety, create conflict between residents (Rosswurm, et al., 1986), and cause unnecessary burden to nursing home staff (Everitt, et al., 1991). Residents who cannot identify paths to desired locations exhibit anxiety, confusion, mutism, and panic (Passini, et al., 2000). The stress caused by disorientation may result in feelings of helplessness, raised blood pressure, headaches, increased physical exertion, and fatigue (Carpman and Grant, 2001).

In dementia, the capacity for decision-making is reduced to decisions based on immediate and visually accessible information (Passini, et al., 2000). Since less visual information is taken in by persons with dementia (Koss and Gilmore, 1998), and they experience other visual challenges such as contrast and depth perception deficits, spatial disorientation, and difficulty judging certain colors, it is imperative that all cues in the environment are created using evidence-based design guidelines.

While the effectiveness of some cueing systems has been empirically tested, more research is needed to provide designers, care staff, and administrators with guidelines that can make a significant difference in environments for people with dementia. Thus, the purpose of this research study was two-fold:

1) gather information about the color, contrast and pictogram preferences of persons with dementia for dining room, activity room, bedroom, and restroom signs; and,

2) use this information for creating signs that increase wayfinding independence.

For this study, we used two methods to collect data. First, in the Human Factors phase, we had 28 persons with dementia identify the characteristics of the signage they preferred. Next, in Wayfinding Observations phase, 23 persons with dementia were observed walking to different locations in the care community pre- and post-intervention (i.e., before and after installing new signs designed based on resident preferences).

Phase 1 was carried out by having the persons with dementia view many different signs on easels placed out in front of them. Participants indicated which sign they preferred and their choices were recorded. From this process we were able to determine which combination of words, colors, and pictograms were the most favored.

Signage with a colored background were preferred over signs with a white background. The participants preferred bright green to dark green or white, bright magenta compared to dark purple or white, and bright royal blue compared to the dark navy blue or white.

In trials that assessed preference for the placement of words (before or after the pictograms), there was a trend to prefer the words to precede the pictogram on the sign, but not a strong preference. Participants were asked their preferences on eight pictograms. For activity room signage, the preference was for a pictogram of people seated playing a game compared to both the pictograms of a TV and people standing/waving. There was a trend to prefer the pictogram of a bowl of soup over a knife and fork or people seated at the table for the dining room signage. Participants preferred a pictogram of a toilet over a pictogram of a shape of the person (man standing) to indicate the restroom. Once we collected all of the data from the Phase 1, we used this data to develop a set of signs that were used during the wayfinding observations in Phase 2.

In the second phase, residents were accompanied on three different routes in the care community before and after installing the new signs. Time to walk to each location as well as the type and number of errors were noted. In general, a majority of participants showed improvement from baseline to post-test, especially with regard to time to navigate routes, though this showed variability across routes and locations. Overall, we found patterns of improvement in wayfinding in residents with dementia in two residential settings on a variety of outcomes. This was accomplished without any intervention other than placing the signage into these environments. Given the results of this study, we must consider that traditional approaches to signage in long-term care communities may not be adequate to support persons with cognitive impairment. There are still many aspects of signage that require in depth study, such as resident preference for other placement options, additional color choices, and the size and shape of signs. Regardless, if preferred designs of environmental cues are in place in dementia care

facilities, residents should be able to navigate more independently, thereby reducing their level of frustration and increasing their autonomy.

You can all of the details about the study in the full article:

Brush, J., Camp, C., Bohach, S., & Gertsberg, N. (2015). Creating supportive wayfinding for persons with dementia. Canadian Nursing Home, 26(1), 4-11.

©2015 Jennifer Brush, may not be reprinted or distributed without permission