Reaching advanced age, people do not wish to be completely dependent on others, forget all the warm and loving memories of a lifetime, or live a life void of purpose. Unfortunately, this is the life that some people living with dementia experience.
The good news is that life in older age or with dementia can be rich, rewarding, and fulfilling. By looking at life with dementia in a different way, people can each do things they enjoy and make them thrive. But in order to be successful at this, they need opportunity.
Montessori is a philosophy of life that gives older adults the opportunity to grow, engage, love, and, most importantly, live. Many have heard about this approach for children. In reality, it’s a philosophy of living for all ages. Maria Montessori, MD, wrote that “joy, feeling one’s own value, being appreciated and loved by others, feeling useful and capable of production are all factors of enormous value for the human soul.”
Culture Change a Necessity
Implementing a Montessori philosophy in a long term care community does involve a culture change process. It begins with teaching staff the Association Montessori International, Montessori for Aging and Dementia curriculum, which starts with a two-day program. Next, staff focus on identifying individual and small group activities and personalized roles in which older adults can participate every day and that match the person’s cognitive abilities.
Specially designed activity materials that involve sensory stimulation, fine and gross motor tasks, language, music, and reading are neatly organized and labeled and physically accessible all throughout the living area.
Care partners practice with older adults to help them relearn previous roles or enjoy new ones. The more frequently older adults do this, the more their skills improve, until eventually they are able to do most or all of the activities on their own.
In a Montessori community, to the extent they are able, older adults clean and set the dining room tables, pour their own beverages, help themselves to drinks and snacks, care for plants, arrange flowers, fold laundry, make beds, dust, sweep, lead sing-alongs, and pass out supplies for group activities.
The authors have enjoyed watching older adults swim, reminisce with sports memorabilia, don jewelry and hats from a group fashion corner, do crafts, engage in topic-specific puzzles and sorting activities, and play music with various instruments. As a result, older adults have been found to display significantly more positive emotions, affect, and feelings of self-esteem than prior to living in a Montessori community, according to Brush, Douglas, and Bourgeois, 2018, in the Journal of Nursing Home Research Sciences.
Activities with a Purpose
These activities and roles have meaning and purpose; they are not busy work, but an opportunity to contribute to the community and a way to enjoy hobbies that have been modified for their ability level. Activities and roles also happen as a normal course of the day, just like they would if the elder were living at home.
The result is a flow of the day during which people are doing different chores and hobbies on their own or in small groups. Older adults are encouraged to choose materials freely and are able to respond to their own internal needs.
Sometimes staff need to invite or remind elders to join an activity or to participate in a role.Other times they initiate the activities themselves as a result of routine or carefully placed signage inviting them to enjoy the available activities (for example, “please enjoy a snack” and “please pour yourself a drink”).
In addition, during care, care partners take their time to encourage independence. They use task breakdowns and give directions one small step at a time so the elder can be successful. Staff develop meaningful relationships with older adults as a result of this person-centered approach. In one community, significant improvements in staff satisfaction were documented one year after implementing a Montessori philosophy, said Brush, Douglas, & Bourgeois, 2018 in the Journal of Nursing Home Research Sciences.
Measuring the Results
Recently the authors conducted an evaluation of the effectiveness of a Montessori program in a memory care household that is part of a continuing care retirement community. Each elder was individually observed during their daily routines nine times before and at the conclusion of Montessori implementation.
During the observations, the observers used the Observed Emotion Rating Scale (Lawton, Van Haitsma, & Klapper, 1996) to describe elders according to their facial affect and physical signs of positive and negative emotion. These emotions included pleasure, anger, anxiety/fear, sadness, and general alertness. The team also spent time conversing with and interviewing each elder using the Dementia Quality of Life Scale (Brod, Stewart, Sands, & Walton, 1999) to find out how each person rated his or her life relative to living in the care community.
The positive emotions, negative emotions, and general alertness observed during 15-minute observations during pre- and post-implementation were compared. Statistical tests determined that there was a significant increase in positive emotions after implementing Montessori for nine months. There was also significant increase in older adult engagement in daily household activities.
When pre- and post-implementation scores from the Dementia Quality of Life Scale were compared, elders reported a 28 percent increase in positive feelings, most notably feeling more useful and more cheerful. Elders reported a 34 percent decrease in negative feelings, most notably less worried, less sad, and less irritable.
Observable Results
Observationally, the quality of activities after implementation of the Montessori philosophy appeared to be more engrossing. Prior to implementation of the project, elders were observed to be sleeping often in their beds or while sitting in chairs, sitting quietly and unengaged in a room full of others doing the same, or watching TV. After implementation, elders were observed engaging in all of the activities previously mentioned and were doing so in the common areas.
Tables were shared for different activities, which created a warm, inviting environment that others seemed to want to sit and be a part of. Although elders were not always interacting with each other or staff, they seemed to be enjoying each other’s company in the shared space through the exchange of smiles and other signs noted through the Observed Emotion Rating Scale.
Other studies have noted a significant reduction in antipsychotic and sedative medication after the implementation of Montessori activities. This medication reduction was noted to be maintained at an 18-month follow-up as well (Barry, 2017).
The implementation of a Montessori environment resulted in more quality communicative interactions as well as improved overall well-being (Sheppard, McArthur, and Hitzig 2016). Similarly, elders who engaged in Montessori training displayed fewer feeding difficulties and an increased ability to feed themselves independently (Roberts, Morley, Walters, Malta, and Doyle, 2015).
No matter the age, people have a desire to live a life that is satisfying and purposeful. Unfortunately, for some, older age brings about mental and physical challenges that result in requiring help from others, which can make a person feel useless and without significance or an ability to contribute.
The Montessori philosophy reminds caregivers to respect each person for the contributions each is able to make, encourage independence, provide meaningful work, and remember that learning and engagement can occur anywhere. Montessori is not a technique, task, or intervention: It’s a way of living one’s life to the fullest extent possible. ■
Jennifer Brush, MA, CCC-SLP, director of Brush Development, is an author, consultant, and researcher in the area of dementia care. She is the only Association Montessori International-certified educator for Montessori for Aging and Dementia in the United States. She may be reached at jennifer@brushdevelopment.com or 440-289-0037. Jeanette Benigas, PhD, CCC-SLP, is a faculty member at the University of Akron, Ohio.