Montessori Methods Improve Quality of Life for Individuals With Dementia

By Jamie Santa Cruz

Engaging cognitively impaired older adults in meaningful activities, similarly to the Montessori principles embraced for educating children, can provide satisfaction and improve quality of life for elders with dementia.

Montessori educational methods are typically associated with the education of children. But in recent decades, a number of researchers and clinicians alike have found that Montessori principles are likewise relevant for another population: older adults with Alzheimer's disease and other dementias. Advocates say Montessori principles not only improve retention of practical life skills, but also help preserve the dignity and overall quality of life of individuals with dementia.

"The more you study the Montessori method and the writings of Maria Montessori, you begin to see that it's based on the values of respect and dignity and equality," says Cameron Camp, PhD, director of research and development at the Center for Applied Research in Dementia in Solon, Ohio, and a pioneer in the application of Montessori methods to adults with dementia. "This approach is a way of living, and it's applicable for all human beings."

Independence as a Primary Value
Maria Montessori, an Italian physician turned educator, opened the first Montessori school in Italy in 1907. The educational system she developed seeks to cultivate children's natural interests and abilities through self-directed hands-on learning. Among other things, the method strongly emphasizes the value of independence, the importance of preparing a child's environment to support independence, and the importance of meaningful activity and meaningful social roles.

There is a popular Montessori saying attributed to Maria Montessori herself: "Everything you do for me, you take away from me." Thus, the Montessori method advocates independence to the greatest extent possible—a principle that Montessori-inspired caregivers say extends just as much to individuals with cognitive loss as it does to children.

"Many times there is a push by caregivers to do as much as possible for the person with dementia, but the consequence of that is that it's possible to teach dependence and for people to lose capacity," Camp says.

According to Gail Elliot, MA, a gerontologist and founder of Dementiability Enterprises Inc, which offers Montessori-inspired workshops that aim to "expose abilities" among individuals with dementia, people with dementia are capable of doing a wide range of tasks for themselves that many care givers would assume impractical. In care centers that have adopted her model, residents peel vegetables, fold laundry, set the table, make deliveries for the building, and other similar tasks.

The biggest obstacle to cultivating independence among individuals with dementia is that caregivers assume they can no longer learn, Camp says. But in reality it is entirely possible for individuals with dementia both to recover previous skills and to acquire new knowledge and skills. As proof that individuals with dementia can learn, Camp provides the example of a person with dementia attending a new day center: After a couple of weeks of sitting in the same chair for lunch, an individual will learn which is "his" chair. If he comes in one day and someone else is sitting in "his" chair, he will become upset.

The capacity to recover previous knowledge and learn new skills exists in part because of the power of procedural (unconscious) memory, Elliot says. Conscious memory (memory of facts) is the form of memory most heavily damaged in the course of dementia, but procedural memory is often spared even late in the course of the disease.

It's due to procedural memory that a resident in a dementia care center can be taught how to fold towels, for example. An individual won't remember having been taught, Elliot says, and after having learned, she will likely believe she has always done it that way—but the significant point is that she will have mastered a new procedure.

In many cases, restoration of independence requires a rehabilitation approach, Camp says. (According to Camp, Montessori educational methods for teaching practical life skills to young children actually draw heavily from rehabilitation approaches.) In the case of eating, for example, self-feeding requires range of motion and ability to grip a spoon, and an individual may need rehabilitation exercises to support both. Teaching the actual skill of self-feeding may be a matter of putting a spoon into an individual's hand, guiding the spoon into a bowl, and then lifting it to the individual's mouth. After a taste, the individual may put the spoon back in the bowl, or he or she may need more practice.

"They will learn by doing as opposed to someone talking to them," Camp says. "You will frontload some effort in working with the person to let them regain that capacity, but the long-term payoff is that you're not having to feed them for the rest of their lives."

Importance of a Prepared Environment
The ability of both young children and individuals with dementia to exercise independence is heavily dependent on how much their environment has been prepared to accommodate them. Thus, another key Montessori principle is that the environment must be prepared "to enable learners to use the abilities they have and to circumvent their deficits," as Camp describes it.

Of course, the specifics of the preparation are different for young children from those for adults with dementia. According to Elliot, developing successful environmental accommodations for adults with dementia requires drawing on evidence from multiple disciplines, including brain and behavior, occupational therapy, nursing, and social work, among others. "You have to use the research in aging and dementia" to prepare the environment appropriately, Elliot says.

One prime example of environmental preparation for adults with dementia is the use of signage. For example, to aid individuals with dementia in visiting the restroom independently, Elliot suggests signage that outlines the necessary steps. "If people have memory issues, they don't know how to sequence in the bathroom. So we put up cues—pull down pants, sit, do your business."

Aside from signage, preparation of the environment means designing a variety of other types of accommodations to enable individuals with dementia to participate in practical activities of daily living. For example, Camp says, take the case of a person with a stroke who is paralyzed on one side. With a well-prepared environment, this individual can still participate, for example, in a cooking group and perform the practical living skills of peeling carrots and potatoes. In this case, caregivers simply need to provide a device to hold the vegetable in place. They can then demonstrate the action of peeling, and then have the person with dementia imitate the same action.

From a completely different angle, environmental preparation might involve the design of doors. "A door is an invitation. If there is a door, you exit," Elliot says. Doors represent a challenge, however, because individuals with dementia may try to exit the building or become frustrated if they are not permitted to exit. Elliot suggests a solution. "We make doors look like bookshelves," she says. "So now you've got the look of home, and you have removed the trigger to leave."

Meaningful Activity
In keeping with her emphasis on a child's ability to be independent, Maria Montessori stressed the need to involve children in meaningful activities, as opposed to simply busy work. For this reason, Montessori schools focus extensively on the development of practical life skills and on incorporating children into the real work required for the normal daily functioning in their homes and schools.

For some advocates of Montessori methods for adults with dementia, this emphasis on activities is the central focus of their work. Such is the case for Meghan Morrissey, PhD, executive director of the Colorado-based nonprofit organization Sensory Outings, which takes Montessori-based activities into residential memory care centers on a weekly or monthly basis.

Morrissey, whose own mother had dementia, realized that activities coordinators at memory care centers often struggle to design activities that actually appeal to residents with dementia, and she saw that her mother was bored and unengaged. Morrissey's children had attended Montessori schools growing up, and memories of their activities inspired Morrissey in the creation of Sensory Outings. "They did a lot of practical work and real life experiences. I said to myself, 'This is what my mom would love to do.'"

With Sensory Outings, activities include everything from flower arranging, stitching, kitchen work (in this case, with Play-Doh), gardening, painting, sculpting, sports-based activities, polishing, and simple building projects, such as with a build-a-box kit. Morrissey focuses on individual interests, not just the group as a whole. "Once we get to know the individual, we bring in the next time what they want," she says. Following Montessori principles, she and her staff demonstrate activities more than giving verbal directions, then they step back and encourage residents to engage in self-directed work as much as possible.

In Morrissey's case, Montessori-based activities are a once-a-week (or once-a-month) offering brought in to centers from the outside. But in the case of Camp and Elliot, both of whom advocate incorporation of Montessori principles into all aspects of an individual's environment, "meaningful activity" means actually participating in the work required to sustain the individual's home or care center—as with helping to prepare vegetables for meals or setting the table.

In one center that has adopted Elliot's Dementiability program, an office worker who was responsible for shredding went on an extended vacation. One of the residents in the center had been wandering extensively—the kind of responsive behavior that, according to Elliot, is most often a sign of either boredom, loneliness, or lack of success. In order to engage the wandering resident, he was brought to the office to help with shredding. After being brought in every day at 3 PM for several days, he started showing up on his own at the appointed time—and even became upset when the office worker who had been on vacation eventually returned and tried to take over "his" job.

In the case of the shredding resident, the activity itself might be outside the norm, but the principle—involving individuals in meaningful work—is the essence of what it means to apply Montessori to the lives of older adults with memory impairments.

"What we're looking at," Camp says, "is how to enable persons with dementia to be as independent as possible, to be able to do as many things for themselves and for each other as possible, and to create … real communities where people have purpose in life and can live well even though they have dementia."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.