Transcript Improving Quality of Life in Dementia

Montessori-Based Dementia
Programming:
From Theory to Practice
Presented by: Gail Elliot, BASc, MA
Assistant Director,
McMaster Centre for Gerontological Studies,
McMaster University
[email protected]
2008
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Interventions for Dementia
from the Neurosciences
Montessori-Based Dementia
Programming®
Spaced Retrieval Techniques
for Dementia
 Developed by Dr. Cameron Camp and colleagues,
 Myers Research Institute, at Menorah Park LTC, Beechwood,
OHIO
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Overview Questions
 Who was Dr. Maria Montessori and how does
her work apply to dementia?
 What are the basic principles of a Montessori
approach and how do these apply to persons
living with dementia?
 Why and when should you used MBPD?
 What are Montessori-based activities?
 How would I present a Montessori activity to my
client?
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Who was Dr. Maria Montessori?
• Dr. Maria
Montessori was the
first woman to be an
M.D. in Italy
• She lived from
1870 - 1952
• Dr. Montessori
worked with
underprivileged
children thought by
some to be “insane”
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Dr. Montessori’s Philosophy:
To enable individuals to be as
independent as possible,
to have a meaningful place in their
community,
to have high self-esteem, and
to have the chance to make
meaningful contributions to their
community.
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Dr. Montessori saw
activities as the basis for
intervention in all aspects of
living.
Quality of life is largely defined
by what
activities are
available.
Children avoided activities that
they considered
“babyish”
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SO . . . .
 If someone questions whether the Montessori
approach for dementia is childish and
infantilizing
You can clearly state that:
 Dr. Montessori said children don’t want to be
treated like children
 So . . . This approach follows the same line of
thinking – adults also don’t want to be treated
like children either.
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and Myers Research Institute
Now a Bit about Dementia
“First - In / Last Out” Theory
posits that abilities that are acquired first in
childhood remain for a long time in persons
with dementia and abilities that are acquired
later in childhood are the first abilities lost in
persons with dementia.
Reisberg calls this developmental pattern of
loss of abilities “retrogenesis” (Reisberg
developed the Global Deterioration Scale)
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First In - Last Out Theory of Memory
in Dementia
M
E
M
O
R
I
E
S
Developmental staging
Loss of abilities: Reverse of dev. stages
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“Dementia is a syndrome consisting of a
number of symptoms that include loss of
memory, judgment and reasoning, and changes
in mood and behaviour.”
(Canadian Alzheimer Society, 2006)
Alzheimer Disease is most common type of
dementia
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and Myers Research Institute
At a personal level . . .
One man describes dementia as
“the feeling of having been betrayed by his
brain, ‘which somehow short-circuited on
him’.”
(Zgola, 1987, pg 1)
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and Myers Research Institute
Dementia
Why the
behaviour?
Why is this
happening?
Plaques and Tangles
responsible for changes
in brain activity
Can help to explain
changes in behaviour
and mood
Look at;
•Environment
•Social
•Physical
•Emotional
•Intellectual/cognitive
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Dementia
Why the
behaviour?
“Providing a positive therapeutic
activity is associated with reduced
disruptiveness, agitation and
wandering (Stokes, 1990).”
• Environment
•Social
•Physical
•Emotional
•Intellectual/cognitive
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Top Ten Responsive Behaviours
Reference: Dupuis, S., Smale, B., (2003) Ontario Dementia Caregiver Needs Project, Murray
Alzheimer Research and Education Program (MAREP), University of Waterloo, Waterloo, ON.
 Constant unwarranted request for attention or
help
 Pacing or wandering
 Repetitive sentences or questions
 General restlessness or agitation
 Complaining or whining





Cursing or verbal aggression
Screaming
Trying to get to a different place
Making strange noises
Grabbing onto people
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MBDP® Combats Invasive Memory Loss
Focuses on spared capacity
Procedural Memory
&
Environmental Supports that build on
existing abilities
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and Myers Research Institute
Memory
Squire (1994)
Declarative
Memory
Facts
World
Knowledge
Procedural
Memory
Events
Skills
Habits
Vocabulary
Simple
Classical
Conditioning
Priming
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Declarative Memory
 When we talk about “remembering” or “our
memory” in ordinary, everyday language, we
are referring to declarative memory.
 We are actually referring to the conscious
recollection of “facts & events”, including
memory for words, scenes, faces and stories
(Squire, 1994).
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WHAT IS PROCEDURAL MEMORY?
Habits
motor learning
classical conditioning
repetitive priming
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© McMaster Centre for Gerontological Studies
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APPLICATION
 Condition an emotional
response
 FOR EXAMPLE:
 A man (staff) is associated with “bad things”
(giving needles, baths, etc)
 We need to change the relationship
 Have him give out prizes at every game
Change the negative to
Positive
association
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Priming
Learning to look at their book to
help them remember important
information
The more they practice, the
better they will get at
looking for the information
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IN OTHER WORDS
The person gets better with
practice
EVEN IF THE PERSON DOES NOT
REMEMBER HAVING LEARNED THE
INFORMATION/TASK/
BEHAVIOUR
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Stages of Dementia & YOU!
Decreasing social, cognitive and
physical function
EARLY
Your role:
Identify unmet needs
Match activity with unmet
needs and interests &
capabilities of the
individual
LATE
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Functional Abilities Through the
Progression of Dementia
Goal is the prevention of excess disability:
 Excess disability refers to the relationship between the
competence of the individual and the stimulation in the
environment.
 When an individual’s competence is low, less environmental
stimulation is tolerated.
 Conversely, when an individual’s competence is high, more
environmental stimulation is tolerated.
 Excess disability results when an individual’s
competence level and the amount of stimulation
provided are not matched appropriately.
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and Myers Research Institute
Excess Disability
 Actual disability is the
disability associated
with the disease.
 Excess disability is
not a result of the
disease. It arises
from the disuse of
remaining abilities.
(Dawson, Wells & Kline, 1993)
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Montessori-Based Programming
Adapted for Dementia
 This method of intervention focuses on
rehabilitation, where rehabilitation is
defined not as a return to a pre-morbid
state, but as a set of methods and
procedures that enable individuals to
circumvent existing deficits to achieve
higher levels of functioning.
 In the Montessori-based context, the
resident is engaged in more meaningful
activity.
 Activities are matched with interests,
strengths, needs and abilities.
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Montessori Based Programming for
Dementia®
Activities for Individuals (e.g. - range of
motion)
Activities for Groups (e.g. - reading,
matching games, social interaction such
as intergenerational activities, “bingo”)
Adopting a Montessori philosophy across
the facility (how do you modify what you
already have?)
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Montessori-Based Dementia Programming™
Method of CREATING
and PRESENTING
activities based upon
models of learning and
rehabilitation
Circumvent deficits
 Reach highest level
of functioning

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and Myers Research Institute
Program at the level of capability
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and Myers Research Institute
Current Use of Montessori Principles in
Dementia Care
 Results of research conducted by Dr. Camp
shows benefits as follows:
Enhance function
Increased display of pleasure (smiling, laughing)
Enhances conversation abilities
Decrease disruptive behaviours (wandering,
repetitive questioning)
Decrease “non-engagement behaviours” (sleeping)
Decrease “self-engagement behaviours”
Improve family member visitor satisfaction, and
decreases family member’s sense of frustration
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Montessori Principles
 Use real-life materials that are aesthetically
pleasing.
 Progress from simple to complex, concrete to
abstract
 Structure materials so that participants will
work from left to right, and from top to bottom.
 Break down activities into component parts, and
practice one component at a time.
 Ensure that participants have the physical and
cognitive capability to manipulate materials and
understand what is required.
 Use as little vocalization as possible when
demonstrating activities.
© McMaster Centre for Gerontological Studies
 Make the materials and activity self-correcting.
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GETTING STARTED
ASSESSMENT
VISION
TEST
READING
TEST
Know the person
DETERMINE
NEEDS
CHECK IT OUT
Dementia?
Depression?
Delirium
Treat the
treatable
Determine Remaining
Skills/Abilities/Strengths
• Cognitive (memory)
•Motor (e.g. – ADL’s)
•Sensory
•Social/Group
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A MODEL:
MONTESSORI-BASED PROGRAMMING FOR DEMENTIA®
FIRST QUESTION: WHY IS THIS HAPPENING?
ASSESS NEEDS, INTERESTS, ABILITIES, STRENGTHS
ESTABLISH GOALS
Complete the Myers Activity Inventory© (2002)
CREATE ACTIVITIES (BASED ON 5 CLASSES OF ACTIVITIES) (CAMEO TOOL)
PRESENT ACTIVITIES
WOULD you like to help me with something?
Demonstrate
SELECT FROM FIVE CLASSESS OF ACTIVITIES BASED ON
ASSESSMENT OF INTERESTS, STRENGTHS, ABILITITIES & GOALS
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Thank you. Would you like to do this again some
time?
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Key Montessori Principles for Dementia© Myers Research Institute
To what degree is each principle present in the activity?
0 = this principle is NOT PRESENT in the activity
1 = this principle is SOMEWHAT PRESENT in the activity
2 = this principle is STRONGLY PRESENT in the activit
CREATION OF ACTIVITIES
(C – A – M – E – O)©
Cueing and/or templates
___ Utilize cueing and/or templates when appropriate and/or necessary.
Explanation of rating:
Other notes (Suggestions):
Avoid unnecessary markings and clutter and ensure materials can be clearly seen.
___ Avoid unnecessary marking and clutter on the materials and on the table upon which the activity is planned.
Explanation of rating:
Other notes (Suggestions):
Manipulatives
___ Provides manipulatives as part of the activity. Think about how the activitiy can be made more difficult, easier or
modified for variety.
Explanation of rating:
Other notes (Suggestions):
Error-free
___ Activities should be an error-free source of success for clients.
Explanation of rating:
Other notes (Suggestions):
Objective is meaningful to the client.
___ Make sure the activities you design and use have a clear objective that is meaningful to the client.
Explanation of rating:
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Other notes (Suggestions):
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Evaluator:________________________________________ Date:_______________
PRESENTATION OF THE MONTESSORI PROGRAM (PICNIC)©
To what degree is each principle present in the activity?
0 = this principle is NOT PRESENT in the activity
1 = this principle is SOMEWHAT PRESENT in the activity
2 = this principle is STRONGLY PRESENT in the activity
Source: C. Camp, Myers Research Institute, Cleveland, OH
PREPARATION
2.
Provide an effective seating arrangement and an
environment free of distractions.
___ Seating should be a closed circle or a square, if
possible, and the room should be free from distractions.
Make sure radio and television is turned off, doors
are closed and background noise is eliminated.
Explanation of rating:
Choice
___ Provide a choice of activities from which clients can make a selection.
Explanation of rating:
Notes/Suggestions:
3.
No such thing as a right way.
___ Always remember that there is not such thing as a right way to complete an
activity – thus, DO NOT repeatedly correct the participant.
Explanation of rating:
Notes/Suggestions:
Implementation
I
Notes/Suggestions:
4.
I
llustrate by physical demonstration.
___ Illustrate how to complete tasks by demonstrating how to complete the task.
Explanation of rating:
1.
nvitation
___ Extend an invitation to clients.
Explanation of rating:
Notes/Suggestions:
Notes/Suggestions:
5.
C
losure.
___ Provide closure to the activity by asking the participant: 1) if he/she enjoyed
© McMaster Centre for Gerontological Studies
him/herself and 2) whether he/she would like to perform the activity again.
and Myers Research Institute
Explanation of rating:
Notes/Suggestions:
General Categories for Determining
Intervention Goals
 Care of the person
 Care of the
environment
 Motor activities
 Cognitive activities
 Group or social
activities
 Sensory
discrimination
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Montessori-based Activities
 Sensory discrimination
 Scooping exercises
 Pouring exercises
 Squeezing activities
 Fine motor activities
 Care of the environment
 Care of the person
 Matching activities
 Seriation activities
Decisions
Made based
On:
Needs
Interests
Strengths
Abilities
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Case Example: Mrs. T
Living a LTC Facility
 Know the person:
 Mrs. T was a competitive swimmer
 Loved cottage life & particularly her garden
 Mother of 3 girls
 Loved to cook; loves to eat
 Very social and active in her church
 An avid reader
© McMaster Centre for Gerontological Studies
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Presenting Issues:
Wanders
Depends on family to attend to her care
Memory problems due to DAT
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Consider Each of the Programming Areas When Making
Decisions about Programming Objectives
 Care of the person: We need to focus on getting
Mrs. T to dress herself again, and find other roles
for the daughters
 Care of the environment: She loves gardening,
therefore a Montessori activity might include
Flower arranging
 Cognitive activities (Sorts or seriation)
 Group or social activities (Reading roundtable)
 Sensory discrimination (not a focus at this time)
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Motor activities
 Mrs. T needs to begin taking care of herself,
rather than relying on her daughters who feel
they need to “help” their mother
 Montessori-Based Programming for Dementia
could focus on physical activities, that are aimed
at maintaining (and perhaps restoring) physical
function. Consider:
Scooping exercises, pouring exercises,
squeezing exercises and fine motor activities
© McMaster Centre for Gerontological Studies
and Myers Research Institute
SCOOPING ACTIVITIES
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Wandering
MBPD: Care of the environment
Presenting Issue:
 Mrs. T loves
gardening, therefore
a Montessori activity
might include Flower
arranging
 Check to ensure
Montessori Principles
are being followed
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and Myers Research Institute
Cognitive
Animal / Plant Sort
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Cognitive
Baking / Sewing Item Sort
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Issue: Wandering
Group orPresenting
social activities
 Mrs. T loved to read
(Montessori Reading books available with
appropriate sized print and group discussion
questions)
 Use Montessori Readers: Gene Kelly, Leonardo DaVinci, The Birth of
The Chocolate Chip Cookie, etc.
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Group Reading:
Large print, everyone takes a turn, discussion
takes place, socially appropriate behaviour
is an outcome as all are engaged in the activity
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You can use Montessori for Dementia
programming with persons in all stages of
dementia.
To be successful you need to assess
needs and set goals and always follow the
principles for creating and presenting
Montessori activities
© McMaster Centre for Gerontological Studies
and Myers Research Institute
A Success Story . . .
 I tried the suggestions you gave me on a resident
today. I purchased at the dollar store a bowl, macaroni
and poker chips (as well as the soft coloured beads and
a tray). I hid the chips in the macaroni. This lady has
mild dementia, is deaf and screams “most of the
time”. For 1 hour she searched through the bowl for the
chips, sorted them by colour and then stacked them up
by colour. She only screamed when the staff came to
get her for lunch. She wanted to continue to sort!!! Just
thought you would enjoy our success.
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Where can you use these techniques?
Anywhere!
Day Programs
LTC
At Home
Assisted Living
Hospitals
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Who Can Use These Techniques?
Anyone who has been trained!
Professionals
(OT, PT, SW, RN’s,
Recreation)
Paraprofessionals
Family
Volunteers
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OUTCOMES of MBPD
REDUCED RESPONSIVE
BEHAVIOURS
Problematic behaviour is
rarely seen since being
engaged and displaying
problematic behaviours
generally are two
mutually exclusive
categories of behaviour.
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Spaced-Retrieval (SR)
AKA: Memory Enhancement
SR involves the use of shaping
technology from behavioral therapy
of information/tasks that
applied to memory. Examples
can be learned:
Memory training to
assist with ordinary
living.
Names of family, friends and staff.
Finding destinations (washroom, bedroom,
kitchen).
Helping the individual to remember when the
next meal is and what time of the day it is
(information finding).
Finding items such as clothing, memory
books, purse or watch.
Remembering his/her own name.
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The ultimate
goal is retention
of and ability to
recall
information over
very long time
intervals (e.g.
months, etc.)
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and Myers Research Institute
Montessori for Dementia
Limited registration
For more information about upcoming
sessions, dates and locations visit our
website at
www.socsci.mcmaster.ca/gerontology
Or email me at [email protected]
© McMaster Centre for Gerontological Studies
and Myers Research Institute
Spaced Retrieval
Will be offered on:
Spring 2008
McMaster University
© McMaster Centre for Gerontological Studies
and Myers Research Institute
For More Information
Gail Elliot, BASc, MA
Assistant Director
McMaster Centre for Gerontological Studies
McMaster University
 phone: 905-525-9140 ext. 24449
 email: [email protected]
 Or
 email Christopher Due at [email protected]
© McMaster Centre for Gerontological Studies
and Myers Research Institute