In dementia care, it is important to foster independence, high self-esteem and a promising future.
The Montessori Method for Dementia is an evidence-based intervention that can enrich quality of life. Activities are the engine that drives this quality of life. A person’s self-esteem and mood can be greatly influenced by the success or failure experienced in activities and that they should always be meaningful to the individual.
If people with dementia are given choice and the opportunity, they can learn new things. With engaging activities, responsive behaviours can be significantly reduced. This approach fosters equality, respect and dignity and carers become ‘enablers’.
To enhance the interaction with the person, it is important to apply all the Montessori principles.
People with dementia are often confronted with what they can no longer do or with the mistakes that they make. Montessori principles are designed to focus on what they can still do. This is a person centred approach focusing on the person’s capabilities, capturing their interest and showing them respect. It is important that the focus includes building on the person’s strengths.
The Montessori principles
1 The activity should have a sense of purpose and capture the person’s interest.
2 Always invite the person to participate.
3 Offer choice whenever possible.
4 Talk less. Demonstrate more.
5 Physical skills; focus on what the person can do.
6 Match your speed with the person you are caring for. Slow down!
7 Use visual hints, cues or templates.
8 Give the person something to hold.
9 Go from simple tasks to more complex ones.
10 Break a task down into steps; make it easier to follow.
11 To end, ask: ‘Did you enjoy doing this?’ and ‘Would you like to do this again?’
12 There is no right or wrong. Think engagement.
1. The activity should have a sense of purpose and capture the person’s interest
Some activities are designed to assist the person maintain or restore certain functions, such as eating more independently. But all activities need to capture the person’s interest; otherwise the activity will be of little or no value. When applying all the other principles, your activities will hopefully result in a pleasant, rewarding and positive interaction.
2. Always invite the person to participate
The first minutes of your visit will usually be the most important ones. This is when you will hopefully connect with the person. It is helpful to introduce yourself on every occasion; this may feel strange at first, but is important unless the person easily and obviously recognises you. For example, say your name and your relationship to them followed by saying that you have come to visit them today and would they mind helping you with some things. Once you have established this connection, you can then build on this foundation. As another example you could say: ‘Hello Mum, its Eva, your daughter. I have come to visit you and was wondering if you could help me today. Would you like to fold towels or arrange flowers?’
The most important thing is that you feel comfortable in the interaction. The person’s response is the best indicator of what you should do. If the person is not interested, try something else.
3. Offer choice whenever possible
As can be seen in the example above, it is helpful to present the person with a choice; for example, the option to fold towels or arrange flowers. When offering this choice it is always best to present two visual prompts (e.g. a towel and a flower). This really assists the person to communicate to you what they would like to do.
Give specific choices. A general question such as ‘What would you like to do today?’ will be very hard to answer for most people with dementia. When offering this choice it is always best to present two visual prompts. This really assists the person to communicate to you what they would like to do.
If the person finds it hard to choose the first time, you can take the lead. Choose something you think will be of interest. Start demonstrating how this activity works, invite them to participate. Again, you will then have to observe their response to decide if you should continue with this activity. If you think that their attention is wandering, you may want to change (also see Principle 9).
4. Talk less; demonstrate more
The first part of this principle, ‘Talk less’, very much depends on the person’s ability to speak. How much you speak should match how much they speak. If the person is (or has become) a chatterbox, feel free to chat just as much. If half of what they are saying sounds somewhat confused, it still may be good to continue talking with them. It’s probably best not to try to clarify what they are trying to say, but just speak back in a calm and warm voice. This may not result in a meaningful conversation, but can still have a reassuring and calming effect on the person. You are acknowledging and honouring their wish to socialise and communicate with you.
However, there are numerous reasons why the person may have become less comfortable with speech. They may lose the ability to speak, or they may revert back to a first language. They may still be able to speak English, but become frustrated because they are aware that their speech is confused or because they lose their train of thought. In these cases, it is best to avoid this frustration and reduce language in your interaction as much as possible. This may require some practice and, again, the person’s response is the main indicator to determine if you can still use some basic sentences or if it is best to greatly reduce your spoken words throughout your visits.
As with most things, the person’s preference may change over time.
Regardless of how much speaking you do, you should always demonstrate every step of each activity. You may have to demonstrate each step of the activity only once, or you may need to repeat each individual step. Demonstrate each step (Principle 10) separately and repeat your demonstration until the person is able to imitate, unless they have lost interest in which case it may be time to change activities.
5. Physical skills; focus on what the person can do
It will help your interaction if you accommodate any physical impairment the person may struggle with.
Many elderly people suffer some hearing and visual impairment, so well-adjusted glasses and hearing aids can improve the person’s experience greatly. Sometimes one ear may function better than the other. Sometimes it will be easier for the person to reach and lift one arm than the other. It is worthwhile enquiring about or exploring their physical skills. If the person is residing in a residential facility, it may be helpful to check with staff intermittently to see if they have noticed any changes in physical functioning. In regard to vision, it may help to test a couple of print sizes to establish if and what the person is able to read. You may want to move around your reading material as well, to find where they are best able to see.
It is usually easiest to do the activities at a table, but be mindful that some chairs can be uncomfortable (especially for people who have had hip problems). Again, trialling a number of set-ups may result in an optimal environment to start the activities. For example, a TV tray may fit over the lap of someone sitting up in bed, and activities can be performed on the tray.
6. Match your speed with the person you are caring for. Slow down
Even though each person is unique, for most people with dementia it is best to slow down, both in speech and movement. If you are speaking (Principle 4), it could help to speak slightly slower than you usually do and articulate well. Don’t speak louder, because the change in tone may agitate some people. If hearing is impaired, it is best to sit close and speak in a calm tone. Even if they can’t hear exactly what you are saying, the sound and tone of your voice may be reassuring. By demonstrating each step of each activity, you can communicate what you are asking them to do anyway.
You may also need to adjust the speed at which you are moving. Your normal pace may be too fast and may add to the person’s confusion. It is best to observe their response to establish the best pace to be working at. As a general rule, it is best to work at a pace that matches the pace of their movements.
7. Use visual hints, cues or templates
When inviting the person to participate, you should use visual cues that represent the activities you are suggesting. Whenever you give them another choice, you can continue to use these visual prompts.
The main cue to use is pointing to direct the person to what you are asking them to do. After you demonstrate the activity (a number of times if necessary), the person may respond to your invitation to do the activity themselves. However, if the activity consists of a number of steps, the person may not remember all the steps. A first response could be to point from the object they are holding to the place where it should go. You can repeat this a number of times; hold their hand to put the object together, or gently take the object from them and demonstrate again.
For any sorting or sequencing activities, it may help if you develop your own templates. This visual cue can help the person to understand what you are asking them to do.
8. Give the person something to hold
This principle especially applies if the person is not actively participating in your activity, which may happen when you first introduce an activity. The person may need to adjust to this form of interaction.
Try not to be discouraged if they do not immediately participate in your activity. You may want to try an activity that is of interest to you. You need to be guided by the person’s response to observe if they share your interest. Even if they are just looking at what you are doing, this may still be a positive interaction. To enable the person to be part of the activity, you can give them one thing to hold. For example, if you are screwing nuts and bolts together, you can hand the person one of each; or hand them the bolt and put the nut within reach on the table. The idea of this principle is that you first of all respect that they may not be ready to participate with what you have in mind. You may still present your materials to see if they capture interest. (If you stop activities every time they do not want to actively participate, you may well never get started.) Secondly, the one thing they are holding could facilitate their participation whenever they are ready.
9. Go from simple tasks to more complex ones
It is helpful to prepare several activities for the person; which activities you prepare may change over time. The person is likely to do two to three activities in half an hour; however sometimes a single activity may take all this time. On days that it is harder to engage the person, you may need to try more than three activities.
It can be best to start with a simple version of each activity, to avoid frustration. The life of a person with dementia is full of things they are not managing, and these activities should not result in stress. Your activities need to be designed so that the person has every chance of feeling competent and appreciated.
However, you do not want to make activities too simple, as this can result in loss of interest.
This principle really focuses on observing the person. Let the person determine what activity you will be doing, and at what difficulty level and pace.
They may not verbally communicate this, but you can see it from their response. Once they have chosen an activity, the observation starts. As soon as you feel that their interest is fading, you can make changes.
The first thing to do is check all your principles:
- Am I talking too much?
- Am I moving too fast?
- Did I forget to demonstrate what I am asking the person to do?
If you feel you are following all the principles, you can consider the difficulty level of your activity. You may come up with other alternatives. If you have adapted the difficulty level, but the response is still quite disengaged, you could consider doing a different activity altogether.
Remember, everything is an activity: even preparing materials for certain activities or clearing the table after you have finished with a certain activity. Just continue applying the principles!
10. Break a task down into steps; make it easier to follow
Every activity consists of steps. For example, sorting pictures includes:
- looking at the picture (together)
- handing the picture to the person to hold
- looking at the template headings
- placing the picture on the template.
You may be able to teach the person every step, one after the other. Or they may only be able to do one step at a time. You can help by pointing and demonstrating each step until they are able to do the whole sequence. It can also be important to present only one object at a time to the person.
Handing them a pile of pictures to sort may be too much to ask. However, if you present one picture after the other, the person can focus on each picture. The same applies to uncluttering the environment: clean the table you will be working at, present materials for one activity at a time, step by step.
11. To end, ask: ‘Did you enjoy doing this?’ and ‘Would you like to do this again?’
It is not necessary to complete a task; the main purpose of the interaction is to engage someone’s interest. If the person does complete a task, you can ask them if they enjoyed doing this and would they like to do it again? In this way, they are in charge of what you are doing with them.
12. There is no right or wrong. Think engagement
This final principle is closely related to the first principle. The aim of your interaction is to have a pleasant time – that’s all. The person does not have to do everything ‘right’ (or anything for that matter); they do not need to complete an activity. If pictures of blue cars keep going on the pile meant for red cars, does it really matter when they are absorbed in the activity? It may sometimes be hard to encourage ‘mistakes’, but try not to correct the person if they are enjoying themselves. If they get frustrated by their mistakes, it is time to make changes (see Principle 9).
RELATE, MOTIVATE, APPRECIATE
A MONTESSORI RESOURCE
Promoting positive interaction with people with dementia