Annotated Bibliography: Montessori-based Activities for Patients with Dementia

1. Ploeg, E. S. V. D., Eppingstall, B., Camp, C. J., Runci, S. J., Taffe, J., & O’connor, D. W. (2012). A randomized crossover trial to study the effect of personalized, one-to-one interaction using Montessori-based activities on agitation, affect, and engagement in nursing home residents with Dementia. International Psychogeriatrics, 25(4), 565–575. doi: 10.1017/s1041610212002128

Problem Statement/Purpose: Dementia is often complemented with agitation, aggression, disinhibition, and other challenging behaviors.  These behaviors reflect patient’s suffering; they create a stressful working environment for staff; and they greatly increase the costs of care.  In the study, researchers compared the levels of observed agitation, affect, and engagement in nursing home residents with dementia and associated high-frequency behavioral symptoms before, during and after personalized activities using the Montessori principles and a relevant control condition.  Research Questions: This randomized crossover design investigated three questions: (1) social interaction alone significantly improves agitation, mood, and engagement; (2) the Montessori-based intervention has a benefit over and above those resulting from social interaction; and (3) because the intervention can be delivered non-verbally, they have more positive outcomes for people who have lost fluency in English. 

Population: There were 44 participants which consisted of 30 females and 14 males with an average age of 78.1 years old.  The Clinical Dementia Rating (CDR) was conducted and found 29 had severe dementia, 13 had moderate dementia, and 2 had mild dementia. 

Design of Study: The crossover study observed three types of engagement including constructive, passive, and negative. 

Conclusions: The Montessori Method and the control condition displayed the greatest increase in constructive and passive engagement during and after the sessions.  The negative engagement score lowered during intervention but returned to the score before intervention.  Both the Montessori intervention and the control condition may assist in nursing home settings according to the results.  

2. Sheppard, C. L., Mcarthur, C., & Hitzig, S. L. (2016). A Systematic Review of Montessori-Based Activities for Persons With Dementia. Journal of the American Medical Directors Association, 17(2), 117–122. doi: 10.1016/j.jamda.2015.10.006

Problem statement: Along with the increasing aging population, the number of individuals diagnosed with dementia is rapidly growing.  In 2010, it was estimated that there were 35.6 million people worldwide with dementia, a number expected to double over the next 20 years. 

Purpose: Systematically assess the quality of the research examining the benefits of Montessori-based activities for persons with dementia.

Rationale: With the growing number of people developing dementia, it is imperative that clinicians and policy-makers have an understanding on the quality of evidence related to the clinical efficacy of available Montessori-based interventions for mitigating the challenges associated with dementia. 

Population: 150 articles were reviewed from six peer-reviewed databases. 

Design of Study: Systematic review

Conclusions: There was a mix of strong level-1 and level-2 evidence, as well as weak level-4 evidence suggesting that Montessori programming heightened constructive engagement, reduced passive engagement, and promoted a more positive affect in persons with dementia. 

3.  Jarrott, S. E., Gozali, T., & Gigliotti, C. M. (2008). Montessori programming for persons with dementia in the group setting. Dementia, 7(1), 109–125. doi: 10.1177/1471301207085370

Purpose: Detail the results of a modified Montessori program designed to support occupation and positive affect of persons with dementia in a small group setting.

Research Questions: (1) Participants will exhibit higher levels of constructive engagement and lower passive engagement, non-engagement, and self-engagement during Montessori activities. (2) Participants will experience more positive affect during Montessori activities than traditional acquired demyelinating syndrome (ADS) activities

Population: 10 individual ADS clients (5 females and 5 males) with dementia.  Participants ranged in age from 74 to 97 years old with a mean age of 83.4.  The Mini-Mental State Examination (MMSE) scores ranged from 8 to 26 with a mean of 18.2. 

Design of Study: Single-subject design

Conclusions: The first hypothesis, which stated that participants would exhibit higher active engagement and lower passive engagement, self-engagement, and non-engagement during Montessori activities compared to traditional activities, was supported for three of four engagement categories.  During Montessori programming participants engaged in constructive engagement more than other engagement categories.  Our results did not support the second hypothesis that positive affect would be higher during the Montessori-based activities compared to traditional activities.

4. Giroux, D., Robichaud, L., & Paradis, M. (2010). Using the Montessori Approach for a Clientele with Cognitive Impairments: A Quasi-Experimental Study Design. The International Journal of Aging and Human Development, 71(1), 23–41. doi: 10.2190/ag.71.1.b

Problem Statement: The steady increase in the number of people with dementia, due, among others, to longer life expectancy, is a growing concern in our society

Purpose: The main goal is to measure the effect of the use of the Montessori approach and activities on people with moderate to severe dementia.

Rationale for the Study: As a result of lack of tools and trained staff to adequately intervene with the heterogenous and growing clientele of patients with moderate to severe dementia, administrators find it difficult to identify appropriate and effective activities. 

Research Questions: (1) The Montessori approach would allow for increasing the self-esteem and accomplishment of individuals suffering from dementia if the activities are corresponding to the capacities and interests of the spersona and that will be observable through the affect, the behaviors, and the participation in the activity. (2) The participants should have a more positive affect during the experimental activities than during regular activities. (3) We should observe a more active participation and less disruptive behaviors during the experimental activities. 

Population: Fourteen participants from a nursing home for veterans were recruited for the study.  The article does not specify if all participants were male but it can be assumed.  All participants experienced mild to severe cognitive impairments.  The Mini-Mental State Examination was conducted on and the residents ranged from 6 to 23 with an average of 15.4.

Design of Study: Quasi-experimental

Conclusions: The use of this approach has a positive impact on affect and participation of people with dementia.  They appear to be more cheerful, show more signs of pleasure, and present fewer signs of anxiety, anger, or fear when they participate in Montessori activities. 

5. Beerens, H. C., Boer, B. D., Zwakhalen, S. M., Tan, F. E., Ruwaard, D., Hamers, J. P., & Verbeek, H. (2016). The association between aspects of daily life and quality of life of people with dementia living in long-term care facilities: a momentary assessment study. International Psychogeriatrics, 28(8), 1323–1331. doi: 10.1017/s1041610216000466

Purpose/Problem Statement: To improve the quality of life of people with dementia living in long-term care facilities, insight into the association between quality of life and how people spend their daily lives is urgently needed.  

Rationale for the Study:  Quality of life of persons with dementia living in long-term care facilities remains a priority in dementia research.

Research Questions: (1) How does the daily life of persons with dementia living in long-term care facilities with a high quality of life differ from those with a lower quality of life? (2) Which aspects of the daily lives of persons with dementia living in long-term care facilities are associated with quality of life?

Population: 18 long-term care facilities in 8 locations in the southern provinces of the Netherlands.  All participants with a formal diagnosis of dementia were included, except if they had a primary psychiatric diagnosis.  115 participants were included in this study with a  mean age of 84.  Most participants were female (75%) and widowed (66%).  The mean Standardized Mini-Mental State Examination (S-MMSE) score was 8.5, which indicates severe cognitive impairment.  The median quality of life score was 31.7 in persons with dementia before the study was conducted. 

Design of Study: Observational study that includes ecological momentary assessments

Conclusions: Residents with a higher quality of life carried out less passive/purposeless activities, were more engaged in active, expressive, and social activities, had more social interaction, and had better mood scores than residents with a lower quality of life. 

6. Orsulic-Jeras, S., Schneider, N. M., & Camp, C. J. (2000). Special Feature: Montessori-based activities for long-term care residents with dementia. Topics in Geriatric Rehabilitation, 16(1), 78–91. doi: 10.1097/00013614-200009000-00009

Purpose:Use of dementia-appropriate materials and activities can reduce agitation and other problem behaviors.

Problem Statement: Studies have shown that behavioral disturbances, such as apathy and agitation, are prominent in persons in the more advanced stages of Alzheimer’s disease.

Rationale for the Study: Studies have shown that behavioral disturbances, such as apathy and agitation, are prominent in persons in the more advanced stages of Alzheimer’s disease.

Research Questions: (1) Long-term care residents would display higher levels of constructive engagement, lower levels of passive engagement and more positive affect during Montessori programming than during regular activities programming. 

Population: The participants included 16 residents (14 women) with Mini-Mental State Examination scores ranging between 0 and 19, with a mean score of 6.1.  The participants ages ranged from 79 to 94 years old with a mean of 88.  Standardized and validated measures of functional status, depression, and agitation levels were taken at the beginning of the study indicated relatively low levels of functional status, low levels of depression, and little agitation among the residents.  

Design of Study: Observational study

Conclusions: Significantly more constructive engagement (defined as verbal behaviors in response to an activity), less passive engagement (defined as observing an activity), and more pleasure while participating in Montessori-based programming than in regularly scheduled activities programming.

7. Vance, D., & Johns, R. (2003). Montessori improved cognitive domains in adults with Alzheimer’s disease. Physical & Occupational Therapy In Geriatrics, 20(3), 19–33. doi: 10.1300/j148v20n03_02

Purpose: Activities assist older adults to maintain physical and cognitive health as well as for adults with Alzheimer’s disease and related dementias

Problem Statement: There is substantial difficulty in finding tasks that can be effectively used by adults with decreased cognitive ability.

Rationale for the Study: To determine how well Montessori benefits persons with Alzheimer’s Disease.

Research Questions: (1)  To determine if specific cognitive domains or abilities were more sensitive to the benefits of the Montessori intervention. (2) It was hypothesized that adults with Alzheimer’s disease who interacted with these materials in their day-care setting would experience beneficial outcomes as measured by delays in different domains of cognitive impairment, including attention, memory, and information processing

Population: The participants were recruited from two adult day-care centers in New Orleans, LA.  Adults who scored 23 or lower on the Mini-Mental Status Examination (MMSE) were considered for the study; the average MMSE was 10.60.  Fifteen of the original 36 participants were unavailable for full analysis; 21 participants were dropped before or during the study due to deteriorating cognition, death, hospitalization or withdrawal from the adult day-care center.  Of the remaining 15 participants, 6 were African American, 9 were Caucasion, three were men, and 12 were women.  The average age of the participants was 77.80 years old. 

Design of the Study: Within-subject design

Conclusions:  The results from this analysis revealed strong support for the Montessori materials to be an effective therapy in ameliorating specific cognitive function with people with moderate to severe Alzheimer’s disease. Although the effects are limited to small changes on neuropsychological tests, it indicates a potential to help adults with Alzheimer’s disease to maximize existing cognitive abilities.

8. Judge, K. S., Camp, C. J., & Orsulic-Jeras, S. (2000). Use of Montessori-based activities for clients with dementia in adult day care: Effects on engagement. American Journal of Alzheimer’s Disease, 15(1), 42–46. doi: 10.1177/153331750001500105

Problem Statement: Persons with dementia exhibit a number of problematic behaviors, when these people are presented with tasks that are beyond their level of functioning, these problem behaviors tend to increase.

Purpose: Investigate methods for developing activities that can be used as forms of intervention for problem behaviors in Alzheimer’s disease and related disorders.

Rationale for the Study:  Researchers report that problem behaviors such as agitation can reduced in frequency and/or intensity when persons with dementia are engaged in stimulating and appropriate activities.

Research Questions: (1) Clients who take part in Montessori-based programming would be more engaged with their social and physical environments than persons not taking part in Montessori activities.

Population: Nineteen participants (11 women and eight men) completed the study.  The Mini-Mental State Examination scores ranged from 7 to 24 with a mean of 17.  All participants were diagnosed by a neuropsychologist, with 14 having probable or possible Alzheimer’s disease, three having probable or possible vascular dementia, and two having mixed dementia.  The participants ranged in age from 60 to 101 years, with a mean age of 81.  76% of participants were Caucasion and 24% were African-American.  Measures of functional status, depression, and agitation indicated relatively high functional status, low depression, and little agitation among these clients.

Design of the Study: Single-subject design

Conclusions: Persons with dementia in an adult day care setting showed significantly more constructive engagement when taking part in Montessori-based activities than in regular programming.  In addition, there was a reduction in passive engagement compared to levels seen in regular programming in some circumstances.

9. Lee, M. M., Camp, C. J., Malone, M. L. (2007). Effects of intergenerational Montessori-based activities programming on engagement of nursing home residents with dementia. Clinical Interventions in Aging, 2(3), 477- 483.

Problem Statement: Caregivers often have expressed anxiety regarding provision of intergenerational activities to persons with dementia, especially those activities involving young children. Concerns have involved agitation, frustration, or aggressiveness potentially being demonstrated by older adults in these contexts, while children have been expected to show confusion or apprehension when interacting with persons with dementia.

Purpose: When the Montessori Method is combined with interacting with young children, the structure provided by this programming works to increase engagement in these older adults with dementia compared with other forms of programming

Rationale for the Study: Intergenerational group program was associated with significantly higher levels of positive affect in older adults with dementia compared to non-IGP activities

Research Question: (1) The effects of Montessori-based activities used in intergenerational group programs (IGP) for residents of a special care dementia unit within a skilled nursing facility.  (2) Can the findings of Camp et al (1997) be replicated and extended into the domain of positive forms of engagement. 

Population: Older adult participants were 14 nursing home residents with a diagnosis of dementia (86% with probable or possible Alzheimer’s disease while the rest, 14%,  had a diagnosis of possible vascular dementia) .  Participants were all Caucasian, predominantly female (93%), and ranged in age from 85 to 94 years old with a mean of 90.2.  Scores on the Mini-Mental State Exam (MMSE) ranged from 5 to 25 with a mean of 14.57, indicating minimal to severe cognitive impairment.  Fifteen children from the facility’s on-site child care center also took part in the study.  Children ranged in age from 2 ½ to 5 years old.    

Design of Study: Single-subject design.

Conclusions: This approach elicited higher levels of positive (ie, constructive) engagement and lower levels of negative (ie, merely passive or non-activity focused) engagement in long-term care residents with dementia than standard activities programming.

10. Skrajner, M. J., & Camp, C. J. (2007). Resident-Assisted Montessori Programming (RAMP™): Use of a small group reading activity run by persons with dementia in adult day health care and long-term care settings. American Journal of Alzheimer’s Disease & Other Dementias®, 22(1), 27–36. doi: 10.1177/1533317506297895

Problem Statement: The need to provide meaningful activities for persons with dementia is an important challenge to caregivers in a variety of settings. 

Purpose: Develop a program where persons with dementia can engage in meaningful, age-appropriate activities and to offer persons with dementia social roles that are challenging and yet can be successfully filled.

Rationale for the Study: Social engagement can reduce agitation, depression, wandering, and the use of chemical restraints.

Research Questions: (1) Persons with dementia can successfully lead small group Montessori activities.

Population: One assisted living resident, 2 nursing home special care unit residents, and 3 clients from an adult day health center were trained to lead a Montessori-Based Reading Activity called Question Asking Reading.  These “leaders” were nominated by meeting the following criteria: (1) aged 65 and older; (2) diagnosis of dementia and/or a score of 23 or below on the Mini Mental State Examination (MMSE); (3) capable of reading large-print text; (4) capable of following simple two-or three-step instructions; and (5) have strong social skills.  Five of the six leaders were female and ages ranged from 75 to 93. A total of 22 persons participated in the study and met the following criteria: (1) aged 60 and older and (2) diagnosis of dementia and/or score of 23 or below on the MMSE.  Almost all of the participants were women (21 out of 22).  Participants had moderate to advanced dementia. 

Design of the Study: Single-subject design.

Conclusions: Participants taking part in RAMP™ generally exhibited significantly more constructive engagement and pleasure, and a decreased amount of other and non-engagement, during Treatment (RAMP™) in client-led activities.