In 1983, geropsychologist Cameron Camp, PhD, was frustrated. Although he had successfully used traditional memory interventions, such as simple mnemonic techniques, to help older adults improve their cognition, those interventions were largely ineffective for people with dementia, Alzheimer's disease or other types of cognitive impairment.
Camp wanted to find ways to improve those individuals' engagement with others and their overall quality of life.
In a happy coincidence, Camp's children had started at a local Montessori school at about the same time. As he watched his children blossom in their school environment, he took note of the method's focus on independence and social engagement and wondered if he could adapt the Montessori approach for people with dementia and Alzheimer's disease.
That adaptation is now known as the Montessori-based Dementia Programming Method, a series of interventions aimed at helping people with dementia improve their motor and cognitive skills to better participate in the world around them. And several studies have shown that its focus on teaching over enabling greatly improves constructive engagement, or appropriate motor or verbal behaviors in response to a specific situation, in this population. (See "Further reading".)
Since 2000, Camp and his colleagues at the Center for Applied Research in Dementia, in Solon, Ohio, have trained thousands of caregivers and family members across dozens of homes and care centers, in the United States and abroad, in this method. In an interview with the Monitor, Camp discussed how psychologists can help people with dementia to lead fuller, healthier lives by tweaking their physical and social environments and, above all, treating them the way we would like to be treated.
What made you think that the Montessori approach might help people with dementia and Alzheimer's disease?
When I looked at the Montessori techniques, I could see that they were based on learning by doing as opposed to the verbal training that is so typical in other interventions. Montessori focuses on abilities rather than disabilities, and how to circumvent deficits. All the dots just connected and I began dabbling, using some of the Montessori teaching methods in the day centers where I was working. And the more we used it, the more we found that it really worked.
It's basically a new paradigm for dementia care. The emphasis is on creating communities of people with dementia and giving them as much independence as possible. They are given control of their own lives. In a Montessori school, it's the children who manage the environment. They manage meals and serve the food. And that's what we're doing. We're teaching people how to engage people with dementia, how to focus on abilities rather than deficits, and how to create meaningful social roles for them so they can remain engaged and present.
Our approach is about trying to live well with dementia, just as we would try to live well with any chronic disability or condition. It's about providing a good quality of life as the treatment modality. The current system isn't providing it because too often people with dementia are put on medications to address their cognitive deficits. But pharmacological treatment should be the treatment of last resort, not first resort. The role of any pharmacological treatment should be to enable non-pharmacologic interventions to be used more effectively.
How does the method work in a typical care center?
If you look around a place that has been retrofitted with our model, you'll see a lot of signs. You'll see a sign listing what job each resident has for the day — each resident has some job to do. There's a sign next to the newspaper rack that says, "Please take one and read." Drawers are labeled so people know what's inside. There are all manner of environmental supports, or cognitive ramps, that encourage engagement and a sense of community, as well as to help people use the environment more effectively. Residents serve meals to other residents. It's a community — and it has a different look and feel than traditional models.
And this goes beyond just the community in the care center itself. At a nursing home in the south of France, for example, the residents prepare appetizers for a Sunday afternoon get-together each week. Everyone in the village is invited, as well as the residents' family members and other people they know. So each weekend the residents have to go to the market to shop, come back and prepare the food and then serve and entertain their guests when they come by. Everyone loves these little parties and has a wonderful time.
So, again, this method is a wholly different approach. It's about being connected with life. And that's the sort of model we teach — we want everyone to live the Montessori values of respect, dignity and equality.
What are some of the challenges of adapting the Montessori Method for adults with dementia?
The biggest challenge is that the older models of care are very embedded in the system. You have to work to get past all the assumptions of how dementia care should be done.
These older models include the hospital model where the assumption is that the person with dementia is diseased, so your priority is to treat the symptoms because dementia can't be cured. The emphasis is to deliver medications, keep people safe and not allow them to leave without a doctor's orders. These people are often called "patients" and they are treated like they're sick.
Another popular model is that of a hotel, where people are guests for life and everything is done for them. They don't have to worry about doing anything. But that model doesn't work so well either. Because you do not live in a hotel, you stay in a hotel. And who wants to stay in a hotel indefinitely? People want to live in their homes.
As Maria Montessori once said, "Everything you do for me, you take away from me." So that's a central assumption in our model. We want them to do for themselves. And that's a key assumption that changes the nature of jobs. It changes the nature of the relationship between the person with dementia and the individuals that provide care. Instead of doing for them, they are helping people with dementia to do for themselves, whether it's getting dressed, serving meals or some other activity.
A nursing home in Neuchâtel, Switzerland, that has adopted our approach has totally new guidelines for staff. It's not the hospital or the hotel model of old. It's a new model that assumes the staff are guests at these people's homes. And the staff need to act that way. It's a very different way of thinking with a fundamentally different set of assumptions of the roles, the responsibilities and what constitutes success for treatment and care.
The Montessori approach is very well respected, yet it has not been adopted by the public school system in the United States. Is adopting it for dementia care the same?
It's exactly the same problem. And it all boils down to a single issue: Giving up control. What we do in our training is teach people how to create a residence that is driven by the people who live there. And we always talk about giving up control to the residents. That's very hard for many people because they want to be in control.
It's the same in a school system. The first Montessori school was called the Children's House — and it was their house. The idea was that a teacher's job was to enable the children to do things for themselves and just step back and let them. That's what constituted success. And that's a very foreign concept to people who like regimentation in these kind of institutions.
You've said you wanted to change expectations about what people with dementia are capable of. How can you do that?
We haven't tested the upper boundary of what a person with dementia is capable of doing. We certainly know the lower boundary. We need to create a very different environment for dementia care — an environment that any one of us would want to live in. And people who have started down our path have seen persons with dementia create photography clubs, do improvisational theater, train puppies from rescue shelters, learn how to use chopsticks, put on musicals and really engage with life and the community around them.
The boundaries that are put on persons with dementia are those of our imagination. They are based on untested assumptions so it's simply a question of starting from a different set of assumptions. We know that a person with dementia can learn new procedures. Procedural learning and memory remains intact. So the first question should be, "What procedures would you like persons with dementia to learn?" The second question should be, "What procedures do they want to learn?"
Your work dovetails nicely with new studies that link successful aging to independence, engagement and activity in life. So why, in your opinion, aren't more long-term care facilities taking a different approach to dementia care?
Change is hard, especially when innovation is involved. And, really, it's a matter of education. But we're working very hard to get the word out there because this approach is also a good business model. It results in a reduction in costs, with a drop in the use of psychotropic medications and staff turnover. You have better inspections. You get higher occupancy. And we've seen that in facilities we work with. It's a matter of letting people know that this is all possible. And we're hoping to do enough education and training to reach a tipping point, where people will try it so they can see how well it works for themselves.
Simply put, we need to rethink our role in working with persons with dementia. We need to become enablers in the best sense of the word. We need to see that our role, as family members and professional caregivers, is to enable people with dementia, to give them a reason to wake up in the morning, to offer things to look forward to and to let them play active roles in their homes and communities. We need to change our expectations of what persons with dementia can do, and what our role should be when we work with them. Because the system we create is the one that we'll one day live in. And if we don't change things now, we will get what we deserve.
Kayt Sukel is an author and science writer in Houston.
