So simple, it's genius.

Before visiting Menorah Park to observe a session of its Montessori-based activities for residents with dementia, Editor Linda Zinn spoke with Cameron Camp, PhD, director of The Myers Research Institute, a division of Menorah Park. The Institute is one of only 11 geriatric research centers in the United States located in a long-term care environment. Dr. Camp and his colleagues pioneered the concept of using the Montessori-based activities for people with Alzheimer's disease and related dementias.

The Myers Research Institute has trained activities staffs of more than 100 facilities in the United States, as well as staffs at facilities in Canada and Spain, in the use of these activities. A visiting scientist from Taiwan is also using this approach in her country.

The Institute's manual, Montessori-Based Activities for Persons with Dementia, Volume I (available through Amazon.com), has been translated into Japanese, Spanish, and Mandarin Chinese. More translations are being planned, and Volume II is expected to be released shortly, along with a manual that will instruct family members in how to have better visits with their loved ones with dementia.

What inspired you to adapt the Montessori approach for use in activities for people with dementia?

Dr. Camp: I first saw the Montessori principles in action when I took my son to a Montessori school. The order, the use of materials to guide toward success, and the matching of activities with individuals' abilities seemed to make a lot of sense for persons with Alzheimer's and related dementias. Thus began our research in the early 1990s.

We continue to go back to classrooms and reread Maria Montessori's work to see more ways to translate it into dementia care. For example, in the Montessori classroom, five-year-olds teach lessons to three-year-olds; based on that principle, we train people with early-stage dementia as group activity leaders for people with more advanced disease.

Are there some residents for whom these activities aren't suitable?

Dr. Camp: We try to work with everyone, across all ranges of dementia, but not every resident is receptive at first. If a person is saying, "I don't want to do anything," we have to ask why this is happening. The answer cannot be because this person has dementia. That's a circular argument: i.e., we know this person has dementia because he exhibits problem behavior, and he exhibits problem behavior because he has dementia.

Often the real reason persons with dementia don't want to participate in these activities is fear of failure. They don't want to display less-than-competent behavior, so they use their unwillingness as a defense mechanism--if they say, "Go away," they won't fail. We use the Tom Sawyer approach to overcome their reluctance. For example, I might sit beside a resident, start working at a task, and say, "Don't mind me. I have to get this done. Pay no attention to me." Then I make a mistake and see if they correct it. The idea is to help this person not to feel threatened or overwhelmed, and to give him or her the chance to just observe--observation is also a form of engagement.

What kind of results have you seen with this approach?

Dr. Camp: We've seen better results than those observed with standard activity programming. We've been able to get a significant increase in positive affect/emotion and a significant decrease in problem behavior. When people with dementia are engaged in an activity, they can't be engaged with their social environment by exhibiting problem behavior; they're focusing their attention on a meaningful activity.

This parallels Maria Montessori's experience when she started her first school. She was asked to work with some children in a poor neighborhood in Italy who were getting into trouble and destroying property. She determined that she needed to educate them in order to make them productive members of society.

Sometimes people are skeptical as to whether Montessori-based activities will work, or they doubt that residents will want to participate. One activities director we had trained in the Montessori approach told me, "I had the training, but I didn't necessarily believe the principles would work. I set up the room and the activities and got started. On the morning of the third day, residents were lining up to get in. That's when I knew something was different about this."

When Montessori-based activities are introduced to residents in early stages of dementia, do the benefits continue when their condition worsens?

Dr. Camp: Yes, they do. For example, we had a man with very early Alzheimer's in one of our research projects who still lived in the community. We trained him to run a group activity (Question-Asking Reading) for other residents, and he came to our assisted living facility twice a week. As his disease progressed he became unable to drive, so he switched to taking a cab and continued for another 18 months. Even though his disability had increased, he could still remember enough procedures to run the activity. It was what he looked forward to. He had been a businessman all his life, and he said that this was the most meaningful work he'd ever done. And the other residents with dementia thanked him profusely for making the activity available.

Speaking of group activities, some activities staffs have rather large groups to work with. Do Montessori-based activities work in that setting?

Dr. Camp: You can work with small groups of 5 or 6, or you can work with larger groups. For example, we were training a facility's activities staff, and we asked them what the typical size of their large group activities was. They had 30 people in their groups, for one-hour sessions. They were doing an activity with a beanbag and a rug with bull's-eye rings painted on it. One resident would toss the beanbag, see where it landed, and hand it to the next person. During this game, everyone but the person throwing the beanbag just watched. I said to the staff, "Let me guess. Those tossing and those about to toss the beanbag are awake; the others are asleep." That's typical of group activities in which the entire group isn't directly involved.

After the training, they adapted the activity. The staff flipped the rug over and drew a pie chart on it. In big, thick letters an instruction was written on each wedge of the pie: "Stomp your feet." "Clap your hands." Shout hallelujah." Now they chose the beanbag tosser at random, instead of residents taking turns in a set order--no one sleeps when they don't know who will be chosen next! They chose another resident to read the instruction written on the wedge where the beanbag landed. A staff member repeated the instruction loudly, so that everyone could hear it, and then everyone stomped their feet or clapped their hands, etc. No one was sleeping.

What other types of equipment and supplies can be used for Montessori-based activities?

Dr. Camp: That actually brings up another advantage of this approach. It's a way of thinking, not a $500,000 program or even a $500 program. We start with the assumption that the money isn't there to fund activities. I tell people to simply look at their shelves and think of ways to use everyday things differently.

I understand you're using these activities in the assessment of people with Alzheimer's and related dementias. How does that work?

Dr. Camp: We received a grant from the National Institute on Aging to develop an assessment tool based on Montessori activities, especially for use with restorative nursing and the MDS system. The existing mental status exams are usually intended for people with moderate to advanced disease, but they're not a lot of help with developing a plan of care, and the MDS score doesn't generally tell you what an individual can actually do.

Our assessment answers such questions as "Can this person read?" "What size print is necessary?" "Can this person categorize objects?" Does he think in a concrete or an abstract manner." "Can he put things in order?" How many steps in sequence can he follow?" "Can he hold things and/or manipulate them?"

This is the sort of information that's needed to develop restorative nursing programs. For instance, if a person has a range of motion beyond resting his hands in his lap, we can give him an activity based on what he's interested in. For example, he can categorize operas by their composers or baseball cards by whether the players are in the National or American League. Practicing putting cards in stacks can help people maintain upper-body range of motion as a byproduct of being engaged in something, and we can get them to do it because it involves something they're interested in.

Are you working on any other developments in dementia care?

Dr. Camp: We've been researching something called the "spaced retrieval" technique, which is aimed at helping people remember new information for clinically relevant periods. We have them practice successfully remembering information for the very short term, and then we expand the intervals incrementally. In other words, we ask them to say or do something immediately, then we wait 30 seconds and ask again, then 1 minute, 2 minutes, 4 minutes, etc. We've found that when we push their window of retention beyond 12 minutes or so, the information starts going into their long-term memory. They might not consciously remember the practice exercise or where it took place but, when asked, they remember how to respond.

For example, a nurse at a long-term care facility in Kansas had heard about this technique, so she practiced it with a resident who was a "low talker"--he only would mutter quietly. She would ask him, "When I talk, what should you do?" and had him respond, "Speak loudly!" She repeated the exercise at longer intervals, and he would answer correctly each time.

One day this resident was pacing, agitated, and muttering to himself. He looked like he was going to explode, and the more people asked him what was wrong, the more upset he became. The staff was discussing whether to give him a sedative orally or by injection when the nurse who had practiced spaced retrieval with him arrived. She asked him. "When I talk, what should you do?" He yelled, "Speak loudly!" Then she asked, "Do you have a problem?" And he said. "My feet hurt!" He had a bunion that was hurting him. The fix wasn't a drug--it was to trim his bunion.

Spaced retrieval can also be used to promote safety. For example, you can have a resident practice so that she remembers to pick up her walker before she begins walking, or you can use the technique to help a resident remember to take a sip of beverage after eating a bite of food--whatever behavior you want. It's an extremely flexible intervention, and you can train both staff and family members to use it.

We're also using this method in a National Institute of Mental Health study in which we're working with older HIV-positive adults, to help them remember to take their medications properly. Some of them are taking as many as 16 medications a day, and they often have memory deficits and difficulties with problem solving and many other functions. A 17th pill won't help, but spaced retrieval will.

To contact Dr. Camp or learn more about the work of Myers Research Institute, visit www.myersresearch.org.