dementia 6(1)

Her Majesty’s Government (2005). Opportunity age: Meeting the challenges of ageing in the 21st
century. London: Department for Work and Pensions.
Her Majesty’s Government/Department of Health (2006). Our health, our care, our say: A
new direction for community services, Cm 6737. London: Department of Health.
Heywood, F., Oldman, C., & Means, R. (2002). Housing and home in later life.
Buckingham: Open University Press.
Netten, A. (1993). A positive environment? Physical and social influences on people with senile
dementia in residential care. Aldershot: Ashgate.
Nicholson, A.-M., & Heather, M. (2004). Design principles for extra care. Housing Learning &
Improvement Network Factsheet no 6. London: Department of Health.
O’Malley, L., & Croucher, K. (2005). Housing and dementia care – a scoping review
of the literature. Health & Social Care in the Community, 13(6), 570–577.
Office of the Deputy Prime Minister (2004). Supporting people: Review of the development of
policy and costs of housing-related support since 1997. London: Office of the Deputy Prime
Minister.
Sullivan, E. (2004). Review of the supporting people programme. Independent report. London: RSM
Robson Rhodes LLP.
Vallelly, S., Evans, S., Fear, T., & Means, R. (2006). Opening doors to independence: A
longitudinal study exploring the contribution of extra care housing to the care and support of older people
with dementia. London: Housing 21.

S I M O N E VA N S , T I N A F R E A R , R O B I N M E A N S
Faculty of Health and Social Care, University of the West of England, Bristol BS16 1QY, UK.
[simon.evans@uwe.ac.uk]
S A R A H VA L L E L L Y
Housing 21,The Triangle, Baring Road, Beaconsfield, Buckinghamshire HP9 2NA, UK.

Montessori-Based Dementia Programming®: Providing

tools for engagement
M E G A N L . M A L O N E A N D C A M E RO N J. C A M P

We take note of all the details of a disease and yet make no account of the
marvels of health.
(Montessori, 1966, p. 45)
The greatest source of discouragement is the conviction that one is unable to
do something.
(Montessori, 1966, p. 169)
Barriers . . . are quite difficult to overcome . . . An inner wall is built up which
closes the spirit and conceals it as a defense against the world. . . . The soul is
frequently separated from all that is beautiful outside that could be a source of
happiness.
(Montessori, 1966, p. 160)

150
 m o r i a rt y: i n n ovat i v e p r ac t i c e
Introduction
The single greatest barrier to the provision of high quality care for persons
with dementia is not a lack of resources, but a belief. It goes by many
names, but the most prominent is that of ‘therapeutic nihilism’ (Camp,
2006b; Clark, 1995). This refers to the belief that because persons have
dementia, they are incapable of learning new things, incapable of showing
anything but decline, and that the best caregivers can do is be patient and
deliver palliative care as the inevitable deterioration of dementia unfolds.
This is, in essence, learned helplessness on a system-wide scale. It results,
in large part, because of an overemphasis on the deficits associated with
dementia (driven by a primary emphasis on diagnosis and treatment of
deficits), to the exclusion of acknowledging and utilizing the strengths and
abilities still available to persons with dementia. Therapeutic nihilism is
insidious because it destroys hope and condones acceptance of the status
quo. How, then, is this barrier to be overcome?
Kitwood (1997) was an especially powerful challenger of therapeutic
nihilism. For example, he described how negative expectations and
negative attitudes regarding dementia could create self-fulfilling prophe-
cies. Kitwood was one of the first to discuss the concept of rementing, the
ability of persons with dementia to sometimes show improvements in their
condition, rather than accept that dementia always produced continual
decline. He also emphasized the role of the interactions between social
systems, physical environment, and the individual in determining quality
of care and quality of life for persons with dementia. As a result of his work
and that of like-minded individuals, a shift has resulted in philosophy of
care provision for persons with dementia. The use of a psychosocial model
is replacing that of the medical model in dementia care.
Phrases such as ‘helping persons reach their optimal level of fulfill-
ment’,‘enriching the lives of our residents’, and ‘promoting the well-being
of older adults’ can be found in the mission statements of most facilities
or programs caring for older adults today. How a facility or program goes
about meeting these goals is a challenge that is faced every day by the staff
members of these facilities. Family members of persons with dementia also
are faced with how to best care for their loved one, while keeping them as
active and independent as possible. Staff of Myers Research Institute of
Menorah Park Center for Senior Living, Beachwood, Ohio, USA, led by its
director (Cameron Camp, Ph.D.), have been involved in research on the use
of an innovative programming method called Montessori-Based Dementia
Programming®, hereafter abbreviated to MBDP® to help facilities,
programs, and families reach these goals more effectively, and combat the
intrusion and effects of therapeutic nihilism.

151
dementia 6(1)
Origins of MBDP®
The need for quality activity programming for persons with dementia,
which engages people while utilizing their remaining skills and abilities
and attending to their past interests, occupations and so on is the foun-
dation of MBDP®. Italian educator Maria Montessori developed the
Montessori system of education in the early 1900s, when she became
concerned about a group of underprivileged children who were labeled
‘unteachable’. Montessori believed education to be a means of increasing
quality of life, and was convinced that these children would be able to learn
if they were shown alternate ways to experience their environment. She
observed that children learn in different ways and at varied paces. After
gathering this information, Montessori developed specific principles, based
on rehabilitation techniques, which make up her unique teaching method.
They are reflective of her training in rehabilitative medicine. See Chattin-
McNichols (1992) for an introduction to Montessori’s life and work.
These principles have guided the staff of Myers Research Institute in
creating a body of research for memory-impaired geriatric populations
which focuses on improving their physical, social and emotional engage-
ment with their environments. This research has involved adapting the
principles and structure of Montessori’s educational method to the needs
of older adults with cognitive impairment in the settings of skilled nursing
facilities, assisted living facilities, community programs such as adult day
care facilities, and within a person’s home (Camp, 2006a; Camp, Orsulic-
Jeras, Lee, & Judge, 2004; Gorzelle, Kaiser, & Camp, 2003; Plautz & Camp,
2001; Vaillancourt & Hage, 2005). Our research also has focused on
training the staff of such facilities, home health workers, and family
members to apply Montessori-based methods to maintain or improve the
level of functioning and independence of these individuals while improv-
ing the overall quality of their lives.

Principles of MBDP®
All MBDP® activities are set up in a similar format, following the prin-
ciples created by Dr Montessori, but adapted to meet the unique needs of
older adults. The activities are considered to be ‘self-correcting’, because
they provide clues to let an individual know if a task has been successfully
completed. For example, you may show a participant a card with a large,
medium, and small circle on it (template). When handing a participant a
cutout of a large circle, the template will serve as a cue to show the partici-
pant that the cutout will only match the large circle’s outline.
Demonstrating how an activity can be completed before asking an indi-
vidual to try it on his or her own is another key concept to this method.
This allows a participant to focus on the procedure of doing the activity

152
 m o r i a rt y: i n n ovat i v e p r ac t i c e
itself, rather than the sometimes confusing verbal directions that typically
accompany introducing an activity or task.
Montessori-based activity items are taken from the everyday environ-
ment, and thus are very familiar in terms of sight and touch. It has been
found in previous research that interacting with these materials provides
access to long-term memory through reminiscence and sensory stimulation.
Adapting Montessori’s principles to apply to persons with dementia
helps to engage those with dementia by tailoring programming to their
current level of functioning. The advantage of this system is that it gives
staff and family members more options for working with persons with
dementia, even as they decline. Caregivers of persons with dementia often
have low expectations of people with the condition. They may feel that
simply keeping the person ‘comfortable’ is all they can do. MBDP® provides
a way for a person’s remaining abilities to be maximized while a person is
engaged in an activity that is interesting and meaningful to them.

MBDP® activity examples

MBDP® activities can be structured to be used in one-on-one, small group,
or large group situations. As stated earlier, activities are chosen for an indi-
vidual based on their abilities and interests. Examples include sorting
pictures or words into categories such as ‘Fruits versus Vegetables’, which
may be given to someone who enjoyed gardening, or ‘Cities in Europe
versus Cities not in Europe’ for someone who enjoyed travel or geography.
Fine motor tasks such as using scissors to cut out pictures to be used in the
category sorting activities or using a screwdriver to help repair a faucet are
activities that can provide practice in maintaining fine motor function
while allowing individuals to create or produce items as a result of their
practice, which is another key Montessori concept.
Persons in the mild to moderate stages of dementia may meet their
social needs through participation in a Montessori-based group activity,
and can also serve as group leaders for these and other activities. An
example of a MBDP® group activity is Reading Roundtable®. Reading Roundtable®
is a unique reading and discussion activity that adapts printed stories to
the abilities of persons with dementia. Each story is in large-print, consists
of cues to guide participants through the story, and is about a topic that
may be of interest to an adult, such as Leonardo da Vinci. The activity is
structured so a group of participants can experience the story together by
each in turn reading a page of the story aloud to the rest of the group and
then asking and answering related discussion questions. Participants can
choose to lead the reading group, read along with the story, or simply
listen to the story. Having a role to fulfill, whether it is leading a group
or simply being a part of one, helps to substantially reduce levels of

153
dementia 6(1)
anxiety or agitation, and fulfills normal and healthy needs for belonging,
security, and self-esteem.
Through this research, Myers Research Institute has been reminded that
persons with dementia have not lost the desire to feel important and
included, and are interested in being exposed to new ideas and infor-
mation. As we say in our training sessions, ‘If you (the caregiver) are bored
by the activity, they (the persons with dementia in your care) are bored by
the activity’. The use of MBDP® can enable persons with dementia to
express their interests, their memories, and ultimately themselves, and
allow staff and family members to play a pivotal role in this process.
For more information on Montessori-Based Dementia Programming®,
including information about MBDP® activities, manuals, and products, and
information about the work of Myers Research Institute and our training
programs, please visit www.myersresearch.org. Readers in the UK in-
terested in purchasing manuals should visit www.winslow-cat.com.

Case study
Client description M was an 85 year-old woman with moderate stage
dementia residing in a long-term care facility. M often refused to take part
in the activities that were offered at the facility, preferring to stay in her
room alone most of the time. This put her at risk for becoming isolated
due to her lack of social interaction.

MBDP® activity The MBDP® activity chosen for M was arranging flowers.
This activity required M to take silk flowers and arrange them in a basket
filled with floral foam, which held the flowers in place once they were
arranged. This activity enhances the use of fine motor skills such as the
pincer grip with fingers (picking up the flowers), and strength (pressing
against the resistance of the floral foam when arranging the flowers), along
with allowing the client to make choices (which flowers to use, where to
place them, and so on.) M had once enjoyed gardening, so it was surmised
that she might find this activity meaningful.
The facility staff member in charge of activities and programs was the
facilitator of the activity. On the first day the activity was introduced, the
staff member walked into M’s room and introduced herself. She asked M
if she would like to arrange flowers with her. M replied that she had no
interest and refused to participate. Not to be discouraged, the staff member
replied, ‘Would it be alright if I worked on the arrangement myself in your
room? It’s very crowded out in the dining room.’ M replied that the staff
member could stay. The staff member began to work on the arrangement
independently and would periodically ask M which flower to use in the

154
 m o r i a rt y: i n n ovat i v e p r ac t i c e
arrangement or where it should be placed. Sometimes M would reply that
she didn’t care. Other times, M would offer a suggestion. The staff member
completed the arrangement and thanked M for her time.
The following day, the staff member returned to M’s room with the
flower arranging activity. She again asked M if she would like to participate.
Once again, M refused. The staff member again asked if she could work on
the activity in M’s room. M agreed. This time the staff member tried to
involve M in the activity more by presenting two flower choices to her and
asking her which she should use. At first M hesitated, but eventually she
would make a choice. This continued for the remainder of the session, with
the staff member asking M which flowers to use or how to arrange them.
Throughout the session, M reminisced about her garden and her favorite
flowers and smiled a great deal, but she did not manipulate the flowers
herself. Near the end of the session, M instructed the staff member to place
a flower on the right side of the basket. The staff member placed it on the
left side of the basket instead. M leaned forward and moved the flower back
to the right side, marking the first time M had manipulated any of the
activity materials. The activity ended with the staff member asking M if she
would like to arrange the flowers again sometime. M replied, ‘As long as
you follow my directions, I will!’ The following day, the staff member
returned to M’s room. Upon walking through the door, M immediately sat
up in her bed and asked if they were going to work with the flowers.

MBDP® principles involved in this activity included:

• Providing a meaningful activity based on remaining skills (fine motor
skills, color discrimination, making choices between two items and so
on);
• Use of everyday/familiar materials (silk flowers, basket);
• Beginning the activity with an invitation;
• Demonstrating how to complete the activity;
• Breaking the activity down into steps;
• Providing closure to the activity by asking the client if they would enjoy
doing the activity again at another time.

Discussion
This case study highlights several important points. First and foremost, it
illustrates that all individuals, no matter what their level of impairment,
can, and should, be provided with opportunities to engage in meaningful
activity. Also, it highlights that some people should be eased into activity
by gradually doing portions of the activity until they discover that they can,
in fact, successfully engage in it. The staff member would invite M to

155
dementia 6(1)
participate in the activity, and if M refused, the staff member would work
on the activity in M’s room alone to spark her interest in the activity and
build rapport. Small choices and decisions, such as which flower to use and
where to place it, were made by M along the way to increase overall
involvement. By the third day, M had become comfortable with the staff
member and her ability to arrange the flowers, and was sitting up in antici-
pation of the activity when the staff member would come into M’s room.

Conclusions
Camp (2001; 2006a; 2006b) discussed the process of translating research
outcomes into practice in the field of dementia care. For this to happen,
interventions must be able to be applied without the assistance of research
staff. Interventions must have face validity to caregivers and those in their
care. And, perhaps most importantly, providing the interventions must take
place within the contexts of regular care routines. At the Myers Research
Institute, we have been working to develop training materials to enable
professional and lay caregivers to apply MBDP® within such contexts, and
to provide evidence to administrators and supervisory staff that such an
approach to activities programming makes sense. This is true both in terms
of reducing ‘problematic behaviors’ (Camp, Cohen-Mansfield, & Capezuti,
2002; Camp & Nasser, 2003) and as a better business model. It is only after
caregivers adopt interventions as ‘their own’ that dissemination and a true
and lasting culture change can take place.
A social change of this type cannot come from the ideas or energies of
individual reformers but from a slow and steady emergence of a new world
in the midst of the old . . .
(Montessori, 1966, p. 207)

Acknowledgements
Support for preparation of this manuscript was provided by grant 21 MH063395-01A2
from the National Institute of Mental Health and from grant R01 AG021508-01A1
from the National Institute of Aging to Dr Camp, Principal Investigator.

References
Camp, C.J. (2001). From efficacy to effectiveness to diffusion: Making the transitions
in dementia intervention research. Neuropsychological Rehabilitation, 11(3–4), 495–517.
Camp, C.J., Cohen-Mansfield, J., & Capezuti, E.A. (2002). Use of nonpharmacologic
interventions among nursing home residents with dementia. Psychiatric Services,
53(11), 1397–1401.
Camp, C.J., & Nasser, E.H. (2003). Nonpharmacological aspects of agitation and
behavioral disorders in dementia: Assessment, intervention, and challenges to
providing care. In P.A. Lichtenberg, D.L. Murman & A.M. Mellow (Eds.), Handbook of
dementia: Psychological, neurological, and psychiatric perspectives (pp. 359–401). New York,
NY: John Wiley & Sons, Inc.

156
 m o r i a rt y: i n n ovat i v e p r ac t i c e
Camp, C.J. (2006a). Montessori-based dementia programming™ in long-term care:
A case study of disseminating an intervention for persons with dementia. In L.
Hyer & R. Intrieri (Eds.), Geropsychological interventions in long-term care (pp. 295–314).
New York, NY: Springer Publishing Company, Inc.
Camp, C.J. (2006b). Spaced retrieval: A case study in dissemination of a cognitive
intervention for persons with dementia. In D. Koltai Attix & K.A. Welsch-Bohmner
(Eds.), Geriatric neuropsychological assessment and intervention (pp. 275–292). New York,
NY: The Guilford Press.
Camp, C.J., Orsulic-Jeras, S., Lee, M.M., & Judge, K.S. (2004). Effects of a Montessori-
based intergenerational program on engagement and affect for adult day care
clients with dementia. In M.L. Wykle, P.J. Whitehouse & D.L. Morris (Eds.), Successful
aging through the life span (pp. 159–176). New York, NY: Springer Publishing
Company, Inc.
Chattin-McNichols, J. (1992). The Montessori controversy. Albany, NY: Delmar Publishers Inc.
Clark, L.W. (1995). Interventions for persons with Alzheimer’s disease: Strategies for
maintaining and enhancing communicative process. Topics in Language Disorders, 15(2),
47–65.
Gorzelle, G.J., Kaiser, K., & Camp, C.J. (2003). Montessori-based training makes a
difference for home health workers and their clients. CARING magazine, 22(1), 40–42.
Kitwood, T. (1997). Dementia reconsidered: The person comes first. Buckingham: Open
University Press.
Montessori, M. (1966). The secret of childhood (M. J. Costello, Trans.). New York:
Ballantine Books.
Plautz, R.E., & Camp, C.J. (2001). Activities as agents for intervention and
rehabilitation in long-term care. In B.R. Bonder & M.B. Wagner (Eds.), Functional
performance in older adults (2nd edn., pp. 405–425). Philadelphia, PA: FA Davis
Company.
Vaillancourt, D., & Hage, S. (2005). Montessori-based programming and spaced-
retrieval techniques: An interview with Megan Malone. Activities Directors’ Quarterly for
Alzheimer’s & Other Dementia Patients, 6(1), 22–27.

MEGAN L. MALONE, CAMERON J. CAMP

The Myers Research Institute, Menorah Park Center For Senior Living, Menorah Park, 27100
Cedar Road, Beachwood, Ohio 44122 USA.
[Ccamp@myersri.com]

Helping students understand aging and dementia: An

innovative program
C H R I S T I N E A . F RU H AU F

Introduction
Educators in the field of gerontology often find their students have limited
contact in working with older adults and specifically with those adults who
have dementia. The purpose of this paper is to outline a program used with

157