A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME).

BACKGROUND AND OBJECTIVES: Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs. RESEARCH DESIGN AND METHODS: Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting. RESULTS: Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention. DISCUSSION AND IMPLICATIONS: CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

Making the Case for Accelerated Withdrawal of Aducanumab.

The controversial approval in June 2021 by the Food and Drug Administration (FDA) of aducanumab (marketed as Aduhelm), Biogen's monoclonal antibody for patients with Alzheimer's disease, raises significant concerns for the dementia field and drug approval process, considering its lack of adequate evidence for clinical efficacy, safety issues, and cost. On 15 December 2021, an international group of clinicians, basic science experts, psychological and social science researchers, lay people with lived experience of dementia, and advocates for public health met to discuss making a recommendation for whether aducanumab's approval should be withdrawn. Attendees considered arguments both in favor of and in opposition to withdrawal and voted unanimously to recommend that the FDA withdraw its approval for aducanumab and to support the Right Care Alliance's filing of a formal Citizen Petition to this effect.

Don't Bother Trying, They Won't Do It! Effect of Responsive Behaviors on the Montessori Assessment System.

OBJECTIVES: The Montessori Assessment System (MAS) is an assessment tool that aims at assessing preserved abilities in persons with moderate to severe dementia and to serve as basis for person-centered interventions. As responsive behaviors are highly frequent in this population, we assessed their possible influence on the MAS administration and results. METHODS: 193 persons with a diagnosis of dementia in the moderate to severe stages living in nursing homes completed the MAS. Responsive behaviors were assessed by the Neuropsychiatric Inventory (NPI). RESULTS: The NPI scores were heterogeneous, but responsive behaviors were present for at least 5 NPI domains in more than 50% of the participants. While NPI scores had weak relationships with MAS completion time and total score, primarily for the hallucinations, euphoria, and aberrant motor behaviors domains, a large majority of the participants fully completed the MAS. CONCLUSIONS: The presence of responsive behaviors as assessed by the NPI does not limit MAS administration, despite minor influence on MAS score and completion time. CLINICAL IMPLICATIONS: The MAS may be applied to persons with moderate to severe dementia presenting responsive behaviors. Assessment of preserved abilities can greatly improve the design of person-centered care plans in this population.

A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia.

OBJECTIVES: One-on-one structured Montessori-based activities conducted with people with dementia can improve agitation and enhance engagement. These activities may however not always be implemented by nursing home staff. Family members may present an untapped resource for enabling these activities. This study aimed to evaluate the impact of the Montessori activities implemented by family members on visitation experiences with people who have dementia. DESIGN: Cluster-randomized crossover design. SETTING: General and psychogeriatric nursing homes in the state of Victoria, Australia. PARTICIPANTS: Forty participants (20 residents and 20 carers) were recruited. INTERVENTION: During visits, family members interacted with their relative either through engaging in Montessori-based activities or reading a newspaper (the control condition) for four 30-minute sessions over 2 weeks. MEASUREMENTS: Residents' predominant affect and engagement were rated for each 30-second interval using the Philadelphia Geriatric Center Affect Rating Scale and the Menorah Park Engagement Scale. The Pearlin Mastery Scale was used to rate carers satisfaction with visits. The 15-item Mutuality Scale measured the carers quality of their relationship with the resident. Carers' mood and overall quality of life were measured using the Center for Epidemiological Studies Depression Scale and Carer-QoL questionnaires, respectively. RESULTS: Linear regressions within the generalized estimating equations approach assessed residents' and carers' outcomes. Relative to the control condition, the Montessori condition resulted in more positive engagement (b = 13.0, 95%CI 6.3-19.7, p < 0.001) and affect (b = 0.4, 95%CI 0.2-0.6, p < 0.001) for the residents and higher satisfaction with visits for carers (b = 1.7, 95%CI 0.45-3.00, p = 0.008). No correction was applied to p-values for multiple comparisons. CONCLUSION: This study strengthens the evidence base for the use of the Montessori programs in increasing well-being in nursing home residents. The findings also provide evidence that family members are an additional valuable resource in implementing structured activities such as the Montessori program with residents.

Denial of Human Rights: We Must Change the Paradigm of Dementia Care.

In far too many instances treatment of persons with dementia has reflected a fundamental denial of basic human rights. At times, these individuals are treated worse than the treatment of animals when the five basic freedoms of animals, described by Pachana in her editorial, are implemented. A number of such examples of dehumanizing (and "de-animalizing") persons with dementia are presented. A case is made for the position that this is the direct result of the "medicalization" of dementia and "Alzheimer Disease." This has led to the disenfranchisement of persons with dementia and their caregivers regarding the treatment of dementia, while medical "expertise" has led to a paradigm of learned helplessness while waiting for "the cure." While the medicalization of dementia has been a financial success in terms of funding failed researcher to find a cure, it has been a catastrophe for the quality of life of persons with dementia and their caregivers. It is time to take control of the treatment of dementia back, and especially to listen to the voices of persons with dementia. It is time to take action NOW - to become disruptive to the current paradigm. The emperor and his cure have no clothes. We deserve better. We must make this change in paradigm our mission, to demand it, and to accept nothing less. Power to the people.

The Lifestyle Engagement Activity Program (LEAP): Implementing Social and Recreational Activity into Case-Managed Home Care.

OBJECTIVES: The Lifestyle Engagement Activity Program (LEAP) incorporates social support and recreational activities into case-managed home care. This study's aim was to evaluate the effect of LEAP on engagement, mood, and behavior of home care clients, and on case managers and care workers. DESIGN: Quasi-experimental. SETTING: Five Australian aged home care providers, including 2 specializing in care for ethnic minorities. PARTICIPANTS: Clients (n = 189) from 5 home care providers participated. INTERVENTION: The 12-month program had 3 components: (1) engaging support of management and staff; (2) a champion to drive practice change; (3) staff training. Case managers were trained to set meaningful social and/or recreational goals during care planning. Care workers were trained in good communication, to promote client independence and choice, and in techniques such as Montessori activities, reminiscence, music, physical activity, and humor. MEASUREMENTS: Data were collected 6 months before program commencement, at baseline, and 6 and 12 months. The Homecare Measure of Engagement Staff report and Client-Family interview were primary outcomes. Secondary outcomes were the Cohen-Mansfield Agitation Inventory; apathy, dysphoria, and agitation subscales of the Neuropsychiatric Inventory-Clinician Rating; the geriatric depression scale; UCLA loneliness scale; and home care satisfaction scale. Staff provided information on confidence in engaging clients and the Utrecht Work Engagement Scale. RESULTS: Twelve months after program commencement, clients showed a significant increase in self- or family-reported client engagement (b = 5.39, t[113.09] = 3.93, P < .000); and a significant decrease in apathy (b = -0.23, t(117.00) = -2.03, P = .045), dysphoria (b = -0.25, t(124.36) = -2.25, P = .026), and agitation (b = -0.97, t(98.15) = -3.32, P = .001) on the Neuropsychiatric Inventory-Clinician. Case managers and care workers both reported significant increases in their confidence to socially and recreationally engage clients (b = 0.52, t(21.33) = 2.80, P = .011, b = 0.29, t(198.69) = 2.58, P = .011, respectively). There were no significant changes in care worker-rated client engagement or client or family self-complete measures of depression or loneliness (P > .05). Client and family self-rated apathy increased over 12 months (b = 0.04, t(43.36) = 3.06, P = .004; b = 3.63, t(34.70) = 2.20, P = .035) CONCLUSIONS: LEAP demonstrated that home care providers can incorporate social and recreational care into usual practice for older clients, and that this benefits clients' engagement, dysphoria, and agitation.

Personalized one-to-one intervention in agitated individuals with dementia: responders versus non-responders.

The aim of the current study was to explore why some individuals with dementia and agitated behavior showed limited response to a personalized intervention. Ten consistently agitated individuals (i.e., non-responders) were compared with 34 individuals who were more settled during the intervention (i.e., responders). Most participants had severe cognitive deficits; however, non-responders were more impaired. Where responders showed large improvements across conditions, agitated behavior remained equally high in non-responders. Responders and non-responders showed increased interest and engagement during the intervention. Increased agitated behavior was associated with severe cognitive impairment. Although studies have shown that psychosocial interventions can reduce agitated behavior, there does seem to be a point where it becomes more difficult to reduce this behavior. However, non-responders still displayed interest, and the authors believe further personalization of the intervention is possible. Therefore, severe dementia and agitated behavior should not exclude individuals from psychosocial interventions; however, a more detailed and timely implementation plan of such treatments may be warranted.

Effects of using nursing home residents to serve as group activity leaders: lessons learned from the RAP project.

Previous research has demonstrated that persons with early to moderate stage dementia are capable of leading small group activities for persons with more advanced dementia. In this study, we built upon this previous work by training residents in long-term care facilities to fill the role of group activity leaders using a Resident-Assisted Programming (RAP) training regimen. There were two stages to the program. In the first stage, RAP training was provided by researchers. In the second stage, RAP training was provided to residents by activities staff members of long-term care facilities who had been trained by researchers. We examine the effects of RAP implemented by researchers and by activities staff member on long-term care resident with dementia who took part in these RAP activities. We also examined effects produced by two types of small group activities: two Montessori-based activities and an activity which focuses on persons with more advanced dementia, based on the work of Jitka Zgola. Results demonstrate that levels of positive engagement seen in players during RAP (resident-led activities) were typically higher than those observed during standard activities programming led by site staff. In general, Montessori-Based Dementia Programming® produced more constructive engagement than Zgola-based programming (ZBP), though ZBP did increase a positive form of engagement involving observing activities with interest. In addition, RAP implemented by activities staff members produced effects that were, on the whole, similar to those produced when RAP was implemented by researchers. Implications of these findings for providing meaningful social roles for persons with dementia residing in long-term care, and suggestions for further research in this area, are discussed.

Study protocol: translating and implementing psychosocial interventions in aged home care the lifestyle engagement activity program (LEAP) for life.

BACKGROUND: Tailored psychosocial activity-based interventions have been shown to improve mood, behaviour and quality of life for nursing home residents. Occupational therapist delivered activity programs have shown benefits when delivered in home care settings for people with dementia. The primary aim of this study is to evaluate the effect of LEAP (Lifestyle Engagement Activity Program) for Life, a training and practice change program on the engagement of home care clients by care workers. Secondary aims are to evaluate the impact of the program on changes in client mood and behaviour. METHODS/DESIGN: The 12 month LEAP program has three components: 1) engaging site management and care staff in the program; 2) employing a LEAP champion one day a week to support program activities; 3) delivering an evidence-based training program to care staff. Specifically, case managers will be trained and supported to set meaningful social or recreational goals with clients and incorporate these into care plans. Care workers will be trained in and encouraged to practise good communication, promote client independence and choice, and tailor meaningful activities using Montessori principles, reminiscence, music, physical activity and play. LEAP Champions will be given information about theories of organisational change and trained in interpersonal skills required for their role. LEAP will be evaluated in five home care sites including two that service ethnic minority groups. A quasi experimental design will be used with evaluation data collected four times: 6-months prior to program commencement; at the start of the program; and then after 6 and 12 months. Mixed effect models will enable comparison of change in outcomes for the periods before and during the program. The primary outcome measure is client engagement. Secondary outcomes for clients are satisfaction with care, dysphoria/depression, loneliness, apathy and agitation; and work satisfaction for care workers. A process evaluation will also be undertaken. DISCUSSION: LEAP for Life may prove a cost-effective way to improve client engagement and other outcomes in the community setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612001064897.

Renovating Alzheimer's: "constructive" reflections on the new clinical and research diagnostic guidelines.

The development of disease concepts for conditions such as Alzheimer's disease (AD) is an ongoing social process that evolves over time. The biomedical paradigm about AD that has informed our culture's understanding of brain aging for the past several decades is currently undergoing a major and timely renovation in the early 21st century. This evolution is reflected in new guidelines issued by the National Institute on Aging and Alzheimer's Association (NIA/AA) for the diagnosis of AD and related conditions that aim at helping researchers identify and eventually treat AD in its presymptomatic stages. The purpose of this article is to offer the scientific, clinical, and ethics communities a critical analysis of the implications of proposed guidelines and prompt deeper reflection about the lessons learned from these new efforts both in terms of their actual content and the cultural context in which they were issued and will be used. From a social-constructivist perspective, we explore the gradual 100-year evolution of AD and summarize the proposed NIA/AA guidelines within this historical context, enumerating what we see as their main benefits and limitations. We then consider the potential implications of these guidelines in the clinical setting, and explore shifts in our cultural paradigm about brain aging that might be engendered by the logic of the guidelines.

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.

BACKGROUND: Increasingly more attention has been paid to non-pharmacological interventions as treatment of agitated behaviors that accompany dementia. The aim of the current study is to test if personalized one-to-one interaction activities based on Montessori principles will improve agitation, affect, and engagement more than a relevant control condition. METHODS: We conducted a randomized crossover trial in nine residential facilities in metropolitan Melbourne, Australia (n = 44). Personalized one-to-one activities that were delivered using Montessori principles were compared with a non-personalized activity to control for the non-specific benefits of one-to-one interaction. Participants were observed 30 minutes before, during, and after the sessions. The presence or absence of a selected physically non-aggressive behavior was noted in every minute, together with the predominant type of affect and engagement. RESULTS: Behavior counts fell considerably during both the Montessori and control sessions relative to beforehand. During Montessori activities, the amount of time spend actively engaged was double compared to during the control condition and participants displayed more positive affect and interest as well. Participants with no fluency in English (all from non-English speaking backgrounds) showed a significantly larger reduction in agitation during the Montessori than control sessions. CONCLUSION: Our results show that even non-personalized social contact can assist in settling agitated residents. Tailoring activities to residents' needs and capabilities elicit more positive interactions and are especially suitable for people who have lost fluency in the language spoken predominantly in their residential facility. Future studies could explore implementation by family members and volunteers to avoid demands on facilities' resources. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12609000564257.

The study protocol of a cluster-randomised controlled trial of family-mediated personalised activities for nursing home residents with dementia.

BACKGROUND: Following admission to a nursing home, the feelings of depression and burden that family carers may experience do not necessarily diminish. Additionally, they may experience feelings of guilt and grief for the loss of a previously close relationship. At the same time, individuals with dementia may develop symptoms of depression and agitation (BPSD) that may be related to changes in family relationships, social interaction and stimulation. Until now, interventions to alleviate carer stress and BPSD have treated carers and relatives separately rather than focusing on maintaining or enhancing their relationships. One-to-one structured activities have been shown to reduce BPSD and also improve the caring experience, but barriers such as a lack of resources impede the implementation of activities in aged care facilities. The current study will investigate the effect of individualised activities based on the Montessori methodology administered by family carers in residential care. METHODS/DESIGN: We will conduct a cluster-randomised trial to train family carers in conducting personalised one-to-one activities based on the Montessori methodology with their relatives. Montessori activities derive from the principles espoused by Maria Montessori and subsequent educational theorists to promote engagement in learning, namely task breakdown, guided repetition, progression in difficulty from simple to complex, and the careful matching of demands to levels of competence. Persons with dementia living in aged care facilities and frequently visiting family carers will be included in the study. Consented, willing participants will be randomly assigned by facility to a treatment condition using the Montessori approach or a control waiting list condition. We hypothesise that family carers conducting Montessori-based activities will experience improvements in quality of visits and overall relationship with the resident as well as higher self-rated mastery, fewer depressive symptoms, and a better quality of life than carers in the waiting list condition. DISCUSSION: We hypothesise that training family carers to deliver personalised activities to their relatives in a residential setting will make visits more satisfying and may consequently improve the quality of life for carers and their relatives. These beneficial effects might also reduce nursing staff burden and thus impact positively on residential facilities. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12611000998943.

A Fluctuating Pattern of Over- and Under-Adherence for HAART: A Case Study from a Videophone Intervention Project.

Highly Active Antiretroviral Therapy (HAART) has transformed HIV from a terminal illness to a chronic condition. While disagreement remains regarding the level of medication adherence required to achieve and maintain viral suppression, the highest possible rate is preferable. This article discusses the case study of "Bob," a 54 year-old man living with HIV for 25 years. At baseline, Bob evinced fluctuating patterns of medication over- and under-adherence and reported numerous negative side effects. Bob participated in eight videophone-administered adherence intervention sessions. His adherence improved to a high of 97.9% at one-month follow-up; his negative treatment side effects subsided considerably. This case study demonstrates that videophone technology is a potential medium by which to assess and intervene upon HIV medication adherence.

Montessori-Based Activities as a Trans-Generational Interface for Persons with Dementia and Preschool Children.

Montessori-based activities for persons with dementia have been used to successfully provide opportunities for programming between older adults and preschool children in shared site. intergenerational care programs. Such intergenerational programming allows older adults with dementia to fulfill roles of teacher or mentor to younger children or as collaborative workmates for persons with more advanced dementia while providing children with positive one-on-one interactions with older adults. We review several studies using this approach, describe characteristics of the programs, participants and results obtained and provide recommendations for those interested in extending this line of work.

Origins of Montessori Programming for Dementia.

The focus of this article is on the evolution of the use of Montessori educational methods as the basis for creating interventions for persons with dementia. The account of this evolution is autobiographical, as the development of Montessori Programming for Dementia (MPD) initially was through the efforts of myself and my research associates. My initial exposure to Maria Montessori's work came as a result of my involvement with my own children's education. This exposure influenced ongoing research on development of cognitive interventions for persons with dementia. A brief description of Montessori's work with children and the educational methods she developed is followed by a description of how this approach can be translated into development of activities for persons with dementia. Assessment tools to document effects of MPD were created, focusing on observational tools to measure engagement and affect during individual and group activities programming for persons with dementia. Examples of the use of MPD by researchers, staff members, and family members are given, as well as examples of how persons with dementia can provide MPD to other persons with dementia or to children. Finally, examples of MPD's dissemination internationally and future directions for research are presented.

Use of Videophone Technology to Address Medication Adherence Issues in Persons with HIV.

Adherence to HAART medication regimens is vital to maintaining suppression of HIV, but persons with HIV face many challenges to adhering consistently to HIV medication regimens. This is particularly true for persons who live in geographically-isolated areas or who have significant levels of cognitive compromise. A videophone-based version of Reynolds' HAART CARE (HC) telephone intervention for medication adherence was pilot-tested with 23 persons living with HIV residing in both urban and non-urban communities. The purpose of the pilot study was to evaluate the feasibility and acceptance of an adherence improvement intervention administered via videophones. Furthermore, the feasibility and acceptability of conducting HIV pill counts through videophones were assessed. The videophone version of HC produced significant increases in self-reported rates of medication adherence and was generally well-received by interventionists and participants. Pill counts conducted via videophone were also well-accepted by participants. Self-reported adherence levels were higher than videophone-based pill count adherence levels. Challenges to the use of videophones included the requirement that only analog landlines be used, poor quality of video and audio transmissions, and high cost for equipment. Methods to overcome these challenges are discussed.

Effects of intergenerational Montessori-based activities programming on engagement of nursing home residents with dementia.

Fourteen nursing home residents on a dementia special care unit at a skilled nursing facility took part in one-to-one intergenerational programming (IGP) with 15 preschool children from the facility's on-site child care center. Montessori-based activities served as the interface for interactions between dyads. The amount of time residents demonstrated positive and negative forms of engagement during IGP and standard activities programming was assessed through direct observation using a tool developed for this purpose--the Myers Research Institute Engagement Scale (MRI-ES). These residents with dementia displayed the ability to successfully take part in IGP. Most successfully presented "lessons" to the children in their dyads, similar to the way that Montessori teachers present lessons to children, while persons with more severe cognitive impairment took part in IGP through other methods such as parallel play. Taking part in IGP was consistently related with higher levels of positive engagement and lower levels of negative forms of engagement in these residents with dementia than levels seen in standard activities programming on the unit. Implications of using this form of IGP, and directions for future research, are discussed.