Tampa, Florida. He holds an MA in Psychology from Hollins College and a PhD in. Psychology from the University of Connecticut. Correspondence sllould be ad ...
Montessori Methods Yield Cognitive Gains in Alzheimer's Day Cares David E. Vance Robert J. Porter, Jr.
ABSTRACT. Alzheimer day-care clients received three months of Montessori type activities and three months of routine activities, in a withinsubjects design. T h e effects of the two conditions were compared using changes in clients' scores on 22 cognitive measures. From this, a measure of performance after the Montessori activities, compared to after routine activities (Montessori Benefit Score), was calculated for each subject and a distribution of subject scores was generated. Using a resampling statistic, the mean Montessori Benefit Score was compared t o o n e obtained under a null hypothesis that n o difference existed in performance between routine and Montessori conditions. T h e observed mean Montessori Benefit Score (m = 7.4) fell outside the 95% confidence interval for the means based o n the null hypothesis, indicating that Montessori materials benefit the Alzheimer's clients in this study. [Article copies available for a fee fr-o~nThe Hawort11 Docu~netltDeliilery Service: 1-800-342-9678. E-mail address: geti~fo@l~awortl~pressi~~c.corn< Website: http://~vww.hu wortllpressir~c. con1 >]
KEYWORDS. Montessori, Alzheimer's, day cares, activities, Piaget, neuroplasticity
The present study investigates the effectiveness of a new form of cognitive intervention designed to help adults with Alzheimer's DisThis project would not have been possible without the assistance of the following: Associated Catholic Charities of New Orleans and their adult day cares for the use of their centers, the Alzheimer's Association of Greater New Orleans for a monetary research award, Nienhuis Montessori of Mountain View, California for materials. Dr. Stephanie Auer for a discount on the OSPD-M, Dr. Kevin Greve and Dr. Matthew Stanford for advice, Beth Aronson for testing assistance, and the caregivers and adults who allowed us to work with them. Activities, Adaptation S: Aging, Vol. 24(3) 2000 O 2000 by The Haworth Press, Inc. All rights reserved.
1
.
.
3
ACTIVITIES, i\ DA PTATION cE AGING
ease (AD). The impetus for the design of the intervention was based on our understanding of two factors related to cognitive change. The first of these is the possibility of "neural plasticity" in the adult brain suggested by the observation that adult, aged rats exposed to enriched environments form new dendritic branching. The aging brain may, therefore, retain the ability to modify itself, especially when exposed to novel materials (Diamond, 1993; Diamond, Krech, & Rosenzweig, 1964; Uylings, Kuypers, Diamond, & Veltman, 1978). The second consideration in the design of our intervention was the observation of "reverse cognitive ontogeny" in AD patients. That is, those aspects of cognitive development found by Piaget to develop earliest in children are also the last to be lost in Alzheimer's (Constantinidis, Richard, & Ajuriaguerra, 1978; Sclan, Foster, Reisberg, Franssen, & Welkowitz, 1990). We reasoned that novel cognitive activities, using methods and materials reflecting Piagetian concepts, might help people with Alzheimer's disease preserve or recover some of their cognitive abilities. Our rationale is further discussed below.
NEUROPLASTICITY Organisms that receive stimulating and novel sensory input display morphological changes in the brain. Diamond (1993), for example, investigated the extent to which three types of social and sensory. environments influence adult rat brains. In an "enriched environmental condition," twelve rats lived together in a large cage approximately one meter square and had access to various objects which were changed regularly. In a "standard condition," three rats were placed in a small cage approximately one foot square; they had no objects to explore. In an "impoverished condition," rats lived alone in small cages (one foot square) with no ob-jects to explore. After the rats lived in these conditions for uniform time periods, the brains were examined. Rats in the enriched environment showed a larger cerebral cortex compared to the brains of rats living in the standard condition. Rats living in the impoverished condition showed a relatively diminished thickness of the cerebral cortex. These findings were consistent in all ages of rats including: (1) rats not yet weaned (Malkasian & Diamond, 19711, (2) rats just after weaning (Diamond, Krech, & Koseazweig, 1964), (3) young adult rats (Ulyings et al., 1978), and (4) very old rats (Diamond, Johnson, Pratti, Ott, & Kajisa, 1985).
D o ~ i dE. Vur~ceatrd Robert .I. Porfet;.It:
3
Assuming that increased cerebral cortex directly corresponds with cognitive ability, and rat brains are comparable to huinan brains, adults with A D who stay active and engaged in their environment may have a greater chance of maintaining some cognitive abilities. Support for this hypothesis is provided by studies suggesting dendritic branching in adults with A D (Geddes & Cotman, 1991; Scheff, 1991). Specifically, researchers (Arendt, Zvegintseva, & Leontovich, 1986) found both regenerative and degenerative dendritic changes in the multipolar giant and reticular neurons in the basal nucleus of Meynert and in the diagonal band nucleus of five A D cases. Mattson (1991) suggested a caveat that, in some cases, too high levels of activity might actually cotttribute to the development of neurofibulary tangles. He suggested, therefore, that optintal cognitive activities would be those neither too hard or too simple, and would target the extent and level of existing functioning. Several investigators have, in fact, shown a cognitive and affective benefit for moderately stimulating activities in A D patients, suggesting that some sort of plasticity may be present. A s one example, Reichenbach and Kirchinan (1991) examined the differential effects of a Multi-strategy Group Prograin (an eclectic paradigm consisting of reality orientation strategies, arts and crafts, and sensory stimulation materials) and that of a traditional home care program upon elderly residents with a variety of organic brain syndromes. The morale, physical self-maintenance, and mental functioning domains of the residents were evaluated. After four months of treatment, subjects in the Multi-strategy Group Program showed significant improvement in all three domains, while those subjects in the traditional home care program actually showed significant decreases. Thus, adults with organic brain syndrome d o receive benefits from enhanced stimulation and increased activity. Other studies have shown the benefits of moderately stimulating activities such as music (Lord & Garner, 1993) and pet therapy (Damon & May, 1986). For example, Lord and Garner (1992) divided 60 A D patients into three groups: Group 1 listened to big band music, Group 2 worked on puzzles, and Group 3 participated in standard recreational activities such as drawing or painting. After six months of daily experiencing these activities, an analysis of variance revealed that participants in Group 1 were happier, Inore alert, and had higher recall of past history than patients in the other two groups.l
4
ACT1 MTIES. ADAPTATION
tG
A GIN(;
Some studies have investigated the effects of general sensory stimulation involving a variety of bright and colorful materials which encourage touching and looking. For example, colorful wind chimes with various shapes in the chiming mechanism may be used to stimulate both sight and sound. Maloney and Daily (1986) attempted to incorporate sensory stimulation activities in a geropsychiatric ward in order to "maximize the use of each resident's remaining sensory channels, prevent a state of sensory deprivation which can occur during age related sensory losses" (p.57). Subjects experienced improvements in both affect and alertness. In a similar study investigating sensory stimulation, six residents in a convalescent home diagnosed with chronic brain syndrome were treated with a combination of group psychotherapy and sensory stimulation to alleviate social and emotional isolation. Before treatment began, subjects were given a full psychiatric clinical examination. Subjects met twice a week and treatment consisted of social time and welcoming, learning simple information about the group, stimulation of the senses, and eight physical activity sessions. After three months, subjects were again administered a full psychiatric clinical examination. All six patients demonstrated improvement (Ernst, Badash, Beran, Kosovsky, Lerner, & Kleinhauz, 1978). Older adults with organic brain disorders also appear to benefit in several cognitive domains after meeting daily for sensory stimulation exercises. Paire and Karney (1984) ascertained the effectiveness of sensory stimulation for geropsychiatric inpatients with either organic brain syndrome or schizophrenia. After controlling for age and level of education, they randomly placed subjects into three groups: (1) the sensory stimulation group, (2) staff attention group, and (3) control group which consisted of having the inpatients performing their normal routine. Adults in the sensory stimulation group significantly improved and maintained their gains in domains of personal hygiene and interest in group activities compared to the adults in the other conditions. This further suggests that functioning can he augmented by the type of input and tasks the brain receives. Certain tasks may be more beneficial in their effects than others. Overall, it appears that older adults with organic brain disorders can experience beneficial gains from engaging in novel and stimulating activities. Adults with AD may be helped by the type of activities they receive, especially
n~rvitlE. V O I I a11d C ~ Robert J. Porter; JI:
5
those activities that incorporate aspects of sensory stimulation, perhaps because these activities particularly exploit brain plasticity.
THE POSSIBILITY OF REVERSE ONTOGENY AND THE MONTESSORI PERSPECTIVE Adults with Alzheimer's disease have been observed to gradually lose their Inore advanced cognitive abilities in formal and concrete operations and regress to cognitive abilities found in preoperational and sensorimotor stages (Constantinidis, Richard, & Ajuriaguerra, 1978). For example, this relative pattern of deterioration is observed with the initial loss of abstract reasoning (formal operation) and the filial loss of object permanence and recognition of self (Biringer & Anderson, 1992; Grewal, 1994). In fact, the cognitive decline of impaired adults with AD can be effectively assessed using Piagetian tests (Auer, Sclan, Yaffee, & Reisberg, 1994; Sclan et al., 1990; Thornbury, 1992). When considered in the context of the plasticity and stimulation data, these reverse ontogeny observations suggest that Alzheimer's disease patients may lose their inore co~nplexneural substrate prior to the loss of the less complex, particularly if their environment does not provide the stimulation optimal to preserve function via changes in the substrate. If this is the case, optimal stimulation activities for Alzheimer's disease patients niight be those which specifically engage the cognitive abilities associated with the Piagetian stage suggested by their existing cognitive abilities. One well known set of activities of this sort (designed for children) are those of Montessori. These tasks might be modified to provide optimally stinlulating activities for AD patients. The Montessori didactic has three aspects which particularly suit it for adults with Alzheimer's disease (Vance, Camp, Kabacoff, & Greenwalt, 1996). First, many of the tasks focus on activities of daily living. Activities of daily living tasks are deeply ingrained in older children and adults as procedural skills. For adults with AD, procedural skills are known to be more resistant to the disease than other cognitive abilities such as semantic and explicit memory (Nebes, 1992). Second, many Montessori tasks (which are not activities of daily living) can be categorized into the different Piagetian stages. By knowing the stage at which an adult is functioning, an optimal task can be chosen for that individual (Thornbury, 1992). A task can be chosen
6
ACTIVITIES, ADAPT4TION 6r AGING
that will maximize, but not strain, their present cognitive abilities, therefore heeding the caveat by Mattson (1991). Third, the loss of cognitive function in AD is associated with deterioration in communication abilities, presuinably because of the intertwined nature of cognition and language and their common neural substrate in the temporal lobes, where the effects of AD are most apparent. Since most Montessori tasks are nonverbal in nature, such tasks may prove ideal stimulation, especially for more advanced patients. The Montessori paradigm contains many inherent advantages as an intervention strategy for working with AD patients. ( I ) Tasks are seqrienced to break down each step for the person, to make it possible for IzinzJlzerto feel siiccess at each step. For an adult with AD, feeling successful at a task may encourage future attempts. (2) Tasksprogress fronz the concrete to the abstract, appealirzg first to the person5 senses and then to the person's thoughts. This is helpful to the person with AD who loses the ability to reason abstractly. For example, math materials such as Cut-Out Numerals and Counters consist of red numerals with red counting disks. The object is to match the number of disks to the actual numeral. Cards that have a place for the counters can be used with the actual number written on the card. The concrete is given an abstract symbol. (3) Tasks are nlailiplilative in nature, based on the fact that the person learns by doing. Tasks are designed not only to be manipulated in a fixed, prescribed way, they are also objects of play and are to be enjoyed. (4) Tasks are designed to isolate the diffiicrilties of the concept being learned. For example, the pink tower is a set of ten cubes progressing in size from one cubic centimeter to ten cubic centimeters. The cubes are all one color in order to emphasize the size gradations, not multiple colors that can confuse the individual. (5) Tclsks provide a control for errol: This control principle is illustrated by the Cylinder Boards task. This task consists of seven cylinders of incremental size and dimension. The object of the task is to place the cylinders into the correct hole on the board. If the hole is too small, the cylinder will not go into it; if the cylinder is placed into a hole that is too big, the cylinder that is supposed to go into it will be left over, indicating an error has been made. Most Montessori materials have such inherent control features that provide feedback which helps individuals learn from mistakes. ( 6 ) Tasks enlplzasize reality. This is similar with aspects of Reality Orientation therapy which attempts to involve the person in histher environment by making one
Iltrrid E. Varrce arrd Robert J . Porter; JI:
7
aware of current activities. (7) Tasks ure uttr-ucli~~e to 1111 tlre serzses. In general, the materials are very colorful, consisting of many bright blues, greens, yellows, and reds, all of which can be easily distinguished by the aging eye. Most of the materials are made of wood and have a nice feel to them. Some of the tasks themselves have a sensory component in which the learner sorts items according to sound, feel, or hue. Such characteristics are similar to Sensory Stimulation materials, except with the noted advantages and modifications (Farrow & Hill, 1975). (8) FWallj: implementatiorl of tasks in an AD day care setting is straiglztjorward. Modifications include such things as selecting items that are most user-friendly to arthritic hands. The present study was designed to determine whether a stimulation regime based in modified Montessori tasks might facilitate the preservation or recovery of cognitive abilities in AD patients in an adult day care setting. To assure that all patients received any potential benefits, a within-subjects design, wherein all patients received interventions, was selected. Patients' cognitive abilities were assessed before and after three months of Montessori intervention, and the results compared to those obtained before and after a comparable period of normal day care activities. Approximately half the subjects began with Montessori intervention.
ME THODOLOG Y Participants Alzheimer's Disease (AD) subjects met the diagnostic criteria developed by the NINCDSIADRDA (McKhann, Drachman, Folstein, Katzman, Price, & Stadlan, 1984) for probable AD. In addition to the primary diagnosis of probable AD, subjects were free of a history of psychiatric illness, head trauma, multi-infarct dementia, alcoholism, serious cardiovascular disease, stroke, or other severe neurological conditions. Adults with AD at two adult day care centers were recruited. Adults scored between 23 and 5 on the Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1975) to be collsidered for the study. A variety of testing materials and therapeutic materials were used in this study.
8
..ZCTIVITIES.ADAI'TATION
cP: AGING
Tc.stirlgMatel.imls. Assessment of treatment was conducted by using several psychological and social-interaction interviews and instruments. Tests were administered at baseline and every three months after baseline. The instruments used include:
1. The Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975). 2. The Dementia Rating Scale (DRS; Mattis, 1988). 3. The Digit Forward-Weschler Memory Scale-Third Edition (WISC-111; Wechsler, 1981). 4. The Vocabulary-Weschler Intelligence Scale-Third Edition (WISC-111; Wechsler, 1981). 5. The Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1978). 6. The Visual-Discrimination Form Task (VDFT; Benton, Hamsher, Varney, & Spreen, 1983). 7. The Parachek Geriatric Behavior Rating Scale (PGBRS; Miller & Parachek, 1974). 8. The Ordinal Scales of Psychological Development (OSPD; Auer & Reisberg, 1995) has five scales that correspond to a Piagetian task: (1) Visual pursuit and object permanence (object permanence); (2) means for obtaining desired environmental events (mean-ends); (3) development of operational causality (causality); (4) construction of object relations in space (space); and (5) development of schemes for relating to objects (schemes). Tllelxzpeiitic Materials. To test the effectiveness of the Montessori training materials, cognitive abilities were compared before and after Montessori training and before and after the normal (Control) stimulation activities used in the day-care centers. In the control activities, a wide variety of materials and tasks were used in an eclectic activity program. These activities included listening to music, socializing, and coloring. In the Montessori paradigm, the materials used can be categorized into three areas: (1) sensorial, (2) daily living, and (3) language and math. Much of the equipment exploits the Piagetian concept of seriation, object permanence, symbolic function, and differentiation of self while utilizing many of the advantages of sensorial stimulation.
Design and Procedure Baseline measures of mental status, cognitive abilities, and behavior were recorded for all subjects at the beginning of the study. During approximately two weeks required to complete testing, day care staff were trained in the use of Montessori materials. Montessori or control interventions lasted three months, with about half the sub.jects starting with Montessori and half with their regular activities. Measures of subjects' cognitive abilities and behavior were, consequently, repeated at three and six months after the beginning of the study. After the first three months, the subjects switched activity materials thus making the previous Montessori group the regular activity group and vice-versa. There were, thus, a total of three data collection periods for each center (see Table 1) with each subject serving as their own control. Subjects in the Montessori condition were exposed to two, one-hour training periods a day using the Montessori manipulatives. A variety of tasks were available; aideslteachers selected the tasks that the adults wanted or could do. When possible, each task was self-contained within a tray or place mat to ensure that the task was presented in an orderly manner which is customary of all Montessori tasks. Consistent with Montessori objectives, activities could be selected in which the individual could engage in competently and tasks with which subjects were successful were used more than those in which subjects experienced particular difficulty performing. TABLE 1. Timed Data Gathering of Study Design PROJECT EVENTS
MONTESSORI
CONTROL
Baseline
Center 1 Gather Data
Center 2Gather Data
ARer Three Months: Post-Montessori (Center 1) Post-Control (Center 2)
Center 1Gather Data and Return Normal Activity Programming
Center 2Gather Data and Implement Montessori Activity Programming
After Three Months: Post-Control (Center 1) Post-Montessori (Center 2)
Center 2Gather Data
Center 1 Gather Data
10
ACTIVITIES. ADAPTATION Sr AGING
Sl~trtrrtaryof Statistical Analysis "Change-scores" were obtained by comparing cognitive measures obtained after Montessori or Control activity periods to those obtained before each intervention period. Scoring was done such that negative change-scores indicated improvement in performance, whereas positive change-scores indicated relative decline; no changehame scores were also considered "improvements" since the absence of decline in AD patients is considered of clinical importance. The number of improvements, declines, and sames for the two conditions were then combined to yield an overall Montessori Benefit Score (MSB) which has an expected value near zero if the Montessori and Control activities were equivalent in their effects on client cognitive abilities. Positive MBS suggest a relative benefit for the Montessori intervention; negative scores suggest a benefit for regular, Control, activities. A resampling design was employed to determine if the scores obtained exceeded those expected assuming a null hypothesis that cognitive measures varied randomly regardless of intervention. Details of the scoring and analysis are provided below.
RESULTS Subject Selection and Demographics At baseline, thirty-six subjects were successfully screened negative for neurological impairments other than AD. Of these, nine subjects were eliminated from the study because they scored less than five on the MMSE. (It is likely that subjects would produce floor effects on other tasks which would prove useless in determining cognitive changes over the course of the study.) During the study, three subjects died, six received convalescent placement, and three were excluded from the final analysis due to their lack of comparable exposure to the treatment conditions due to absence from the center and similar factors. With both centers combined, a total of fifteen subjects7 data were available for analysis. The average age of this combined sample was 78.4 (range was 60 to 87; S.D. = 7.84). The average years of onset was 3.27 years (range was 1 to 9 years; S.D. = 2.23). The average obtained years of education was 12.2 (range was 5 to 18; S.D. = 2.93). This
l ) n ~ i rE. i Vnlice n11rt Robert J . Porter; J I :
I1
sample was composed of three males and twelve females. The basic demographic and personal characteristics of the qualified subjects are listed in Table 2.
Testirtg Criteria artd Scores The Dementia Rating Scale (DRS), the Ordinal Scale of Psychological Development-Modified (OSPD-M), WISC-111-Vocabulary, the Mini Mental Status Exam (MMSE), and the Parachek Geriatric Behavior Rating Scale (PGBRS) were scored as specified by their respective authors. To increase the overall sensitivity and avoid floor effects, certain TABLE 2. Demographic and Personal Characteristics of Qualified Subjects
12
ACTIVITIES, ADAPT4TION & AGING
test scores were slightly modified to provide maximal sensitivity to cognitive functioning. I11 the Boston Naming Test, all correct responses, whether it be "no cue," "stimulus cue," or "phonemic cue" were tallied together to derive an overall score on word ideation fluency. That is, no analysis of the subcategories was performed even though the three types of responses may be presumed to measure different language processing abilities. In the Visual Forin Discrimination task (VFD), separate analyses were not conducted on each of the five categories of responses: correct, peripheral error, major rotation, major distortion, and no response. Instead, the correct responses and the peripheral error responses were tallied together as suggested by the authors; two points for a correct response and one point for a peripheral error (Benton, Hamsher, Varney, & Spreen, 1983). In WISC-111Digit, forward and backward scores were not analyzed separately; instead both the forward and backward digit scores were combined to derive a single value. In all, 22 tests and/or subtests were employed in this study. For reference purposes, scores for all measures, for one example subject, at all three data collection periods, is provided in the Appendix. Montessori Benefit Scores
We wanted to be able to examine overall benefits or declines in patients' performance before and after Montessori and Control conditions. Unfortunately, no existing method provides a way to combine the 22 different test scores to yield a single interval or ratio scale score. This is because the tests scored a variety of behaviors reflecting cognitive abilities ranging from attention and orientation to social skills and language. In addition, these tests had different measurement scales and few of the tests have norms, especially Alzheimer's norms. For these reasons, an ordinal-scale statistical procedure was used to summarize test results and provide a single measure that would indicate overall benefit or decline for each subject. The procedure is summarized below. The raw data consisted of scores obtained on 22 tests, obtained at three times. Using these three data points, we made ordinal comparisons of pre- and post-scores, on each test, and counted the number of improvements, declines, or no changes in test performance for each of the two experimental conditions. This yielded a frequency count, for each subject, of the number of times the comparison revealed a higher
Drrvid E. Varlce a11dRobert J . l'orter; JI:
13
(inlpr.ovcnlent), a no change (equal), or a lower (decline) post-score compared to the pre-score. Thus, each subject's raw data generated two sets of impr-ovenletlt, equal, and declirle frequencies, one set for the Montessori condition, and one set for the Control condition. A Montessori Benefit Score (MBS) was derived from these frequencies, for each subject, by adding together the following: The frequency of intpr.overnerlts in the Montessori condition less those in the Control condition, plus the frequency of equals in the Montessori condition less those in the Control condition, plus the frequency of declirles in the Control condition less those in the Montessori condition. The resulting total, or MBS, is an ordinal, integer index whose positive value reflects an overall benefit to the Montessori condition relative to the Control condition: that is, a greater frequency of improvements, andlor a greater frequency of equals, andlor-a lower frequency of declines. A negative value reflects the reverse; that is, greater benefit to the Control condition. Appendix A provides an example of ChangeScores and Montessori Benefit Score Calculations for the example subject. MBS scores for all subjects are summarized in Table 3. As seen in the table, eleven (11) or 73.3% of the subjects showed benefits (Positive MBSs). These ranged in size from +2 to +22 (see Table 3). We can also see in Table 3 that subjects from Center 1 were arbitrarily distributed throughout the scores-suggesting that although Center 1 and Center 2 received the Montessori materials and their Control activities in different orders, there appears to be no systematic difference in results between centers. The data from both centers were therefore combined for further analysis.
Resnmplirrg to Test Significance As seen in Table 3, eleven subjects' MBSs were positive-reflecting benefit from the Montessori condition while only four were zero or negative. The mean MBS for the group was 7.40 (S.D. = 9.30). To investigate the possible significance of this positive mean, the data were analyzed using a null hypothesis, resampling approach. The resampling approach refers to using the observed data and an appropriate null hypothesis to produce new samples on which to base statistical inferences (Westfall Rc Young, 1993). This approach is particularly useful for studies with small samples, unbalanced designs,
14
ACTIVITIES, ADAPTATION
cC
ACING
TABLE 3. Montessori Benefit Score (MBS) for the Original Data
and/or nonnormal distributions (Marcoulides, 1989). The application of the resainpling procedure may be summarized as follows: 1. The Null Hypothesis: The null hypothesis adopted was that there was no difference between the three scores obtained for each subject on each sub-test, at each of the three testing times. That is, the scores obtained before and after the Montessori or the Control conditions were assumed to differ only randomly. 2. Generation of "New Samples": The three scores for each subtest, for each subject were randomly reordered with respect to lime-of-testing. This procedure generated a new set of data hav-
ing the general numeric properties of the original, but with each subject's test scores arbitrarily assigned to pre- and post-condition tests. Under the null hypothesis (that the activities between pre- and post-tests have no effect on scores), this random reordering would produce MBSs comparable to those obtained with the original data. If, on the other hand, the original pre- and post-scores represented non-random changes due to the intervening conditions, the new MBSs would differ from the original. If, furthermore, the effect of the Montessori intervention provided a greater benefit to the subjects than did normal activity, the original MBSs should be significantly more positive than those based on reordering the scores. Each subjects' three data points for each test were randomly reordered. Reordering was done using a random roll of a die to select one of the six possible reorderings. Reordering was done for each subject, independent of other subjects. Once the three measures were reordered for all subjects, the resulting data were submitted to the same changescore analysis, and MBS analysis, as the original data. In order to estimate the population parameters for MBSs calculated from reordered scores, reordering was done ten (10) times, thus yielding ten random data sets with which to compare the actual data. 3. Mean and Standard Deviation: The mean and standard deviation. for the MBSs obtained from each of the 10 randomized score samples were calculated (Table 4). 4. Determining Significance: Under the null hypothesis, the mean of the ten means (m = 0.76) shown in Table 4, provides an estimate of the mean of the population of means of samples of size n = 15, and the standard deviation of these means provides an estimate of the standard error of the means of that population of means (S.D., = 2.63; df = 9). In other words, the expected value for MSB is near zero, with a standard error of the lrleans of 2.63. Based on ten reordered data sets, and given the null hypothesis, the 95% confidence interval for a mean obtained for a sample of 15 subjects is, therefore, 0.76 ? t.os(9) x 2.63 = - 5.18 to 6.69. The mean score actually obtained for the 15 subjects in this study (see Table 2) was 7.40 which falls outside the confidence interval. In fact, the obtained mean exceeds all of the ten means obtained by random reordering. Thus, the mean MBS for our subjects is significantly more positive than would be expected by
I6
ACTIVITIES, ADAPTATION d AGING
TABLE 4. MBS Distribution for Simulations
chance. Another way to state this result is to say that the order of the test scores appears nonrandom, suggesting that the Montessori and Control conditions had different effects on subjects' scores such that Montessori intervention provided a relative benefit. This conclusion can be seen graphically in Figure 1 where the ten randomly generated means (X's) are compared to the MBS mean (0)ubtailled for the original data set. Importantly, the significance of the group mean is representative of individual data: The majority of the individual MSBs (see Table 3) are positive, several extremely so, supporting a general conclusion that our ii~terventionsprovided sig-
Ua~vidE. Valrce nlrd Roho-1 J . Porter; JI:
17
nificant benefits for these clients. Note that this conclusion may even apply to those clients whose MSB scores were small or negative, since these subjects might be supposed to have had less decline than they might have without the Montessori intervention.
DISCUSSION It was proposed that adults with AD who received Montessori materials in their day care setting would experience beneficial cognitive outcomes compared to when they received the routine, Control activities. The results support our expectation that Montessori materials can be of benefit in ameliorating cognitive function with people with moderate to severe Alzheimer's Disease. We speculate that the gains may reflect plasticity of the adult brain and a consequent ability of AD patients to cognitively benefit from exposure to optimally selected activities. This study is not the first to find benefits of stimulating activities for adults with AD or related dementias. Paire et al. (1984) found improvements after incorporating sensory stimulation for geropsychiatric inpatients; Ernst and colleagues (1978) discovered gains in social, emotional, and physical domains after administering sensory stimulation with patients with Chronic Brain Syndrome; and Lord and Garner (1993) found music to be of therapeutic value to adults with AD. The present study, however, extends these types of findings to an intewention based in established techniques for enhancing cognitive change as well as one targeted at those cognitive abilities in greatest decline. One particular advantage of this study is that it was based in actual practice in adult day care settings. The implementation was straightforward and did not require extensive retraining of personnel. Since our intervention did not attempt to control daily routines, holiday schedules/programs, and variable staff-client-activity interactions, the signifiFIGURE 1. Comparison of MBS Mean (0) and Randomly Re-Ordered Data Means (Xs) X
X
X X X X
XXXX
0
IN
ACTIVITIES, ALIAI'TATION S: A (;IN(;
cant results suggest that the intervention effects are robust enough to warrant their inclusion in settings typical of most adult day care centers. Our conclusions require some qualification. The first author and an occasional assistant sometimes helped staff administer the Montessori intervention. In addition, the day care staff appeared to enjoy the use of the Montessori materials. The materials' novelty and the investigators' and staff's interest level may have had a positive effect on subjects regardless of any effects of the Montessori intervention itself. Future work could investigate the benefits obtained when Montessori Interventions are compared to other novel interventions in the same settings. In summary, the results of this study support a conclusion that some limited neural plasticity might be exploited when moderate AD patients' activities are selected with Piagetian levels of cognitive function considered. The robustness of the effects, together with the ease of use of Montessori methods, makes their inclusion in adult day care settings practical as well as potelltially beneficial. Whereas the possibility of other effects may preclude the strongest conclusion in favor of Montessori intervention, the results do offer hope for ameliorating cognitive declines with cognitively stimulating tasks based in existing cognitive abilities.
AUTHOR NOTE David E. Vance, MGS, MA, is the Birmingham Site Project Coordinator for REACH (Resources for Enhancing Alzheimer's Caregiver Health), an NIH funded study developing and testing new ways to help caregivers manage the daily activities and the stresses of caring for people with Alzheimer's Disease or related disorders. He holtls an MGS from Miami University and an MA in Applied Developmental Psychology frurn the University of New Orlea~ls.Correspondence should be addressed to David E. vance, The University o f Alabama at Birmingham, Community Health Services Building-19th, 933 19th Street South, Suite 218S, Birmingham, AL 35294-2041. Robert J. Porter, Jr., PhD, currently retiring from academia from the University of New Orleans, is a consultant in applications of psychology and is a respecialization trainee i n clinical psychology at the Sarasota School of Professional Psychology in Tampa, Florida. He holds an MA in Psychology from Hollins College and a PhD in Psychology from the University of Connecticut. Correspondence sllould be addressed to Robert J. Porter, Jr., Department of Psychology, University of New Orleans, New Orleans, LA 70148.
NOTE 1. In the Lord and Garner (1993) study, reports of improvement were based upon subjective ratings and were not dependent upon calibrated instruments. For studies of this nature, i t may be more useful to use calibrated instruments such as the Dementia Rating Scale (Mattis, 1988), since they allow one to gauge improvements and declines more precisely.
REFERENCES Arendt, T., Zvegintseva, H. G., & Leontovich, T. A. (1986). Dendritic changes in the basal nucleus of Meynert and in the diagonal band nucleus in Alzheimer's disease-A quantitative Golgi investigation. Nellroscietzce, 19, 1265-1278. Auer, S. R., & Reisberg, B. (1995). Mollified Ordirzal Scales of Psycl~ologicnlDeveloptnetzt. New York, NY: Aging and Dementia Research Center, New York University Medical Center. Auer, S. R., Sclan, S. G., Yaffee, R. A., & Reisberg, B. (1994). The neglected half of Alzheimer's disease: Cognitive and functional concomitants of severe dementia. Jorrrtzol of Atlzericatz Geriarric Society, 4 2 , 1266-1272. Benton, A. L., Hamsher, K., Varney, N. R., &: Spreen, 0. (1983). Cotztribrr~iorzto Neirt~opsycltologicalAssesstnet~t:A Clitlical Matzual. New York, NY: Oxford University Press. Biringer, F., & Anderson, J. R. (1992). Self-recognition in Alzheimer's disease: A mirror and video study. Jourtlal of Gerorztology, 46(6), P385-388. Constantillidis, J., Richard, J., & A.juriaguerra, J. (1978). Denlentias with senile plaques and neurofibrillary changes. In A. D. Issacs & F. Post (Eds.) Studies itz geriarricpsycl~iat,:v.New York, NY: Wiley, 119-152. Damon, J., & May, R. (1986). The effects of pet facilitative therapy on patients and staff in an adults day care center. Special Issue: Therapeutic activities with the impaired elderly. Activities, Adoptariotz d Agirlg, 8(3/4), 117-131. Diamond, M. (1993). An optimistic view of tlie aging brain. Gerzerarioru,17, 31-33. Diamond, M. C., Krech, D., & Rosenzweig, M. R. (1964). The effects of an enriched environment on the histology of the rat cerebral cortex. Joiirrlal of Cor~zparative Nerlrologv, 123, 111-120. Diamond, M. C., Johnson, R. E., Protti, A. M., Otl, C., & Kajisa, L. (1985). Plasticity i n the 904-day-old-rat. E,~peritlzet~tal Nelrrology, 87, 309-317. Ernst, P., Badash, D., Beran, B., Kosovsky, R., Lerner, K., & Kleinhauz, M. (1978). Sensory stimulation of elderly patients: Preliminary report on the treatment of patients with Chronic Brain Syndrome in an old age home. Tlte Israel Ailtzals of P.~vc/liorryatzd Related L)isciplirze,16, 315-326. Farrow, E., Sr Hill, C. (1975). Motlressori otz a lirlzired bi!dger. I,os Angeles, CA: Education Systems Publisher. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "MINI-MENTAL STATE": A practical method for grading the cognitive state of patients for the clinician. Jolrrttol of Psj~clriarricRellobilitnriotz, 12, 189-198.
20
ACT1 VITIES, AIIAPTATION B AGING
Cieddes, J . W.: S: Cotman, C. W. (1991). Plasticity in Alzheimer's disease: 'foo much or not enough'?Ne~rrobiologyofAgitrg, 12, (4), 330-333. Grewal, R. P. (1994). Self-recognition in dementia of the Alzheimer's type. Perceptrttrl trrrd hioror- Skills, 79(2), 1009-1010. Kaplan, E. F., Goodglass, H., 8: Weintraub, S. (1978). The Boston Nntning Test. Boston, MA: E. Eaplan 5: H. Goodglass. Lord, T. R, Sr Garner, J. E. (1993). Effects of music on Alzheimer patients. Perceptual and Motor Skills, 76, 451-455. Malkasian, D., 5: Diamond. M. C. (1971). The effect of environmental manipulation on the morphology of the neonatal rat brain. Inter-national Jo~rrnulof Ne~rr-oscience,2, 161-170. Maloney, C. C., & Daily, T. (1986). An eclectic group program for nursing home residents Tl~erupy111 Geriatrics, 14(3), 55-80. with dementia. Pl~vsicul&Occlrpntio~~ul Marcoulides, G. A. (1989). The estimation of variance components in generalizability studies: A resampling approach. PsvcliologicalReports, 65, 883-889. Mattis, S. (1988). DRS Dementia r-atitig scale: Professional tna~i~lal. Odessa, FL: Psychological Assessment Resources, Inc. Mattson, M. P. (1991). Activities in cellular signaling pathways: A two-edged sword? N~III-obiologv ofAgitlg, 12,343-346. McKhann, G., Drachman, D., Folslein, M., Katzman, R., Price, D., and Stadlan, E. M. (1984). Clinical diagnosis of Alzheimer's Disease: Report of the NINNCDSADRA work group under the auspices of the department of health and human services task force on Alzheimer's disease. Netrrology, 34, 939-944. Miller, E. R., & Parachek, J . F. (1974). Validation and standardization of a goal-oriented, quick-screening geriatric scale. Joco-ttal of tlir At~er-icanGeriatricsSocie~, 22(6), 278-283. Nebes, R. D. (1992). Cognitive dysfunction in Alzheimer's disease. In F. I. M. Craik & T. A. Salthouse (Eds.) The l~andbookof aging and cogt~ition.Hillsdale, NJ: Lawrence Erlbaum Associates. Paire, J. A., Sc Karney, R. J. (1084). The effectiveness of sensory stimulation for geropsychiatric inpatients. T l ~ Atnrricatl e Jo~rt.tralof Occ~~pational Tiler-up): 38, 505-509. Reichenbach, V. R., 8: Kirchman, M. M. (1991). Effects of a multi-strategy program i~polielderly with organic bruin syndrome. Plrjsical and Occr~putionalTlierapy it1 Ger-itrtr-ics,9 , 13 1- 15 1. Scheff, S. W. (1991). Use or abuse. Ne~rrobiologyofAgirig, 12(4), 349-351. Sclan, S. Ci., Foster, J. R., Reisberg, B., Franssen, E., & Welkowitz, J. (1990). Application of Piagetian measures of cognition i n severe Alzheimer's disease. Psycllintric .Jo~rr~~ul of tlie U11iversit.vof Ottnwa, 15(4), 221-226. Thornl)ury, J. M. (1992). Cognitive performance on Piagetian tasks by Alzheimer's in N~~r-sit~gdlI Healtl~,15(1), 11-18. disease patients. Hesrn1~11 Uylings, H. B., Kuypers, K., Diamond, K., Sc Veltman, W. A. (1978). Effects of diffe~eiitialenvironments on plasticity of dendrites of cortical pyramidal neurons in adult rals. E.tperitnrnt~11 Ne~rr-ology,63(3),658-677. Vance, D., Camp, C., Kabacoff, M., Cireenwalt, L. (1996, Winter). Montessori meth-
ods: In~lovative interventions for adults with Alzheimer's Disease. Morllessor-i Life7 10-12. Wechsler, D. A. (1981). IK?clr.sler~Ad~rir Ir~telliger~ce Scale. New York, NY: Psychological Corporation. Westfall, P. H., & Young, S. S. (1993). Resa~ilpli~zg-brrsed ~~liiltiple testing: E x a ~ ~ l ~ l e s atld ~izethodsfor p-~rnliien d j ~ ~ s t ~ i t New e ~ l t .York, NY: John Wiley &: Sons, Inc.
RECEIVED: 08/97 ACCEPTED: 11/97
Appendix. Example of Change Scores and Benefit Calculations SUBJECT #2
I
1
-3
13
11
2
7
0
7
4
3
9
2
7
4
3
OSPD-Means-Ends
10
OSPD-Cause and Effect OSPD-Space
GBS-General
7
0
7
-2
9
GBS-Social
6
0
6
2
4
# DECLINES (+)
12
10
# IMPROVES (-)
1
3
# SAMES (0) 11
MBS = (C,-Mi)
I
I
+ (M - - C - )
t
9
I
(MO-C0= (10-12) + (1-3) + (9-9) = -4
I
9
I
1 I
