**EVALUATION OF THE MONTESSORI-BASED ACTIVITIES PROGRAM OF THE**

**ALZHEIMER'S AWARENESS AND CARE PROGRAM**

Elia E. Femia

A Report Prepared for

The D.C. Office on Aging

And

Home Care Partners

October 2006

This evaluation was funded by a grant to the D.C. Office on Aging by the
U.S. Administration on Aging under their Alzheimer's Disease
Demonstration Grants to States Program.

TABLE OF CONTENTS

+-------------------------------------------------------------------+---+
| > Executive Summary                                               | i |
|                                                                   | i |
|                                                                   | i |
+-------------------------------------------------------------------+---+
| > I. Background and Introduction                                  | 1 |
+-------------------------------------------------------------------+---+
| > The Montessori Activities Method                                | 2 |
+-------------------------------------------------------------------+---+
| > Goals of the demonstration                                      | 3 |
+-------------------------------------------------------------------+---+
| > II\. Methods and Procedures                                     | 3 |
+-------------------------------------------------------------------+---+
| Description of Participating Adult Day Centers and Participants   | 3 |
+-------------------------------------------------------------------+---+
| > Design of the Evaluation                                        | 4 |
+-------------------------------------------------------------------+---+
| > Description of MBAP Sessions                                    | 5 |
+-------------------------------------------------------------------+---+
| > Description of MBAP Activities                                  | 6 |
+-------------------------------------------------------------------+---+
| > Measures                                                        | 7 |
+-------------------------------------------------------------------+---+
| > Planned Analyses                                                | 7 |
+-------------------------------------------------------------------+---+
| > III\. Evaluation Results                                        | 8 |
+-------------------------------------------------------------------+---+
| > Characteristics of the participants                             | 8 |
+-------------------------------------------------------------------+---+
| > Participants' Interests and Activities                          | 1 |
|                                                                   | 0 |
+-------------------------------------------------------------------+---+
| > Table 1. Characteristics of participants                        | 1 |
|                                                                   | 1 |
+-------------------------------------------------------------------+---+
| > Baseline Levels of Engagement and Behavior                      | 1 |
|                                                                   | 2 |
+-------------------------------------------------------------------+---+
| > Measure Description                                             | 1 |
|                                                                   | 2 |
+-------------------------------------------------------------------+---+
| > Evaluation Results                                              | 1 |
|                                                                   | 4 |
+-------------------------------------------------------------------+---+
| > Impact of MBAP on Engagement and Behavior Over Time             | 1 |
|                                                                   | 6 |
+-------------------------------------------------------------------+---+
| > Evaluation Results                                              | 1 |
|                                                                   | 6 |
+-------------------------------------------------------------------+---+
| > Table 2. Changes in Engagement and Mood Over Time during MBAP   | 1 |
| > and non-MBAP activities                                         | 7 |
+-------------------------------------------------------------------+---+
| > Comparison of Activity Type on Engagement and Mood at Each Time | 1 |
| > Point                                                           | 9 |
+-------------------------------------------------------------------+---+
| > Evaluation Results                                              | 2 |
|                                                                   | 0 |
+-------------------------------------------------------------------+---+
| > Three and Six-Month Engagement                                  | 2 |
|                                                                   | 0 |
+-------------------------------------------------------------------+---+
| > Three and Six-Month Behavior                                    | 2 |
|                                                                   | 2 |
+-------------------------------------------------------------------+---+
| > Staff Report and Satisfaction                                   | 2 |
|                                                                   | 2 |
+-------------------------------------------------------------------+---+
| > Measure                                                         | 2 |
|                                                                   | 3 |
+-------------------------------------------------------------------+---+
| > Evaluation Results                                              | 2 |
|                                                                   | 3 |
+-------------------------------------------------------------------+---+
| > Table 3. Staff satisfaction with MBAP at three and six Months   | 2 |
|                                                                   | 5 |
+-------------------------------------------------------------------+---+
| > Table 4. Staff evaluation of impact of MBAP on participants at  | 2 |
| > three and six months                                            | 6 |
+-------------------------------------------------------------------+---+
| > Qualitative observations                                        | 2 |
|                                                                   | 7 |
+-------------------------------------------------------------------+---+
| > IV\. Conclusions                                                | 2 |
|                                                                   | 9 |
+-------------------------------------------------------------------+---+
| > V. Acknowledgements                                             | 3 |
|                                                                   | 2 |
+-------------------------------------------------------------------+---+
| > VI\. References                                                 | 3 |
|                                                                   | 3 |
+-------------------------------------------------------------------+---+
| > VII\. Appendix                                                  | 3 |
|                                                                   | 5 |
+-------------------------------------------------------------------+---+

**Executive Summary**

-   An evaluation was conducted of the Montessori-Based Activities
    Program, an activities program based on Montessori principles for
    people with dementia (PWD) attending four adult day service (ADS)
    centers in the District of Columbia.

-   MBAP programming was implemented two days per week over a six month
    period by a trained MBAP specialist. Each MBAP session lasted
    approximately one hour.

-   MBAP principles and activities were shared with ADS staff. Staff was
    trained to implement programs, and support was provided to help the
    centers continue with programming efforts beyond the demonstration
    period.

-   MBAP sessions were structured to provide maximum engagement of
    participants. Activity kits were prepared that contained all the
    materials necessary for the task. Most kits were designed as an
    individual activity, although many could also be used as a small
    group activity.

-   The demonstration was carried out in two phases: Two ADS centers
    participated in the first phase, recruiting a total of 24
    participants. The remaining two ADS centers participated in the
    second phase, recruiting a total number of 26 participants.
    Participants had to be attending ADS a minimum of three days per
    week, have memory or behavior problems consistent with a dementia
    diagnosis, and be able to attend MBAP sessions. Prior to the start
    of the demonstration, staff obtained written consent from the
    participants' primary caregiver and completed a client background
    and interest survey. The evaluation consultant then observed and
    recorded participants' behavior during a regular non-MBAP activity.
    This observation served as a baseline report of client behavior.
    Over the subsequent six month period, the MBAP specialist worked
    with clients and staff to implement the MBAP activities. At the mid
    and end-points of the demonstration (three months and six months),
    the evaluation consultant made a repeat observation of client
    behavior and engagement during the MBAP activity, as well as during
    a regular non-MBAP activity.

-   In terms of engagement, longitudinal findings over the six month
    period included the following:

    -   During non-MBAP activities, levels of *constructive engagement*
        decreased over time, while during MBAP activity, the level of
        constructive engagement remained stable.

    -   Levels of *passive engagement* remained stable over time during
        both non-MBAP and MBAP activities.

    -   Levels of *non-engagement* remained stable during non-MBAP
        activities, but during MBAP activities, levels went down
        significantly over the six month period.

    -   Levels of *helping behavior* towards other participants remained
        stable during non-MBAP activities, but during MBAP activities,
        levels went up significantly from baseline to six months.

    -   Level of *difficulty with the* activity went up during non-MBAP
        activities, while during MBAP activities, the level went down
        slightly, though this change did not reach statistical
        significance.

-   Cross-sectional comparisons of MBAP and non-MBAP activities revealed
    significant differences at three and six months. MBAP activities
    were associated with higher levels of *helping behavior* at three
    months. At six months MBAP activities were associated with higher
    levels of *constructive engagement*, lower levels of
    *non-engagement*, increased *helping behavior*, and less *difficulty
    with the activity*.

-   In terms of the behavior and mood of the participant with dementia,
    longitudinal findings included the following:

    -   The amount of time that participants exhibited *positive
        behavior* (a.k.a. expressed pleasure) during the activity went
        down during non-MBAP activities, while during MBAP activities,
        the amount of positive behavior went up between three and six
        months.

    -   The amount of time that participants *slept or expressed
        boredom* during the activity went down during MBAP activities.

    -   Disruptive and restless were not reported during either the MBAP
        or non-MBAP time periods; thus, change in these behavior domains
        could not be assessed.

-   Cross-sectional comparisons of MBAP and non-MBAP activities showed
    no significant differences in behavior and mood at three months
    between types of activity. At six months the amount of positive
    behavior was higher during MBAP activities, and the amount
    sleeping/boredom was lower during MBAP activities as compared to
    non-MBAP activities.

-   In terms of staff satisfaction with the MBAP programming, the
    overwhelming majority was very satisfied, enjoyed the program, and
    commented that the activities successfully engaged the participants.
    They noted that the activities were fun and that other clients at
    their centers could benefit. A few difficulties were noted and
    included comments such as it was difficult to convince the
    participant to participate, that the activities were sometimes too
    juvenile for the participants, and that it was a hassle to get ready
    for MBAP. These difficulties were also noted as possible barriers to
    the continued implementation of MBAP beyond the demonstration
    period.

-   Overall, MBAP presents a promising and useful tool among the many
    tools that adult day centers have to engage their participants and
    improve their mood. Careful planning of MBAP activities, training of
    staff to appropriately implement the program, and fostering an
    environment that is open to the change from traditional programs are
    key variables that can influence the success of MBAP.

**I. Background and Introduction**

The Montessori-Based Activities Program (MBAP) was implemented as part
of the Alzheimer's Awareness and Care Program (AACP) funded by the D.C.
Office on Aging. The funds were made possible by the U.S. Administration
on Aging's Alzheimer's Disease Demonstration to States program. The
goals of AACP were to reach at-risk members of the African American
community who were not previously linked to services and to provide an
innovative program of MBAP within four adult day centers who receive
funding from the D.C. Office on Aging.

One of the most promising ways of addressing care needs for people with
dementia living in the community is through adult day service programs
(ADS). These programs provide structured activities that utilize
participants' remaining abilities, and give caregivers a break from the
often continuous pressures to provide care and supervision. ADS programs
are widely available in most states and communities and are continuing
to gain in popularity (Cox, 2003). ADS is not as costly as alternatives
such as having paid help come to the home, or placing the PWD in a
long-term care institution, and their use has been linked to positive
client outcomes (Femia, Zarit, Stephens, & Greene, in press;
Orsulic-Jeras, et al., 2000; Woodhead, Zarit, Braungart, Rovine, and
Femia, 2005; Zank and Schacke, 2002). Research by Woodhead and
colleagues (2005) showed that over a three month period, participants
with dementia experienced a decrease in depressive symptoms during the
time they attended an ADS program. One notable finding is that the type
of activity that the ADS client participated in influenced the gains
that were experienced. Activities that were actively engaging (e.g.,
games, arts and crafts, singing, drama, discussion groups) were
associated with greater improvements in mood and behavior than
activities that were less engaging. These findings are encouraging,
though unsurprising. Activities that are less engaging can lead to
boredom, which often causes problems such as aggression, agitation, and
withdrawal. On the other hand, activities that are engaging can
effectively stimulate a person with dementia, leading to the
improvements thus mentioned.

[The Montessori Activities Method]{.underline}

Montessori activities, based on the principles developed by Maria
Montessori, involve the teaching of cognitive, social, and functional
skills to participants, breaking down tasks into steps that progress
from simple to complex and from concrete to abstract (Bowlby, 1993;
Dreher, 1997). Historically, these methods were applied in the context
of early childhood education, but more recently, have found success
within the older adult population, notably, for people with dementia
(Camp, 1999). Montessori methods have been developed and implemented
within the long-term care setting with success, and most recently,
within the adult day care environment. The evolution of the Montessori
method in the adult day care setting is an example of an appropriate fit
between the person and his/her environment: Adult day programs emphasize
daily routine through activities and socialization, and the Montessori
methods emphasize the fit between the activity and the person's ability
level.

Research on Montessori-based activities in the adult day care setting
has shown Montessori activities to improve engagement, enhance mood, and
reduce behavior disturbances of people with dementia (Judge, et al.,
2002). Activities have also been shown to provide sensory and cognitive
stimulation that allow the expression of existing social skills (Camp
and Mattern, 1999). One unique aspect of the Montessori approach is the
ability to modify the activity based on the participants' physical and
cognitive ability *as well as* that person's cultural background and
interest. In this way, Montessori-based activities have the potential of
reaching a wide range of participants, which includes both the person
with dementia and the helpers guiding the activity itself.

[Goal of the Demonstration]{.underline}

Given these positive findings, the Alzheimer's Awareness and Care
Program sought to implement Montessori-based Programming (MBAP) within
four adult day centers affiliated with the D.C. Office on Aging. The
concept of MBAP was new to each of the centers, and its success could
potentially offer them a new activity method that could be integrated
into their current program offering. The goal of the demonstration was
to implement MBAP into the Centers, train staff in its usefulness and
method, assess the impact of MBAP on the clients' engagement, mood and
behavior, and support the center staff in taking over the program once
the demonstration period ended.

**II. Methods and Procedures**

[Description of Participating Adult Day Centers and
Participants]{.underline}

Four adult day service (ADS) centers participated in the demonstration
over a two year period: These were not-for-profit centers who receive
funding from the D.C. Office on Aging, and included Center Care Day
Treatment Program (CC), Isabella Breckinridge Center (IONA; Year One),
Genevieve N. Johnson Senior Day Care Program (GJ), and Downtown
Cluster's Geriatric Day Care Center (DC; Year Two). These programs
served a primarily African American population living in the District of
Columbia. Compared to other ADS participants in other regional areas,
some of the participants in this demonstration had potential challenges
including lower income levels, lower educational attainment, and limited
life opportunities not uncommon in this generation of African American
elders.

Participating centers referred clients to the demonstration program,
assigned staff to be available during MBAP sessions, as well as made
accommodations in their space for the MBAP activities. This included
moving non-participating clients to another room or space, or creating a
new space for the MBAP participants to participate. At the end of the
demonstration period, centers received a \$1,000 stipend for their
participation as well as a collection of materials, a bookshelf storage
area, activity kits, a research manual, training videos, and training by
the MBAP specialist.

Prior to the start of the program, staff from each of the four centers
received an orientation from the MBAP specialist. Staff included the
center's director, activity assistants, and other relevant personnel who
were invited by the director to attend. For the first two centers
participating in Year 1 (CC and IONA), the orientation was fairly brief,
involving higher level staff and focusing more on the logistics of the
program. For the second two centers in Year 2 (GJ and DC), the
orientation was expanded to include training on specific MBAP methods.
The training lasted for three hours and included information on the
principles of Montessori-based activities, a demonstration of sample
activities and kits, and a description and timeline of the six month
long program including the evaluation and observation components. Staff
from the first two centers were included in this more intense training
session to boost and solidify their MBAP skills.

[Design of the Evaluation]{.underline}

In total, the four centers had a combined total of 50 seniors with
cognitive impairments who were eligible for the program. Participants
had to be attending ADS a minimum of three days per week, have memory or
behavior problems consistent with a dementia diagnosis (but not
necessarily a definitive diagnosis), and be able to attend MBAP
sessions. The program was explained to the participants' primary
caregiver, who gave written consent for the participant to participate
in the demonstration.

MBAP participants participated in MBAP sessions twice a week over a
24-week period (six months). Prior to the start of the MBAP activities,
a baseline observation of the participants' engagement and behavior was
made by the evaluator (the author) during a non-MBAP activity. Following
the start of the program, follow-up observations were conducted mid-way
(three months) and at the end of the program (six months). Two types of
observations took place at these follow-up periods: an observation of
behavior during the MBAP session and an observation of behavior during a
non-MBAP activity.

In addition to these observations, data were collected by the center
staff on the MBAP participants' history, interests, and capabilities.
This data were used by the MBAP specialist to design activity kits that
would match the interests and ability levels of the participants.

At each of the follow-up assessments, staff people at the centers were
given written surveys to measure their satisfaction and evaluation of
the program. This gave them the opportunity to explore potential
barriers to successfully implementing the program and potential
difficulties in continuing the program beyond the demonstration period.

[Description of MBAP Sessions]{.underline}

MBAP sessions lasted approximately one hour during which participants
were seated individually or in small groups to participate in an MBAP
activity. Activities were packaged in "kits" that were developed and
prepared for in advance, based on the information gathered about the
clients' background and interest. These kits consisted of a shoe-box
size, clear plastic container that held all of the materials necessary
for that activity. These kits were stored and prominently displayed at
each day care site on an open bookshelf that was purchased for the
center. The open shelves provided visibility and accessibility by the
participant and the center staff. A description of activities is
provided in the Montessori-based Activities Manual (Appendix A of this
report).

During each MBAP session, the MBAP specialist arranged the participants
in either small groups or at the participant's individual workspace for
work on an individual activity. After introductions were made, she
offered participants a choice of activities and with the help of center
staff, oriented the participant to the activity. Participants were given
an activity kit and encouraged to participate in the activity through
modeling of the activity by the specialist or center staff or through
spoken directions. Most of the time, however, the activities were
self-directed and self-explanatory, meaning that the participant was
able to engage in the activity with minimal direction from the
specialist or center staff. Throughout the session, the MBAP specialist
provided healthy encouragement and a pleasant environment, observing
whether the activity was appropriate to the ability level of the
participants, and whether it was engaging and stimulating to them.
Depending on each, the specialist encouraged either greater or lesser
challenge or offered a different activity when one was done.

[Description of MBAP Activities]{.underline}

The Montessori-based activities included a variety of stimulating,
visually-appealing materials taken from the everyday environment. This
approach made it easy and appealing for staff to see how additional kits
could be created from inexpensive, easily-replaceable materials (many
purchased from the Dollar Store). Activity kits represented five domains
of functioning: 1) Cognitive stimulation; 2) life skills; 3) motor
movement and fitness; 4) sensory stimulation; and 5) socialization.
Examples of cognitively stimulating activities included containers full
of multi-colored poker chips, clothes pins, colorful straws, dominoes,
number tiles, or matching cards. Participants could spread out the
objects and sort them, physically move them, examine relationships
between the objects, count them, or spell, arrange, or reminisce about
the objects. Activities utilizing life skill functions include kits
containing baby clothes, napkins, towels, socks, yarn, etc. Participants
exercised the skills of folding clothes, "cooking," preparing foods,
folding yarn, polishing shoes, etc. Examples of activities that utilize
motor skills include cutting with scissors, working with tongs or
tweezers, tearing paper, forming shapes with clay, squeezing clothes
pins, sanding wood, and so on. To exercise gross motor skills,
participants could roll dice, toss bean bags, sweep/vacuum, and stretch
large bands. Examples of sensory activities include massaging hands with
hand lotion, finding hidden items in cheerios, sand or corn kernels,
"koosh" balls, slinkies, bubbles, bells, wind chimes, or arranging
flowers. Finally, examples of socialization activities include
"fill-in-the-blank" expressions, a discussion of favorite
foods/holidays, or jokes and humor. These activities were done in small
groups and were intended to maximize enjoyment and laughter.

[Measures]{.underline}

The evaluation instruments for this demonstration project were designed
to assess the engagement, behavior, and mood of the MBAP participants.
The data were collected by the evaluator through observing the
participants during MBAP and non-MBAP activities on a selected day at
three and six months. In addition, staff provided information about any
changes in participants' health and memory, as well level of engagement
during the day, and during the MBAP activities. The presentation of
results will first describe the evaluation instruments used and then
present the results from the analyses conducted.

[Planned Analyses]{.underline}

The first step was to examine the background characteristics of
participants, comparing these characteristics across the four centers to
assess comparability. Any differences between participants were used as
covariates in subsequent analyses. The second step was to look at the
changes in engagement and behavior over the six month period during both
a non-MBAP activity and during the MBAP activity. This allowed us to
examine the changes in participants' engagement and behavior over time.
The next step was to look at each follow-up observation separately and
compare the participants' engagement and behavior during the MBAP
activity with their performance during the non-MBAP activity. This
allowed us to directly compare the impact of the type of activity to the
participants' engagement and behavior. The last step involved an
assessment of the staff's evaluation and satisfaction with the program.

Repeated and one-way Analyses of Variance (ANOVA) were used to analyze
the steps described above. Where the four centers were significantly
different from one another, these variables were included in the
analyses as control variables. It was expected that MBAP activities
would provide considerable benefit to the participants in terms of their
constructive engagement and mood both over time and compared to non-MBAP
activities. Since each center provided high quality programming to their
participants, and the prevalence of behavior disturbances was already
low, it was not expected that there would be significant differences in
problematic behavior between MBAP and non-MBAP activities. A
significance level of .05 was used for all tests. However, because the
sample size used for these analyses were relatively small, the results
should be viewed with some caution, as a reduced level of power
increases the likelihood of Type I error (rejection of the null
hypothesis when it is in fact, true).

**III. Evaluation Results**

## Characteristics of the Participants

Table 1 shows the characteristics of the participants across the four
adult day center sites. Taking the participants all together, the
overwhelming majority were women (89.4%) of African American descent
(82.0%), with a mean age of 89.4 years. Almost all were not married
(83.3%). In terms of their place of residence, most participants lived
with their primary caregiver (69.4%) or with other family or friends
(14.3%). A few lived in a facility setting such as a nursing home or
assisted living (12.2%) and even fewer lived alone (4.1%). All
participants had a primary caregiver, which was most often the adult
child (66.0%), followed by another family member or friend (24.0%), and
least common, a spouse (10.0%). Turning to the participants' impairment
profile, almost all had a dementia diagnosis: 71.7% had an Alzheimer's
diagnosis, and 19.6% had some other diagnosis, such as Vascular
dementia. Only 6.7% had no diagnosis for their memory impairments but
did have symptoms consistent with a diagnosis. MMSE scores were
available for participants from two of the centers, where the mean score
was 13.2 (range: 0-30), indicative of the middle stages of dementia.
This score was consistent with the amount of ADL impairment within the
group: A minority of participants (26.0%) had no impairments in any of
the 3 domains of eating, hygiene (dressing and bathing), or toileting,
while most required assistance with one or two ADLs (54.0%), and 20.0%
required help with all three ADLs. Finally, in terms of enrollment at
the day care centers, the mean number of days that the client attended
per week was 4.5 days, and the mean number of hours attending per day
was 5.7 hours.

Comparing participants across the four centers, we found that
participants were roughly equivalent in terms of demographic
characteristics, with one minor difference, client education. IONA
participants had higher levels of education and lower weekly attendance
than the other three centers. In addition to differences in education
level, there were other background differences, namely, weekly
enrollment, daily attendance, and ADL limitations. GJ participants
attended the center fewer hours per day (explained by the fact that the
center itself is only open five hours each day). DC participants were
slightly more impaired in terms of ADL performance while IONA
participants were the least impaired. It was hypothesized that
differences in client education, weekly enrollment, or attendance would
not influence the evaluation results, so these differences were
considered largely ignorable. However, it was considered possible that
differences in ADL limitations could affect participants' level of
engagement, behavior, and mood; consequently ADL impairment was used as
a covariate to account for potential differences in the impact of MBAP
on participants' outcomes.

## Participants Interests and Activities

Prior to the start of the program, center staff members were asked to
report on the history, background, and interest of MBAP participants.
Participants were a dynamic group of individuals who came to Washington
D.C. from sixteen different states in the U.S., and two countries
(Jamaica and Trinidad). In fact, only five of the fifty participants
(10%) were originally from the District. Almost all of them were
previously employed in jobs ranging from university professor,
government employees, and telephone operators. Many participants had
physical challenges --needing glasses (62%), hearing aids (7%),
communication difficulties (55%), or limiting medical condition (83%);
however, none of these conditions prevented their ability to participate
in the program. This is because rather than having the participant
adjust themselves to the MBAP activity, it was the activity itself that
was modified to suit the ability and limitations of the participants.

Table 1. Demographic and Background Characteristics of MBAP Participants

<table>
<colgroup>
<col style="width: 30%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td><p>ALL</p>
<p>(N=50)</p></td>
<td></td>
<td><p>CC</p>
<p>(n=14)</p></td>
<td></td>
<td><p>IONA</p>
<p>(n=10)</p></td>
<td></td>
<td><p>DC</p>
<p>(n=13)</p></td>
<td></td>
<td><p>GJ</p>
<p>(n=13)</p></td>
</tr>
<tr class="even">
<td><p>Client gender</p>
<p>% Female</p></td>
<td></td>
<td>89.0%</td>
<td></td>
<td>85.7%</td>
<td></td>
<td>100.0%</td>
<td></td>
<td>69.2%</td>
<td></td>
<td>70.0%</td>
</tr>
<tr class="odd">
<td>Client age (Mean years)</td>
<td></td>
<td>89.4</td>
<td></td>
<td>83.5</td>
<td></td>
<td>83.8</td>
<td></td>
<td>84.1</td>
<td></td>
<td>83.5</td>
</tr>
<tr class="even">
<td><p>Client race</p>
<p>%African American</p>
<p>%White or other</p></td>
<td></td>
<td><p>82.0%</p>
<p>18.0%</p></td>
<td></td>
<td><p>100.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>40.0%</p>
<p>60.0%</p></td>
<td></td>
<td><p>100.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>77.0%</p>
<p>23.0%</p></td>
</tr>
<tr class="odd">
<td><p>Client education*</p>
<p>%Less than HS</p>
<p>%HS Graduate</p>
<p>%Post-college</p></td>
<td></td>
<td><p>23.3%</p>
<p>48.8%</p>
<p>28.0%</p></td>
<td></td>
<td><p>40.0%</p>
<p>50.0%</p>
<p>10.0%</p></td>
<td></td>
<td><p>25.0%</p>
<p>25.0%</p>
<p>50.0%</p></td>
<td></td>
<td><p>58.3%</p>
<p>25.0%</p>
<p>16.7%</p></td>
<td></td>
<td><p>30.8%</p>
<p>53.8%</p>
<p>15.4%</p></td>
</tr>
<tr class="even">
<td><p>Client marital status</p>
<p>%Married</p>
<p>%Not married</p></td>
<td></td>
<td><p>16.7%</p>
<p>83.3%</p></td>
<td></td>
<td><p>15.4%</p>
<p>84.6%</p></td>
<td></td>
<td><p>20.0%</p>
<p>80.0%</p></td>
<td></td>
<td><p>15.4%</p>
<p>84.6%</p></td>
<td></td>
<td><p>16.7%</p>
<p>83.3%</p></td>
</tr>
<tr class="odd">
<td><p>Living Arrangement</p>
<p>%With primary caregiver</p>
<p>%With other family/friends</p>
<p>%Assisted living or similar</p>
<p>% Lives alone</p></td>
<td></td>
<td><p>69.4%</p>
<p>14.3%</p>
<p>12.2%</p>
<p>4.1%</p></td>
<td></td>
<td><p>61.5%</p>
<p>7.5%</p>
<p>31.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>70.0%</p>
<p>10.0%</p>
<p>10.0%</p>
<p>10.0%</p></td>
<td></td>
<td><p>69.2%</p>
<p>31.8%</p>
<p>0.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>83.4%</p>
<p>8.3%</p>
<p>0.0%</p>
<p>8.3%</p></td>
</tr>
<tr class="even">
<td><p>Relation (client to caregiver)</p>
<p>%Spouse</p>
<p>%Parent</p>
<p>%Other</p></td>
<td></td>
<td><p>10.0%</p>
<p>66.0%</p>
<p>24.0%</p></td>
<td></td>
<td><p>0.0%</p>
<p>78.6%</p>
<p>21.4%</p></td>
<td></td>
<td><p>10.0%</p>
<p>80.0%</p>
<p>10.0%</p></td>
<td></td>
<td><p>15.4%</p>
<p>69.2%</p>
<p>15.4%</p></td>
<td></td>
<td><p>15.4%</p>
<p>38.5%</p>
<p>46.1%</p></td>
</tr>
<tr class="odd">
<td>#days attending per week*</td>
<td></td>
<td>4.5</td>
<td></td>
<td>5.0</td>
<td></td>
<td>3.4</td>
<td></td>
<td>4.3</td>
<td></td>
<td>5.0</td>
</tr>
<tr class="even">
<td>#hours per day attending*</td>
<td></td>
<td>5.7</td>
<td></td>
<td>6.9</td>
<td></td>
<td>6.2</td>
<td></td>
<td>4.0</td>
<td></td>
<td>6.8</td>
</tr>
<tr class="odd">
<td><p>Dementia diagnosis</p>
<p>%Alzheimer’s disease</p>
<p>%Other dementia</p>
<p>%No diagnosis</p></td>
<td></td>
<td><p>71.7%</p>
<p>19.6%</p>
<p>6.7%</p></td>
<td></td>
<td><p>71.4%</p>
<p>21.4%</p>
<p>7.1%</p></td>
<td></td>
<td><p>75.0%</p>
<p>25.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>69.2%</p>
<p>30.8%</p>
<p>0.0%</p></td>
<td></td>
<td><p>72.7%</p>
<p>27.3%</p>
<p>0.0%</p></td>
</tr>
<tr class="even">
<td><p>MMSE</p>
<p>(Mean (s.d.); range 0-30)</p></td>
<td></td>
<td>13.2 (7.6)</td>
<td></td>
<td>n/a</td>
<td></td>
<td>n/a</td>
<td></td>
<td>10.5 (6.6)</td>
<td></td>
<td>16.3 (7.7)</td>
</tr>
<tr class="odd">
<td><p>ADL limitations (of 3)*</p>
<p>%No impairment</p>
<p>%1-2 impairments</p>
<p>%Impairment in all 3 areas</p></td>
<td></td>
<td><p>26.0%</p>
<p>54.0%</p>
<p>20.0%</p></td>
<td></td>
<td><p>28.6%</p>
<p>64.2%</p>
<p>7.1%</p></td>
<td></td>
<td><p>50.0%</p>
<p>50.0%</p>
<p>0.0%</p></td>
<td></td>
<td><p>0.0%</p>
<p>46.2%</p>
<p>53.8%</p></td>
<td></td>
<td><p>30.8%</p>
<p>53.9%</p>
<p>15.4%</p></td>
</tr>
</tbody>
</table>

NOTE: CC = Center Care; DC = Downtown Cluster; GJ = Genevieve Johnson

\* Indicates a significant difference across centers at [p]{.underline}
\< .05 level.

Staff indicated that participants enjoyed a variety of activities --
cards, music, dancing, arts and crafts, etc. From this information, the
MBAP specialist created a selection of activity kits that addressed a
variety of purposes and needs of clients, including cognitively
stimulating activities, activities that utilized life skills, activities
that stress motor movement and fitness, sensory-stimulating activities,
and socializing-type activities. These activities were described above
and found also in the MBAP Manual (Appendix A). Initially, approximately
ten different kits were assembled and give to the center. Throughout the
program, based on staff and client feedback, new kits were added, or
existing ones were modified.

[Baseline Levels of Engagement and Mood]{.underline}

[Measure Description.]{.underline} Participants' baseline level of
engagement was observed by the evaluator prior to the start of the MBAP
programming and during a regularly scheduled non-MBAP activity. During
the observation period, three categories of engagement as well as
helping behavior and difficulty with the activity were assessed. These
categories were taken from the Engagement Measure developed by Judge and
colleagues (2000). The categories of engagement included constructive
engagement, passive engagement, and non-engagement.

*Constructive engagement* was defined as any physical, verbal, or
emotional response directly related to the activity that the participant
was participating in. For example, putting puzzle pieces together,
stacking blocks, arranging flowers, making comments, discussing ideas,
or contributing to the discussion were all considered forms of
constructive engagement. *Passive engagement* was defined as listening,
attending to, and/or looking at the activity. For example, listening to
the discussion or speaker, watching others manipulate objects were all
considered forms of passive engagement. *Non-engagement* was defined as
attending to things other than the activity: staring into space,
sleeping, or any physical or verbal action not related to the activity
that the participant was participating in. *Helping behavior* was
defined as one participant helping another participant with the
activity. Examples include pointing out answers, assisting another
participant with the activity materials, giving clues to another
participant, helping another participant read, and so on. Finally,
*difficulty with the activity* was defined as a participant's attempt to
engage, but could not because of difficulty concentrating, having
difficulty coming up with responses, or generally finding the activity
too challenging.

For each of the categories of engagement, the evaluator rated how
engaged (constructively engaged, passively engaged, etc.) each client
was on a five point scale, ranging from 1=not at all engaged to
5=extremely engaged. This coding scheme differed from the original
Engagement Scale, which asked observers to measure the length of time
each type of engagement was exhibited. At baseline, the evaluator and
the MBAP specialist observed the participants' engagement and behavior
at two of the four centers; inter-rater agreement (i.e., the level of
agreement between the two raters) among the 24 participants observed was
greater than 90% (i.e., ratings for participants were similar 90% of the
time or higher) and deemed acceptable.

In addition to these measures, participants' mood and behavior were also
assessed in five domains: Positive behavior, depressed mood or sadness,
sleeping/boredom, disruptive behaviors, and restlessness/agitation. This
measure was based on the Affect Measure used by Judge and colleagues
(2000), and modified slightly to include five commonly-reported domains
of behavior in dementia. Positive behavior was defined as any expression
of pleasure, laughing, smiling, and overt enjoyment of the activity.
Depressed mood or sadness was defined as tearfulness, crying, and any
vocal expressions of sadness. Disruptive behaviors was defined as loud
vocalizations, arguments, irritability, threats to hurt others, and
general aggression. Restlessness and agitation included hand wringing,
rocking, anxiety, and other restless vocalizations. For each of these
domains, the observer indicated the length of each behavior, ranging
from 1=behavior did not occur, 2=up to ½ of the activity time; 3=more
than ½ of the activity time; and 4=the entire period. Inter-rater
agreement on this measure was also greater than 90% and deemed
acceptable.

[Evaluation Results.]{.underline} At baseline, before the
Montessori-based activities were introduced, the participants at each of
the four centers were observed during a regularly-scheduled activity.
Activities at each center were different and included
reminiscence/current events discussion (at two centers), bingo, and
exercise. On average, activities lasted 40 minutes (range: 25 -- 60
minutes), involving the selected MBAP participants and staff as well as
other clients at the center. The average group size was eighteen
participants and two staff members.

In terms of participation, 49 of the 50 MBAP participants participated
in the non-MBAP activity. Two participants resisted the activity, and
three tried to leave; however no one actually left the activity.
Generally, the activities were effective in constructively engaging the
participants: The mean level of constructive engagement was four out of
a possible five points, which translated into roughly 75% of
participants engaged either "very much" (value=4) or "extremely"
(value=5). Consistent with this, the level of passive engagement was
also high (M = 4.4), with 83% of participants oriented to and attending
to the activity, even if not "actively" participating. The level of
non-engagement was fairly low with a mean of 2.0. More than half (60%)
of participants did not demonstrate non-engagement; however, this also
meant that 40% did exhibit some form of non-engagement. In fact, 19% (10
participants) were either "very" or "extremely" non-engaged. In terms of
difficulty, exactly half of the participants found the activity "not
difficult at all" (value =1); however, that indicated that the other
half had some difficulty with the activity: Twenty-seven percent had a
little difficulty; 14.5% had some difficulty; and the remaining 8.5% had
"very much" to "extreme" difficulty with the activity. Finally, in terms
of helping others with the activity, the mean level was low (M=1.3);
half of the participants did not exhibit this behavior at all, while 27%
showed a little helping; 15% showed the behavior "somewhat", and 8%
showed it "very much" or "extremely."

Turning to the behavior and mood of participants, only two of the five
domains were exhibited by participants: positive behavior and
sleep/boredom. Pleasure was observed by 87% of participants; 29% for the
entire activity period; 29% for more than half the period; 29% for less
than half the period, and 13% did not show positive behavior at all
during the activity. For the sleep/boredom domain, the overwhelming
majority (73%) did not exhibit the behavior at all during the activity;
however, 21% exhibited it for less than half the period, and 6% for more
than half the period. The other three behavior domains, depressed mood,
disruptive behaviors, and agitation/restlessness were virtually not
observed during the activity; only two participants showed these other
behaviors and for less than half of the activity. Due to the lack of
variability on these behavior measures, changes in these behaviors could
not be assessed, and these variables were not included in subsequent
analyses.

To account for these baseline findings, a series of one-way Analysis of
Variance analyses were conducted using ADL impairment as a covariate to
assess whether participants' level of impairment could have affected
their baseline levels of engagement or behavior. Results revealed one
trend: Participants with fewer ADL impairments were more engaged than
those with greater amounts of impairment, although this difference did
not reach statistical significance. The one area where impairment had a
marginally significant effect was in level of difficulty with the
activity, where the most impaired participants (those with three of the
three ADL impairments) had greater difficulty with the activity (M =
2.7; F = 2.65; df = 3; p = .06) than those with no to fewer impairments
(M = 1.43).

Following this first set of analyses, a second set of one-way Analysis
of Variance Models were constructed, using the adult day center variable
as the covariate. The rationale here was that the particular activity
done at each of the centers could have affected the participants'
engagement and behavior. Results showed that the center did have a
significant effect on two measures: level of passive engagement and
positive behavior. The center that had exercise as an activity showed
significantly higher levels of passive engagement (M=4.85; F = 3.74; df
= 3; p = .02) and higher levels of positive behavior (M=3.23; F = 5.22;
df = 3; p = .00). Conversely, the centers that had reminiscence/
discussion group activities showed slightly higher levels of
non-engagement and fewer helping behaviors; however, these differences
were only marginally significant.

[Impact of MBAP on Participant Engagement, Behavior, and Mood Over
Time]{.underline}

MBAP was hypothesized to positively affect participant engagement,
behavior, and mood. Specifically, constructive engagement was expected
to increase, and non-engagement was expected to decrease. Since
Montessori activities are flexible and self-correcting in terms of
"activity rules," we also expected level of difficulty to decrease. In
terms of behavior, positive behavior was expected to increase while
sleep/boredom was expected to decrease from baseline through the end of
the demonstration period. It should be noted that the changes in
engagement and behavior for the MBAP activity, is in fact, a comparison
of a non-MBAP activity at baseline to MBAP activities at each of the
follow-up observations. These changes were compared to changes in
engagement and behavior during non-MBAP activities over the six month
period.

Table 2

Changes in Engagement and Mood Over Time during MBAP and non-MBAP
activities

+-------------------+---+--------+--------+--------+---+--------+--------+
|                   |   | No     |        |        |   | MBAP   |        |
|                   |   | n-MBAP |        |        |   | Ac     |        |
|                   |   | Ac     |        |        |   | tivity |        |
|                   |   | tivity |        |        |   |        |        |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Variable          |   | Ba     | 3      | 6      |   | 3      | 6      |
|                   |   | seline | -Month | -Month |   | -Month | -Month |
+-------------------+---+--------+--------+--------+---+--------+--------+
| ENGAGEMENT        |   |        |        |        |   |        |        |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Constructive      |   | 4.25   | 4.25   | 3.80\* |   | 4.41   | 4.64   |
| Engagement        |   |        |        |        |   |        |        |
|                   |   | (0.91) | (0.89) | (1.48) |   | (1.10) | (0.95) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Passive           |   | 4.65   | 4.40   | 4.10\* |   | 4.55   | 4.77   |
| Engagement        |   |        |        |        |   |        |        |
|                   |   | (0.67) | (0.82) | (1.25) |   | (1.10) | (0.61) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Non-Engagement    |   | 1.90   | 1.75   | 1.95   |   | 1.68   | 1.36   |
|                   |   |        |        |        |   |        |        |
|                   |   | (1.25) | (0.97) | (1.23) |   | (1.13) | (0.95) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Helping Behavior  |   | 1.05   | 1.15   | 1.25   |   | 2.00   | 1.91\* |
|                   |   |        |        |        |   |        |        |
|                   |   | (0.22) | (0.67) | (0.64) |   | (1.02) | (1.27) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Difficulty with   |   | 1.75   | 1.45   | 2.01   |   | 1.41   | 1.41\* |
| Activity          |   |        |        |        |   |        |        |
|                   |   | (0.91) | (0.76) | (1.40) |   | (0.92) | (0.85) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| BEHAVIOR and MOOD |   |        |        |        |   |        |        |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Positive          |   | 2.65   | 2.90   | 2.10\* |   | 3.18   | 3.14\* |
| (Pleasure)        |   |        |        |        |   |        |        |
|                   |   | (0.93) | (1.07) | (0.97) |   | (1.00) | (0.89) |
+-------------------+---+--------+--------+--------+---+--------+--------+
| Sleep/Boredom     |   | 1.30   | 1.40   | 1.60   |   | 1.18   | 1.14   |
|                   |   |        |        |        |   |        |        |
|                   |   | (0.57) | (0.68) | (0.82) |   | (0.50) | (0.47) |
+-------------------+---+--------+--------+--------+---+--------+--------+

NOTE: Range of engagement scales is 1 = not at all engaged to 5 =
extremely engaged; Range of behavior and mood scales is 1 = behavior did
not occur; 2 = less than ½ activity; 3 = more than ½ activity; 4 =
entire period.

\* Significant change of measure over time (p \< .05).

[Evaluation Results.]{.underline} Follow-up observations were conducted
mid-way (at three months) and at the end of the demonstration period
(six months). As to be expected in this group of impaired elders, there
was some attrition in the sample. At three months, two participants were
discharged from the respective center (5%), thus reducing the sample to
48 participants. By six months, this number was reduced further, with
four clients discharged from their center (8.3%), three clients who died
(6.3%), and one client who moved into a nursing home (2.1%). The
resulting end sample size was forty participants; however, not all of
these individuals were present during the observations due to a variety
of reasons (e.g., vacations, sickness, etc.); hence, in some instances,
the power to detect significant effects was potentially limited by the
low sample size.

To assess changes over time, repeated measures Analysis of Variance
Models were constructed using ADL impairment as a covariate. These
models were analyzed for a significant time effect, which would indicate
a change in mean levels over time. Additionally, the models could also
show a significant interaction term---time by ADL impairment\--which
would indicate a differential change among those with higher or lower
ADL impairment. For the sake of simplicity, the results of the ANOVA
models are not presented; however Table 2 shows the means and standard
deviations of engagement and behavior across time during both non-MBAP
and MBAP activities.

Turning first to the engagement measures, results showed that levels of
*constructive engagement* decreased over time during non-MBAP activities
(F=5.64; df = 2; p = .02) while during MBAP activities, the levels
increased somewhat, though not significantly. During both types of
activities, ADL impairment was not significant, indicating that level of
impairment did not differentially affect constructive engagement. For
*passive engagement* during non-MBAP activities, results showed a
significant decrease in levels over the six month period (F = 6.08; df =
2; p = .01) and that higher levels of ADL impairment was related to this
decrease over time. In other words, participants with greater impairment
had lower levels of passive engagement over time. During MBAP
activities, passive engagement remained stable over six months, and ADL
impairment did not significantly influence this change. That is,
participants, regardless of how much impairment they had, showed stable
levels of passive engagement over time during MBAP activities. For
non-engagement, there were no significant changes over time during
either the non-MBAP or MBAP activities.

In terms of helping behavior, results showed no significant changes
during the non-MBAP activity; however, during the MBAP activity,
*helping behavior* significantly increased over the six month period (F
= 8.72; df = 2; p = .00). The biggest change was between the non-MBAP
baseline observation and the three month MBAP observation, jumping from
a mean value of 1.1 (indicating that the behavior mostly did not occur)
to a value of 2.0 (indicating a small amount of helping between
participants). Interestingly, ADL impairment was not a significant
predictor, indicating that participants, regardless of impairment level,
showed similar levels of helping behavior. Finally, in terms of
*difficulty* *with the activity*, during the non-MBAP activity,
difficulty tended to increase somewhat over time, although this increase
did not reach statistical significance (F = 2.62; df = 2; p = .10). In
contrast, during MBAP activities, the *level of difficulty* showed a
marginally significant decrease (F = 3.13; df = 2; p = .07). Again, the
biggest difference was between baseline and three months.

Next, a similar series of analyses were conducted for two of the five
domains of behavior, positive behavior and sleep/boredom. Recall that
the three other domains (depressed mood, disruptive behavior, and
restlessness/agitation) could not be analyzed due to insufficient
variability in the variable (i.e., participants did not exhibit the
behavior). Results showed a marginally significant decrease in positive
behavior over time during non-MBAP activities (F = 2.89; df = 2; p =
.09), but a marginally significant increase in *positive behavior*
during MBAP activities (F = 3.17; df = 2; p = .07). In the domain of
sleep/boredom, there were no significant changes over time during either
MBAP or non-MBAP activities.

[Comparison of Activity Type on Engagement and Behavior at Each Time
Point]{.underline}

Following the longitudinal analyses, a series of cross-sectional
comparisons were made to assess differences in engagement and behavior
between non-MBAP and the MBAP activities. At each observation period, a
paired-samples t-test was conducted, and the means of engagement and
behavior were compared between the non-MBAP and MBAP activity. These
analyses served to answer the question of which type of activity was
associated with higher or lower levels of engagement and behavior at
each time point. Because each center had a different type of non-MBAP
activity, the analyses were also conducted using center as a covariate
to account for possible differences in the type of non-MBAP activity on
engagement and behavior.

[Evaluation Results]{.underline}. Table 2 shows the mean levels of
engagement and behavior at three and six months during both the non-MBAP
and MBAP activities.

*Three and Six Month Engagement.* At three months, the mean differences
in constructive engagement, passive engagement, and difficulty between
non-MBAP and MBAP activities were not statistically significant. The
levels of *constructive engagement* during both types of activities was
relatively high, (M = 4.5 during non-MBAP and M = 4.4 during MBAP
activities; range 1 -5). Levels of *passive engagement* were similarly
high during both non-MBAP (M= 4.4) and non-MBAP activities (M = 4.6) as
were levels of difficulty (M = 1.4 for both non-MBAP and MBAP
activities). Turning to levels of *non-engagement and helping behavior*,
however, analyses revealed a significant difference between types of
activities: In both instances, MBAP activities showed a greater benefit.
The levels of *non-engagement* were significantly lower during MBAP
activities (M = 1.6) as compared to non-MBAP activities (M = 1.9; F =
5.03; df = 1; p = .04). Here, the adult day center variable was also
significant, suggesting that the type of non-MBAP activity also
influenced levels of non-engagement. At the center that conducted a
reminiscence/ discussion activity, participants were more non-engaged
than participants at centers that conducted other types of activities
(bingo, singing, and exercise). For *helping behavior*, analyses also
revealed significant mean differences; namely, that during the MBAP
activity, participants showed significantly higher levels of helping (M
= 2.00) compared to non-MBAP activities (M = 2.00; F = 17.9; df = 1; p =
.00). The variable, center, was not significant, suggesting that the
type of non-MBAP activity did not influence levels of helping behavior.
On the other hand, MBAP activities were more likely to promote helping
behavior between participants.

At six months, the mean differences between non-MBAP and MBAP activities
were more distinct for all the measures of engagement. Table 2 above
shows these results. For *constructive engagement*, the mean difference
between MBAP and non-MBAP activities was about 0.7 points higher during
the MBAP activity (M = 4.6 vs. M = 3.9; F = 17.7; df = 1; p = .00). For
*passive engagement*, this difference was marginally significant (M =
4.2 during non-MBAP activity vs. M = 4.5 during the MBAP activity; F =
3.5; df = 1; p = .08), and for *non-engagement* and *helping behaviors*,
the differences were significant and striking. The mean levels for
non-engagement were 2.0 during non-MBAP activities and 1.4 during MBAP
activities (F = 9.4; df = 1; p = .01), and for helping behavior the
means were 1.2 during non-MBAP activities and 1.7 during MBAP activities
(F = 12.3; df = 1; p = .00). In the case of helping behaviors, there was
also a significant center effect whereby, one center that had
successfully implemented MBAP programming into their regular activities
had a much higher level of helping behavior during MBAP as compared to
non-MBAP activities. Finally, for *difficulty with the activity*, the
mean difference between non-MBAP and MBAP activities was also
significant (M = 2.2 vs. M = 1.4; F = 7.6; df = 1; p = .01), with
participants having much less difficulty with the MBAP activity compared
to the non-MBAP activities. These results suggest a greater match
between the participant's ability level and the activity's demands
during MBAP activities as compared to non-MBAP activities.

*Three and Six Month Behavior*. In terms of behavior domains, mean
differences in behavior between non-MBAP and MBAP activities were not
significant at three months. The amount of positive behavior and
sleep/boredom were not significantly different during non-MBAP
activities compared to MBAP activities (see Table 2). However, at six
months, significant mean differences emerged in both of these behavior
domains. For positive behavior the duration of the behavior was almost a
full point higher during MBAP activities as compared to non-MBAP
activities. During the MBAP activity, positive behavior was observed on
average, for almost the entire one hour activity period (M = 3.0 during
MBAP vs. M = 2.1 during non-MBAP; F = 17.7; df = 1; p = .00). For
sleep/boredom, results showed similar findings, although the
differential was not as great as for positive behavior (M = 1.5 during
non-MBAP activities, and M = 1.1 during MBAP activities). This finding
reflects the fact that sleep/boredom were rarely reported during MBAP
activities, but was observed in several participants for up to ½ of the
activity during non-MBAP activities. Again, this result is impressive
considering that MBAP activities lasted one hour in length as compared
to non-MBAP activities, which lasted on average, twenty minutes shorter.

[Staff Report and Satisfaction]{.underline}

One of the primary goals of this demonstration was to introduce and
educate staff on the MBAP methods and provide training, support, and
initial funding so that centers could continue the program beyond the
demonstration period. Throughout the program, activity staff attended
the MBAP sessions, during which the MBAP specialist modeled the
principles behind the MBAP method and provided guidance to staff on ways
to interact with participants that would maximize their abilities and
enjoyment. The staff at each center was given the additional opportunity
to evaluate the program and assess their readiness to take over the
program at the end of the demonstration period.

[Measure]{.underline}

Staff members were given a written survey to complete at the three month
and six month observation periods. First, they were asked to rate their
overall satisfaction with the MBAP program on a scale of zero to four,
with zero indicating "very dissatisfied" and four indicating "very
satisfied." In addition, they rated their level of satisfaction on seven
different aspects of the program, including the room, the lighting, the
supplies and materials, the amount of time, and so on. Subsequently,
staff members were asked the extent to which they agreed or disagreed
with a series of eight statements that dealt with participants'
enjoyment, participation, and difficulty with the MBAP activities. These
were rated along a five point scale with a score of one indicating
strong disagreement and five indicating strong agreement. Items included
such things as MBAP participants enjoy participating in MBAP; it is a
hassle to get participants ready for MBAP; MBAP is successful in
engaging the participants, and MBAP activities are fun and interesting.
Finally, staff were asked about the major benefits and drawbacks of
MBAP, the top barriers for continuing the program, and their level of
confidence and readiness to continue the program when the demonstration
period ended. For the latter two items, staff rated their level of
confidence and readiness on a scale of one to ten, with one indicating
"not at all ready" and ten indicating "extremely ready."

[Evaluation Results]{.underline}

The staff completing the written evaluation included the four center
directors, one assistant director, two center social workers, four
activity directors, and six recreation staff. A total of seventeen staff
completed the survey at three months, and fourteen completed the survey
at six months. Table 3 shows the results for staff satisfaction on the
program overall and on individual aspects of the program.

In terms of overall satisfaction, staff members were overwhelmingly very
satisfied with the program, and as well, were satisfied with many of the
logistical elements \-- the room, lighting, materials used, and amount
of time devoted to the program. In particular, they were very satisfied
with the skill of the MBAP specialist, often suggesting that she was
instrumental to the success of the program. Of the seven items assessed,
staff suggested only two areas that could have used improvement: the
room for the activities and the type and range of activities. In terms
of the room, it was important that participants had sufficient table
space and a place where there was not too much ambient noise or
activity. At one center, the space devoted to MBAP activities was the
dining room, which was difficult to set up and move around in. However,
by six months, the space was moved, and the level of satisfaction on
that item reflected the improvement. The other item that scored lower
than the others was the type and range of MBAP activities. Here, some
staff initially made comments that the activities appeared juvenile or
inappropriate for their adult participants. However, as staff continued
to learn about the MBAP method and principles, and as different types of
activities were introduced into the center, there came to be greater
acceptance of the activities. At six months, the satisfaction level with
activities did improve.

Table 3. Staff Satisfaction with MBAP at Three and Six Months

+-------------------------------------+------+-------+---+-------+------+
|                                     | 3-Mo |       |   | 6-M   |      |
|                                     | nths |       |   | onths |      |
|                                     |      |       |   |       |      |
|                                     | (n   |       |   | (     |      |
|                                     | =17) |       |   | n=14) |      |
+-------------------------------------+------+-------+---+-------+------+
|                                     | Mean | S.D.  |   | Mean  | S.D. |
+-------------------------------------+------+-------+---+-------+------+
| Overall satisfaction with MBAP      | 3.54 | 0.97  |   | 3.86  | 0.36 |
| (range: 0 -- 4)                     |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 1\. Room used for activities        | 4.17 | 1.40  |   | 4.79  | 0.43 |
| (range: 1 -- 5)                     |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 2\. Lighting in room used for       | 4.70 | .48   |   | 5.00  | 0.00 |
| activities                          |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 3\. Supplies and materials used for | 4.46 | 0.97  |   | 4.64  | 0.63 |
| MBAP                                |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 4\. Amount of time for MBAP         | 4.58 | 0.67  |   | 4.79  | 0.58 |
| sessions                            |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 5\. Number of days per week MBAP    | 4.54 | 0.88  |   | 4.79  | 0.43 |
| offered                             |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+
| 6\. Skill of MBAP specialist        | 4.75 | 0.62  |   | 4.86  | 0.54 |
+-------------------------------------+------+-------+---+-------+------+
| 7\. Types and range of MBAP         | 4.38 | 1.12  |   | 4.64  | 0.63 |
| activities                          |      |       |   |       |      |
+-------------------------------------+------+-------+---+-------+------+

Turning to the staff's evaluation of the impact of MBAP on participant's
engagement and behavior, in general, staff believed that MBAP was having
a positive impact on their clients with dementia. At both three and six
months, staff strongly agreed that MBAP participants seemed to enjoy
participating in the program and that the program was successful in
engaging the participants. The mean levels of both these items went up
slightly from three to six months although this increase was not
statistically significant. In terms of behavior, staff reported
relatively little difficulty with convincing the participants to
participate in MBAP activities. The level of this variable went up
slightly in a positive direction (from more difficulty to less) although
this increase was also not statistically significant. In addition, at
three months staff neither agreed nor disagreed with the statement that
MBAP participants were easier to handle after participating in MBAP
activities. By six months, however, staff reported a marginally
significant increase, indicating a stronger level of agreement that the
statement was true (F = 4.67; df = 1; p = .07).

Turning to the staff's report of the more logistical aspects of the
program, they rated the activities as fun and interesting and that other
clients could benefit from MBAP activities. They also "somewhat
disagreed" with the statement that it was a hassle to get participants
ready for MBAP, suggesting a good integration of MBAP in the center's
daily activities. Similarly, they reported increasing agreement with the
statement that other staff was supportive of MBAP. Again, these positive
findings provided evidence for a good foundation for the program to
continue beyond the demonstration period. This finding was further
supported by the other two quantitative measures: confidence and ability
in continuing the program beyond the six month period. In terms of
confidence, staff reported an average confidence of 8 out of 10 at three
months, and 9 out of 10 at six months. This increase was marginally
significant (F = 3.45; df = 1; p = .11). In terms of ability, however,
staff reported a three month level of seven out of ten, and at six
months, a level of almost nine out of ten. This increase was
statistically significant (F = 24.96; df = 1; p = .00).

Table 4. Staff Evaluation of Impact of MBAP on Participants at Three and
Six Months

  ------------------------------------- ---------- ------- -- ---------- -------
                                        3-Months              6-Months   

  (Range: 1 -- 5)                       Mean       S.D.       Mean       S.D.

  1\. MBAP participants enjoy MBAP.     4.67       0.65       4.79       0.43

  2\. Difficult to convince             2.85       1.67       3.07       1.64
  participants to participate.                                           

  3\. Hassle getting ready for MBAP.    4.00       1.47       4.14       1.46

  4\. Participants are easier to handle 3.15       1.28       4.00       0.46
  after MBAP.                                                            

  5\. MBAP is successful in engaging    4.69       0.48       4.79       0.43
  participants.                                                          

  6\. Other clients could benefit from  4.42       1.24       4.71       0.83
  MBAP.                                                                  

  7\. MBAP activities are fun and       4.46       1.20       4.64       0.84
  interesting.                                                           

  8\. Other staff at center are         4.00       1.41       4.36       0.75
  supportive of MBAP.                                                    

  Confidence that center will continue  8.00       2.58       9.29       1.64
  MBAP (range: 1 -- 10)                                                  

  Readiness of center to continue with  6.92       2.43       8.64       2.02
  program beyond demonstration period                                    
  (range: 1 -- 10)                                                       
  ------------------------------------- ---------- ------- -- ---------- -------

[Qualitative Findings]{.underline}

The quantitative findings described above only paint some of the story
in terms of the impact of MBAP programming on participants' engagement
and mood. Qualitatively, additional benefits and challenges were noted
over the six month demonstration period. Many of these findings took
place one-on-one between particular clients and staff, who may have had
initial challenges but who showed tremendous progress over the
demonstration period.

One MBAP participant was observed as becoming easily agitated and upset
at the beginning of the program, and who would only sit and watch the
MBAP activity in a passive way. This participant would not allow the
MBAP specialist to approach her. As a result the center staff person who
had the strongest relationship with the participant began working with
her one-on-one, and after several sessions the participant began to
constructively engage in the activity. Over time, the participant could
stay focused on the activity for short intervals without constant
one-on-one support. In addition, she slowly gained the ability to
self-engage into the activity after the staff person set the activity up
for her.

Another participant initially was shy and quiet. As she was exposed to
the MBA, she began blossoming and within three months became very
conversational and would regale everyone with funny memories of growing
up on a rural farm. Besides socially engaging with the group, she also
became more confident of her ability to work with activity materials.

Two participants at another center with very low functional capability
initially only sat passively watching others in the group or napping.
Mid-way through the six month project, one of the activity aides began
working one-on-one with each of them experimenting with different
tactile objects to try and engage them. With this aide's patience,
support and gentle cueing within several sessions both participants were
engaging for 10 to 15 minutes with tactile manipulatives. Their
enjoyment and interest was evident by their focused determination and
smiles visible on their faces.

One of the centers at the time of the project had no male participants
with dementia so the MBA project included only women. After several
months of exposure to the MBA, several of the women in the group began
calling the MBA time "the ladies who laugh a lot" as the sessions were
fun and evoked much laughter. It was especially noteworthy that the
participants themselves 'labeled' their time engaging in the MBA this
way since it expressed how they were experiencing the MBA sessions.

In addition to these breakthroughs with participants, there were also
significant instances of breakthroughs with center staff. At one center,
one of the staff people was initially suspicious of the program and kept
a distance from the activities. However, within the first 3-months, that
staff person began setting up and starting the program before the MBAP
specialist arrived. The comment from this staff person was that he heard
so much laughing that he wondered what was going on during MBAP
sessions. This was especially encouraging because that center had a more
strict hierarchical structure where this type of self-initiative and
inventiveness was less typical.

Beside breakthrough experiences with participants and staff, a number of
other significant qualitative outcomes were noted. One of the centers
has a high number of staff and activity aides employed at the center
(approximately 18). During the MBA project, all of the staff and aides
rotated to have an opportunity to work with the MBA. The MBA specialist
noted that a few of them lacked certain personality traits that would
have enabled them to be more successful with the program. These traits
included an over-emphasis on successful completion of a task (as opposed
to a greater degree of flexibility) and an over-analytical approach to
the program steps that hindered their ability to master even the basic
Montessori principles. Unfortunately, in these cases, staff had a more
difficult time engaging the participants, apparent through a
qualitatively higher level of boredom and lower level of positive
behavior by the participant.

On the other hand, several key staff members were able to successfully
grasp the Montessori principles and not only succeeded in engaging
participants, but also in creating new kits and committing themselves
and the center to continuing the program after the program period. These
staff were those that understood dementia and its impact on participants
as well possessed a flexibility and openness that enabled them to adjust
their expectations of success with an activity.

**IV. Conclusions**

Overall, MBAP presents a promising and useful tool among the many tools
that adult day centers have to engage their participants and improve
their behavior and mood. The findings of this evaluation found that MBAP
participants were generally engaged in both non-MBAP and MBAP types of
activities, and experienced few to no behavior problems during the day.
In this regard, the adult day programs are successful in serving their
clients. However, the addition of MBAP activities into the center's
daily program can greatly enhance this success. This evaluation showed
that during non-MBAP activities (e.g., bingo, exercise, reminiscence
therapy, discussion groups) over time, levels of constructive engagement
tended to go down while levels of difficulty with the activity tended to
go up. One might expect this finding to be the result of the
participants' increasing level of impairment. However, two findings
discount this. First, the data suggest that impairment levels (out of a
possible three ADLs) and the participant's cognitive abilities tended to
remain stable over the 6-month period. Second and more compelling,
results showed that during MBAP activities, levels of *constructive
engagement* were higher than during non-MBAP activities and remained
stable over the six month period. Similar results were found for
*difficulty with the activity*, where levels during MBAP activities were
lower than non-MBAP activities and tended to decrease over time.
*Passive engagement* and *non-engagement* remained stable during
non-MBAP activities; however, during MBAP activities levels of
non-engagement went down, indicating that participants were more
actively engaged in the MBAP activity than during the non-MBAP activity.
These findings suggest that MBAP activities has a positive impact on the
participants' impairment despite levels of ADL or cognitive impairment.

The most notable finding in terms of engagement was in the level of
*helping behavior.* These types of social interactions between
participants were rarely found during non-MBAP activities; in fact, most
of the time, the participants rarely talked with one another during the
activities. More commonly, it was usually the staff who interacted with
participants. However, during MBAP activities, the level of helping
behavior increased significantly over the six month period. Participants
began to interact with one another, reaching out to assist or comment on
another participant's success.

In terms of behavior, the impact of MBAP programming was less on
problematic behavior (disruptive, restless, etc.) since these behaviors
were rarely reported. Rather, the impact was on the expression of
positive behavior -- expressions of pleasure, laughter, smiles -- which
went up during the six month period as compared to non-MBAP activities,
where levels tended to go down over time. The impact of MBAP was also
felt on participant's expressions of boredom (closing their eyes,
sleeping, staring). During MBAP activities, most participants were
focused on the activity in either a constructive or passive way and
rarely expressed any level of boredom.

Limitations of the study include the single-group design and the limited
number and time frame of observations. Since there was no comparison
group, there was less control over carry-over effects between MBAP and
non-MBAP activities, bias by staff members and the evaluator. To account
for potential threats to validity, it would be necessary to replicate
these findings with larger samples of participants and within a greater
number of centers.

MBAP provide meaningful activities that can improve an adult day
participant's engagement and mood, which arguably, can provide a greater
sense of self-worth, purpose, and quality of life. The implementation of
MBAP programming offers some challenges, but as the results of this
evaluation showed, staff were overwhelmingly supportive of the
activities and reported only a few difficulties in its implementation.
Selecting the right kind of activities, ones that present a good fit
with the participants' abilities and interests is important. In
addition, training staff on effective Montessori principles is crucial,
as their interaction with participants can mean the difference between a
participant's feeling of frustration or pride. Staff who tried to do too
much (i.e., force the participant into following the "rules" of the
activity; take over the activity from the participant; or not allow
enough time for the participant to engage) were ultimately less
successful in producing positive outcomes.

Although the results of this evaluation showed positive benefits of MBAP
activities, ultimately, the key issue is whether the program can be
integrated within the center and whether the center staff can conduct
the activities in the face of scheduling and organizational constraints.
In this regard, the most important factor determining the continuation
of the program is the cultural environment of the center, that is,
whether the center director and staff are open to the innovation that
MBAP provides and supports staff at all levels to the continuation of
the program. In other words, centers with inculcation of MBAP at all
levels of staff have the best change of successful implementation.
Unfortunately, at one of the four centers, staff turnover (of the center
director and assistant director) and a lack of commitment and training
by remaining staff has contributed to difficulty in maintaining the
program. At a second center, the center director believes in the program
and is personally committed to it; however, staff resistance and space
restrictions have limited its use to occasional at best. At the third
and fourth centers, a more positive picture emerges. There, directors
support the program's continuation; staff at multiple levels has been
trained; the MBAP specialist has been consulted; and funds have been
directed to purchase and maintain MBAP materials and supplies. At one of
these two centers, the big test came when two key staff with the most
MBAP experience resigned. Undoubtedly, the continuation of MBAP was in
jeopardy; however, the center director consulted with the MBAP
specialist, who provided training to the new staff, and happily, the
program survived and continues. Participants at these two centers
participate in MBAP activities on a daily basis, and staff continue to
find ways to improve quality and implementation.

**V. Acknowledgements**

Thanks goes first to the D.C. Office on Aging who provided general
oversight and funding for this demonstration project and evaluation. In
addition, they helped provide the initial vision and structure for the
MBAP program which contributed to its success. A hearty acknowledgment
also goes to the Administration on Aging whose Alzheimer's Disease
Demonstration Grants to States program has provided the District of
Columbia the opportunity to provide help and support people and families
affected by Alzheimer's. A special thanks goes to Karen Love, the
program's MBAP specialist for her assistance and insight in helping with
the planning of MBAP and for helping to prepare this report. She is the
author of the Montessori-Based Activities Program Manual included in the
Appendix. Thanks also go to Marla Lahat, executive director of Home Care
Partners, who provided invaluable guidance and technical assistance for
the project. Finally, a very special thank you to the center directors,
their staff, and the participants of the Montessori program -- without
their hard work and commitment to improving the lives of older adults,
none of this would be possible.

**VI. References**

Bowlby, C. (1993). Therapeutic activities with persons disabled by
Alzheimer's disease and related disorders. Gaithersburg MD: Aspen.

Camp, C. J., (1999). *Montessori-based activities for persons with
dementia: Volume 1.* Beachwood, OH: Menorah Park Press.

Camp, C. J., & Mattern, J. M. (1999). Innovations in managing
Alzheimer's Disease. In D. E. Biegel & A. Blum (Eds.), *Innovations in
practice and service delivery across the lifespan* (pp. 276-294). New
York: Oxford University Press.

Cox, N. (2003). A National Study of Adult Day Services. Presented at the
First Annual Conference of the National Adult Day Services Association.
Miami Beach, FL.

Dreher, B. B. (1997/June). Montessori and Alzheimer's: A partnership
that works. *American Journal of Alzheimer's Disease, 12*(3), 138-140.

Femia, E. E., Zarit, S. H., Stephens, M.A.P., & Greene, R. (In press).
Impact of adult day services on behavioral and psychological symptoms of
dementia.

Judge, K. S., Camp, C. J., and Orsulic-Jeras, S. (2000). Use of
Montessori-based activities for clients with dementia in adult day care:
Effects on engagement. *American Journal of Alzheimer's Disease, 15,*
42-46.

Love, K. (2006) *Montessori-Based Activities: A Guide for Using
Therapeutic Engagement to Enhance Function for Individuals with
Dementia.* D.C. Office on Aging: Washington , D.C.

Orsulic-Jeras, S., Judge, K. S., and Camp, C. J. (2000).
Montessori-based activities for long-term care residents with advanced
dementia: Effects on engagement and affect. *The Gerontologist, 40,*
107-111.

Orsulic-Jeras, S., Schneider, N. M., Camp, C. J., Nicholson, P., and
Helbig, M. (2001). Montessori-based dementia activities in long term
care: Training and implementation. *Activities, Adaptation, and Aging,
25,* 107-120.

Woodhead, E. L., Zarit, S. H., Braungart, E. R., Rovine, M. R., & Femia,
E. E. (2005). Behavioral and psychological symptoms of dementia: The
effects of physical activity at adult day service centers. *American
Journal of Alzheimer's Disease and Other Dementias, 20,* 171-179.

Zank, S., & Schacke, C. (2002). Evaluation of geriatric day care units:
Effects on patients and caregivers. *Journal of Gerontology:
Psychological Sciences, 57B,* P348-P357.

Zarit, S. H., Stephens, M. A. P., Townsend, A., & Greene, R. (1998).
Stress reduction for family caregivers: Effects of adult day care use.
*Journal of Gerontology: Social Sciences, 53B,* S267-S277.

**VII. Appendix**