Topics in Geriatric Rehabilitation Volume 27, Number 4, 278288 Copyright 2011 Wolters Kluwer Health | Lippincott Williams &

mp; Wilkins
DOI: 10.1097/TGR.0b013e31821e5945

Cognitive-Linguistic Interventions for

Persons With Dementia
A Practitioners Guide to 3 Evidence-Based Techniques
Nidhi Mahendra, PhD, CCC-SLP; Amanda Scullion, BA; Cassandra Hamerschlag, BA
The purpose of this article is to present practitioners with
current empirical evidence on 3 nonpharmacological,
cognitive-linguistic interventions for persons with dementia.
We begin with a brief review of cognitive-communicative
functioning in Alzheimer disease, followed by presenting
rationale for conducting comprehensive assessments and
systematic interventions for persons with dementia. We then
review recently published evidence and new empirical data
on the treatment outcomes of 3 contemporary intervention
approachesspaced retrieval training, use of memory books
and wallets, and Montessori-based interventions. These interventions were selected on the basis of high quality, replicable
evidence of positive treatment outcomes, interdisciplinary
appeal, and potential for optimizing functioning and quality of
life of persons with dementia and their caregivers.
Key words: Alzheimer disease, cognitive impairment,
cognitive-linguistic training, Montessori

he syndrome of dementia is characterized by pervasive memory impairments and the impairment of

at least 1 other cognitive domain, including executive function, language, praxis, or visuospatial ability. For
a clinical diagnosis of dementia, these impairments must
occur in the absence of delirium and be severe enough
to interfere with a persons social participation, occupation, and daily living.1 Alzheimer disease (AD) is the most
common cause of dementia, accounting for 60% to 80%
of all diagnosed persons, followed by vascular dementia.2 Approximately 5.3 million Americans currently have
AD,3 and the prevalence of AD is greater in women than
Author Affiliations: Department of Communicative Sciences and
Disorders, California State University East Bay, Hayward (Dr Mahendra);
and Aging and Cognition Research Clinic (Dr Mahendra and Mss Scullion
and Hamerschlag).
Preparation of this article was made possible by an Alzheimers Association research grant and a faculty development grant from California State
University East Bay.
The authors have disclosed that they have no significant relationships
with, or financial interest in, any commercial companies pertaining to this
article.
Correspondence: Nidhi Mahendra, Room MB 1099, Department of Communicative Sciences and Disorders, California State University, East Bay
25800, Carlos Bee Blvd, Hayward, CA 94542 (nidhi.mahendra@csueastbay.edu).
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men and among older adults of African American and

Hispanic ethnicity.4
Dementia is a progressive syndrome. However, it has a
long trajectory and, in AD, postdiagnosis survival duration
ranges from 7 to 10 years for persons diagnosed in their
60s and 70s.5 Furthermore, multiple researchers have demonstrated that persons with dementia (PWD) have spared
neuropsychological abilities at each stage of dementia severity6-8 and can benefit from specific pharmacological and
nonpharmacological, cognitive interventions that enhance
functioning and quality of life.9-12 Historically, clinicians and
caregivers have been plagued with therapeutic nihilism,13
a negative attitude entailing assumed limited potential of
PWD to benefit from cognitive interventions. Yet, this type
of attitude is increasingly being rejected by researchers, clinicians, and consumers in light of mounting empirical evidence to the contrary and 4 important observations. First,
PWD are being diagnosed and identified much earlier in the
disease process, at a time when they are prime candidates
for interventions that build cognitive reserve and neuroplasticity. Next, great strides have been made and continue to
be made in developing novel pharmacological treatments
for AD and related dementias. Third, neuroscientists have
made significant advances in understanding experiencedependent neuroplasticity and have identified behavioral
interventions and experience as critical for optimizing such
plasticity after brain damage.14 Fourth, researchers have
begun to demonstrate that PWD have superior treatment
outcomes when provided a synergistic combination of
pharmacological and nonpharmacological behavioral interventions15-17 compared to drug treatment alone.
In this article, we invite practitioners to revisit the importance of cognitive linguistic interventions for PWD and
to examine state-of-the-art evidence on 3 influential therapeutic approaches. The 3 approaches that we detail in this
article are spaced retrieval training (SRT), interventions using memory books and memory wallets, and Montessoribased interventions (MI). Throughout the article, we focus
on AD, because it is the most common cause of dementia,
and most published studies most often include findings
from persons diagnosed with AD. To facilitate readers in reframing the way in which dementia is defined, we begin by
discussing both impaired and the overlooked but well-documented, spared cognitive-communicative abilities in AD.
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COGNITIVE-COMMUNICATIVE FUNCTION IN
AD: IMPAIRED AND SPARED ABILITIES
In this section, a brief review is provided of attention,
executive function, and memory impairments resulting from AD. Attention is the gateway to what happens
in the rest of human cognition. It is the ability to focus on sensations received from the environment and
internal needs and desires.7(p262) Along with the hallmark episodic memory (EM) deficits, impairments of
attention are among the first to appear in AD.18 Attention may be categorized as selective attention (ie, focusing on a specific stimulus), sustained attention (ie,
maintaining focus on a stimulus for a specific length of
time), divided attention (ie, simultaneously attending
to multiple stimuli/tasks), or attention switching (ie,
shifting attention from one task to another). Whereas
persons with AD are easily distracted and have earlyappearing attention impairments, researchers have
shown that in the early stages, sustained attention and
divided attention7,19 are somewhat spared, whereas all aspects of attention are impaired in mild dementia. Because
sustained attention is preserved in early stage AD, persons can typically follow 2-step and 3-step commands and
carry on conversations. By the middle stages of AD, typically 4 to 10 years after diagnosis, individuals can usually
follow 2-step commands, participate in standardized testing, and make relevant statements about tangible stimuli
in conversation.7 In the late stages of AD, corresponding
with the final 1 to 3 years of the disease, persons with AD
are still able to attend to pleasant stimuli (eg, music).
Executive function encompasses multiple higher-order
cognitive abilities such as decision making, planning, selfmonitoring, initiation, organization, cognitive flexibility,
and inhibition. In AD, significant executive function impairments appear in the very early stage of AD20 and precede
impairment of praxis (ie, ability to carry out a skilled motor
activity such as dressing or using utensils to self-feed) or
communication.21

Next, we detail the impact of AD on human memory systems. Human memory is widely agreed upon to consist of
2 primary aspectsshorter-duration sensory and working
memory (WM) versus long-term memory. Long-term memory (Figure 1) consists of 2 neuroanatomically and functionally distinct systems of stored knowledgedeclarative or
explicit memory and nondeclarative or implicit memory.22
Working memory is a dynamic, short-term, limited capacity
buffer that enables storing information briefly and actively
manipulating it while it is being processed.23(p8) It has multiple components, with some more affected by AD than others. An example of one type of WM called the articulatory or
phonologic loop is when we repeat a phone number to ourselves to remember it long enough to dial it. Impairments
of WM and EM appear earliest in AD. These impairments of
WM interact with selective attention deficits, also present in
AD to make persons less efficient at encoding information.1
In general, WM deficits worsen with increasing dementia
severity. Yet, persons with AD retain simpler aspects of WM
capacity, as demonstrated on digit span tasks24 (ie, being
able to remember a short string of numbers in sequence).
Episodic memory is a component of declarative or explicit memory that allows us to consciously recall episodes
and events.25 An example of an EM problem in AD may be
having a telephone conversation with someone and minutes later, having no recollection of the specific details of
this conversation. The neuropathology distinctive of AD
begins in brain areas important to EMspecifically the
hippocampus and the entorhinal and perirhinal cortices in
the medial temporal lobe (Table 1). Thus, early-appearing
and severe EM impairments are the hallmark of AD and
are required for its clinical diagnosis. In contrast, semantic memory (ie, knowledge of facts and conceptual knowledge of the world) is more spared early on than EM.9 Next,
we discuss nondeclarative memory in AD.
Nondeclarative memory (Figure 1) consists of habits,
procedural memory, priming, and conditioned responses.1
Habits are well-rehearsed and almost automatic, behavioral

Figure 1. The structure of human long-term memory.

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TABLE 1

Major Memory Systems and

Associated Neurobiological
Substrates22,29

Memory System

Neurobiological Substrates

Working memory

Frontal Lobes
Dorsolateral prefrontral cortex (DLPFC)
Brocas area
Inferior parietal and inferior temporal
cortices
Occipitoparietal cortex

Declarative memory

Medial temporal lobe (hippocampus,

entorhinal cortex, perirhinal cortex,
parahippocampal cortex)
Basal forebrain
Amygdala
Lateral temporal lobe, thalamus, and
hypothalamus
Sensory association cortices
Modulated by estrogen and
acetylcholine

Nondeclarative
memory

Corticostriatal system (i.e. reciprocal

connections between the cortex and
the basal ganglia, via the thalamus)
Cerebellum
Primary motor and sensory cortices
Modulated by dopamine

Adapted with permission from Mahendra, N. and Apple, A. (November 27,

2007). Human memory systems: A framework for understanding dementia.
The ASHA Leader, 12, 8-11.

routines that we use daily. Procedural memory enables

an individual to learn motor and cognitive skills through
repeated practice and performance. Priming is an unconscious ability to detect, identify, or respond to a stimulus
favorably after recent exposure to it or a related stimulus.
Finally, conditioned responses are automatically produced
behaviors that are induced by a specific stimulus.23 There is
substantial evidence that persons with AD have spared aspects of implicit memory,7,26-28 likely because brain areas responsible for this type of nondeclarative memory22,29 (Table 1)
remain spared until later stages of AD.
Individuals with AD can benefit from interventions designed to take advantage of their relatively preserved implicit memory abilities and to minimize demands on WM
and EM.9,10,30,31 Next, we discuss language production, its
comprehension, and functional communication in AD.
As a direct result of these aforementioned memory
impairments in AD, production and comprehension of
spoken and written language as well as functional communication are affected. These impairments worsen as
AD progresses and dementia severity increases. Persons
with AD are able to comprehend most of what they hear
and read but then quickly forget it. The form of language
(eg, phonology and syntax) often remains relatively spared

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throughout AD, even when meaningful verbal output has

diminished significantly in later stages. Anomia, that is, the
inability to retrieve the name of an item, becomes common as AD progresses and semantic content of language
becomes empty with less cohesion and frequent repetition
of ideas. In the middle stages of AD, affected persons can
hold small amounts of information in WM and are able to
repeat single words or short phrases.7 In the late stages of
AD, individuals frequently retain nonverbal, social communicative behaviors such as shaking hands and waving.32
Functional communication includes automatic, overlearned communication actions, pragmatics or the social
use of language, and other skills that support activities of
daily living.7,33,34 These communication abilities change significantly over the course of AD. In early stages of AD, individuals can answer open-ended questions and contribute
meaningfully to discussions while adhering to turn-taking
conventions.7 Yet, as AD progresses, persons become less
adept at following conversational rules, interpreting abstract or nonliteral language (eg, in idioms, metaphors, or
sarcastic remarks), and using conversational repair strategies35 and struggle with cognitively demanding communicative activities36 (eg, those requiring reading or calculating).
In the middle stages of AD, the ability to produce stereotypical social utterances and to greet, name, converse, and
express basic needs remain somewhat preserved.32,34 In
the late stages of AD, functional communication is markedly reduced and discourse impairments are prominent.
These are characterized by echolalia (repetition of another
speakers utterances), incoherent statements, utterance of
nonsense syllables, or muteness1,32 (being unable to use
speech to communicate). Yet persons with late-stage AD
may be able to answer simple yes/no questions, read single
words aloud, and retain the ability to greet others or respond appropriately to a compliment.32 It must be emphasized that if the aforementioned spared communicative
abilities can be utilized, persons with AD may successfully
participate in and benefit from cognitive interventions.

SPARED ABILITIES IN DEMENTIA:

EXTENDING THE PURPOSE OF
COMPREHENSIVE ASSESSMENT
Having discussed spared abilities in AD, it is important to
reflect on the scope and purpose of a comprehensive assessment for a PWD. Undoubtedly, key goals of a comprehensive assessment are to establish a clinical diagnosis, rule
out alternative explanations for cognitive impairments, and
quantify the severity of cognitive-communicative deficits.
Such assessments for staging dementia severity23,35 are well
established, widely used, and enable clinicians to generate meaningful profiles of cognitive domains that are most
spared versus most impaired. Another important, yet often
overlooked, purpose of an assessment is to yield objective

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evidence of restorative potential and to provide data that

explicitly demonstrate the candidacy of a PWD for a specific intervention. Indeed, the Centers for Medicare and
Medicaid Services require such evidence to be present in
assessment reports to favorably reimburse claims for therapeutic interventions provided.36
A thorough understanding of spared abilities that are
retained at various stages of dementia allows clinicians to
showcase a patients restorative potential and to capitalize on these strengths when designing interventions. Key
spared abilities in persons with mild to moderate AD include aspects of attention, recognition memory (ie, being
able to identify or recognize previously presented stimuli),
implicit and procedural memory, and somewhat spared semantic memory, responsiveness to cueing (ie, benefiting
from a verbal or nonverbal prompt) and select functional
and social communication abilities. Standardized assessments are very useful in identifying dementia and quantifying the severity of resulting cognitive impairments. However, alternative testing approaches are better suited to reveal
evidence of the ability of PWD to participate in and benefit
from a specific intervention or therapeutic strategy. Such
approaches include dynamic assessment techniques37 that
incorporate test-teach-retest methodology, use of rating
scales, environmental observation, and documentation
of participant response to a brief trial of an intervention
strategy.

INTERVENTIONS
Cognitive-linguistic interventions may be direct or indirect. Direct interventions are those in which PWD participate in restorative or compensatory programs.10 These are
contrasted with indirect interventions, which impact the
functioning of PWD through training of professional and
personal caregivers, environmental modifications, and
the development of meaningful and stimulating therapeutic activities.38 Another method of categorizing interventions is with regard to their intended impact. The World
Health Organization39 has developed a conceptual frameworkthe International Classification of Functioning,
Disability, and Health (Figure 2)that illustrates how
dementia affects an individual at 3 levels. Thus, dementia affects a persons body functions and structures (ie,
a persons physiological or psychological functioning),
activities (ie, ability to complete specific tasks), and participation (ie, being able to participate fully in life roles).
A persons performance at each level is, in turn, impacted
by environmental and personal factors. Hopper40 stresses
that the purpose of designing and administering skilled
interventions to PWD is not to alter their body functions
and structures or underlying impairment but to impact a
persons activity and participation despite his or her dementia diagnosis.

Topics in Geriatric Rehabilitation

Figure 2. World Health Organization International Classification of Functioning.

FEATURES OF A SUCCESSFUL
INTERVENTION FOR PERSONS WITH
DEMENTIA
In this section, we emphasize important features that render an intervention more likely to succeed for PWD. Based
on emerging principles of experience-dependent neuroplasticity14 and published research1,9,10, these features are as
follows:
a. Providing repeated presentation of target
information;
b. Incorporating learning by doing and requiring
active generation of target responses;
c. Reducing the possibility of errors during initial
learning;
d. Tapping into relatively spared sustained attention
and minimizing distractions; and
e. Using rich, tangible sensory stimuli and
meaningful cues to support retrieval.
These features are all exemplified in the 3 interventions reviewed in this article. We selected SRT,41-43 memory
books and wallets,44,45 and MI46,47 for discussion in this article. These 3 techniques were chosen for analysis based on
the quality of available scientific evidence supporting their
use, strong evidence of positive treatment outcomes for
PWD, and their potential to address the activity and participation levels of World Health Organizations framework.39
Furthermore, these techniques have interdisciplinary appeal and have been successfully implemented by clinicians
and researchers from multiple disciplines (recreational activities, speech-language pathology, occupational therapy,
physical therapy, and nursing).

Intervention 1: spaced retrieval training

Description and existing evidence
Spaced retrieval training was first detailed by Landauer
and Bjork48 as a technique for enhancing episodic recall in
healthy young adults. Later, in a landmark study, Schacter et al43 reported on the efficacy of SRT for teaching
face-name associations to individuals with memory disor-

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ders. Subsequent to these early studies, Camp42 adapted

SRT for persons with AD. Spaced retrieval training is best
conceptualized as a shaping paradigm applied to memory training49 and has been used with considerable success for facilitating new learning of facts and procedures
in persons with early-stage, mild, and moderate dementia severity. In SRT, new facts are presented42,49,50 or a new
motor procedure is demonstrated51 to a PWD who first
recalls the information or demonstrates the procedure
immediately and then over gradually lengthening time intervals. Time intervals after each successful recall attempt
are doubled, whereas intervals subsequent to unsuccessful recall attempts are maintained or reduced in duration
(see Figure 3 for a visual display of recall attempts). Thus,
PWD learn and retain functionally relevant information or
skills over longer periods of time, and this new learning,
in turn, supports improved functioning, greater independence, and reduced need for assistance or cueing during
specific activities. Consider a PWD who comes to a nursing station, repeatedly asking a question (eg, when do we
have coffee?). Instead of staff recurrently answering this
question and reinforcing this undesirable response, SRT
may be used to teach this person to reinforce a desired
response of looking at a laminated card attached to his or
her walker or handbag that lists the times on which coffee
is served daily.
Many empirical studies provide evidence for the success
of SRT for PWD41,42,49-51 as well as for persons with amnesia,43 traumatic brain injury,52 and anomia53 associated with

aphasia. For persons diagnosed with dementia, SRT has

been efficacious for teaching items on word lists49; cue-task
associations6,54; names of people41,55,56; object orientation
tasks57; prospective memory tasks58; and compensatory
strategies for safe swallowing,51 communication with caregivers,59 and using external memory aids.60 Readers are directed to a recent evidence-based systematic review on the
outcomes of SRT for persons with AD.50
In a recently completed research study, we reported
positive outcomes of computer-assisted SRT for teaching
face-name associations61-63 and novel motor procedures63
to 25 persons with mild to moderate dementia of the Alzheimer type. More than 21 (80%) of our 25 dementia participants successfully learned and recalled novel and previously familiar (but forgotten) names of caregivers over a
32-minute interval and maintained this performance for
8 weeks posttraining. These same participants64 learned
multistep, novel procedures (eg, using a digital camera,
sending e-mail, and compensatory memory strategies) using digitized video clips that were played followed by participants demonstrating the entire procedure successfully
over gradually increasing time intervals. Twenty-two (88%)
of these 25 PWD learned and retained novel procedures
over a 32-minute interval and maintained this new learning
for 6 to 8 consecutive weeks posttraining.
Why does spaced retrieval training work?
A central question about SRT is how and why it works to facilitate recall and retention in PWD, despite their significant

Figure 3. Visual schematic of spaced retrieval training for a fall prevention strategy.

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EM deficits. Although this mechanism is not fully understood, current evidence reveals several factors that underlie
the success of SRT. It is likely that SRT works because of repeated opportunities to retrieve target information,6,10 emphasis on retrieval success,41 and gradual building up of duration over which recall is maintained.60 Furthermore, SRT
capitalizes on relatively spared implicit memory processes59
and requires little cognitive effort from dementia patients.49
Another reason why SRT works so well is because of
the incidental use of errorless learning in its implementation.59 Errorless learning is contrasted with routine trial
and error learning. For persons with intact EM, trial and
error learning works well as individuals remember their
erroneous response and subsequent corrective feedback
and retain the entire episode of making the error and being corrected. This retention of the learning episode reduces the likelihood of subsequent erroneous responses.
For PWD, however, the very act of making an error is undesirable early in the learning process. This is because
PWD have severe EM impairments and remember neither
their errors nor corrective feedback in response to errors.
Therefore, they make the same errors recurrently,64 and
the more frequently an error is made, the more it gets reinforced. Thus, using errorless learning principles65,66 for
constraining stimulus presentation, task instructions and
permitted responses may better facilitate new learning in
PWD. Errorless learning is incorporated into SRT by ensuring that participants always end a recall trial or therapeutic
session with a correct desired response (eg, recalling facts
or procedures).
It is important to establish whether the positive outcomes of SRT are because of the repeated retrieval attempts or the gradual increase in interval spacing. Most
investigators have used gradually lengthening time intervals in SRT; however, 2 groups of researchers have recently reported similar successful outcomes from spaced and
fixed length of recall intervals. Hochhalter et al67 compared
expanding intervals to other rehearsal schedules (eg, random intervals and uniformly distributed intervals) with a
small sample of persons with AD and found no significant
advantage for spaced retrieval over equally spaced practice
schedules. Similarly, Balota et al68 found no advantage of
expanded retrieval over an equal interval schedule in improving the memory performance of healthy older adults
and PWD. Together, these results suggest that spaced
intervals may not be as critical to the success of SRT as
repeated presentation and frequent retrieval of a correct
response.
Another issue for practitioners implementing SRT
pertains to activities conducted during recall intervals.
It seems intuitive that task-related activities during intervals may maximize learning, whereas unrelated activities may interfere with and adversely impact subsequent
recall performance. However, empirical evidence does
Topics in Geriatric Rehabilitation

not support this intuition. Recently, Hopper and her colleagues56 demonstrated that filling intervals with tasks unrelated to a target face-name association did not negatively
impact learning by persons with mild to moderately severe
AD. This finding has important implications for practitioners because it suggests that various activities such as conversation, having a snack, or taking vital signs can be nested
within SRT recall intervals. Regarding candidacy for SRT,
Hopper et al50 suggest that this technique is effective for
PWD with mild to moderately severe dementia, associated
EM impairments, and the ability to attend to structured
learning tasks.

Intervention 2: memory books and memory wallets

Description and existing evidence
Memory aids, such as memory books (Figure 4) and
memory wallets (Figure 5), have been shown to enhance
functioning and quality of life of PWD by improving verbal
communication and factual content in conversations,44,45
supporting turn taking and topic initiation,69 encouraging meaningful verbal interaction between PWD and
caregivers,70-71 and reducing caregivers nonfacilitative
communicative behaviors. In 1990, Bourgeois44 conducted the first experiment validating the use of memory wallets with 3 persons with mid-stage AD. Twice a day, these
participants read approximately 30 sentences in their
memory wallets out loud to their partners during therapy
sessions. Subsequently, these PWD made more on-topic,
factual statements and decreased irrelevant statements.
Originally designed to enhance conversational efficiency,
memory wallets and memory books have since been used
to enhance orientation and expression of basic needs
and to reduce repetitive question-asking and disruptive
vocalizations.45,72 Bourgeois72(p61) cited an example of the
frustration a daughter felt with her father who frequently
asked about the whereabouts of her deceased mother.
When she told her father that the mother was deceased,
he would react with surprise and distress and they would
both end up crying. They created a memory book page
with a picture of her gravestone and this statement My

Figure 4. Sample memory book page.

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content in conversations and when asked about his prior

work or his hobbies (eg, I dont know, Yeah, sure). At
baseline, he could not correctly answer questions about
himself (eg, his children, his recent retirement). After
seven 50-minute sessions over 4 weeks, he required only
occasional verbal reminders to use his memory book and
could answer short, biographical questions (eg, what is
your daughters name?, what work did you do prior to
retiring?) with 60% or better accuracy.

Figure 5. Sample insert from a memory wallet.

wife, Lillian, died of liver cancer in 1995 and is resting
peacefully in Woodlawn Gardens. The daughter would
hand her father his memory book, opened to that page,
when he asked about his wife. Eventually, he stopped asking about his wife. In this situation, using a memory book
allowed this individual with dementia to review important
biographical information and eventually modify his repetitive behavior.
Memory books and memory wallets also can be used to
enhance orientation to self, time, place (immediate environment and local community), and person. To enhance
orientation to self, a memory book may include past and
current self photos with short descriptive titles such as This
Is Me in High School and This Is Me Now at Age 90. To
enhance orientation to immediate locations, a page in the
memory book can have a picture of an individuals house
and a description such as This is my home (Figure 4)
and the persons address.72 A memory wallet (Figure 5)
typically consists of written and graphic cues to aid PWD
with prompt recall of personally relevant and meaningful
information. It may be thought of as a memory book on
a smaller scale and is designed to be portable so that its
consistent use may be facilitated in all contexts. A memory
book or wallet should be personalized and designed to fit
the needs of the person using it. Therefore, physical characteristics such as the size of the pages, images, and the
font and color of the text should be appropriate. Similarly,
the number of pages, weight of the book or wallet, and the
length of sentences or phrases should match the cognitive
abilities of the person for whom it is designed.
Recently, we conducted single-subject studies in which
we taught 2 individuals with young-onset AD to use
memory books as a compensatory strategy to answer basic biographical questions. Participant 1 was a 52-year-old
woman with moderate dementia and progressively diminishing verbal output. After eighteen 50-minute sessions
over a 10-week timeframe, she learned to use a memory
book to answer biographical questions with 80% or better
accuracy, given minimal cueing. Participant 2 was a 63-yearold man with mild dementia and increasingly nonspecific
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Why do memory books and memory wallets work?

Memory books and memory wallets provide tangible sensory cues (eg, words, pictures) that reduce reliance on
impaired EM and WM in PWD. Next, use of once-familiar
information and simple-written text offers individuals
with dementia the opportunity to utilize their relatively
spared recognition memory and oral re.ading abilities.73
Furthermore, memory books/wallets can enhance communication of wants and needs for PWD who have recently moved from their home to a residential facility
and have limited ability to verbally express preferences.
The content in a memory book primes personally relevant information and biographical details and also assists
professional caregivers in becoming more familiar with
an individual and his or her preferences. For example, a
page with the heading My Favorite Lunch Foods could
have 4 pictures (eg, a turkey sandwich, soup, fruit salad,
green salad) and labels underneath the pictures.72 Finally,
memory books and memory wallets can increase positive engagement and facilitate independence in activity
completion by helping an individual remember his or her
preferred activities and steps or procedures to participate in these activities. For instance, a page may include
simple steps accompanied by pictures reminding an individual how to water plants or make a pot of coffee.72
Memory books are ideally suited for use with persons
who have mild to moderate dementia, who possess the
requisite reading and visual processing ability, procedural
memory, and the motivation to enhance their functional
communication.

Intervention 3: Montessori-based interventions

Description and existing evidence
In the last decade, researchers have demonstrated the
efficacy of MIs for maximizing functional cognitive and
communicative performance in PWD as well as improving
engagement and participation in activities (see Mahendra
et al47 for an evidence-based systematic review). Montessoribased interventions are inspired by the Montessori method, developed in the early 1900s, by Italian educator Maria
Montessori. This influential instructional method has been
widely applied in child pedagogy. The guiding principle
for designing MIs is to provide a stimulating experiential
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environment that allows individuals to learn at their own

pace, while promoting independence.47 Other key elements that make Montessori methods especially well suited for planning activities and designing functional treatments for PWD include the following:
a. Breaking down tasks and activities into
component parts;
b. Using guided repetition and cues to reduce
errors;
c. Progressing through tasks sequentially or in
stages; and
d. Moving from tasks based on simple, concrete
concepts to those based on complex, abstract
concepts.
Multiple researchers have demonstrated that MIs have a
positive effect on cognitive functioning of PWD74,75 on participant motivation74 and on observed affect and engagement during therapeutic activites.47,76 Vance and Johns,74
and Vance and Porter75 used change scores from 22 cognitive measures to derive a Montessori benefit score to compare overall cognitive function of PWD before and after
Montessori interventions and routine activities (eg, watching TV). They reported improved cognitive performance
(based on change scores) and observed that dementia
residents seldom became agitated during Montessori activities. Because PWD often experience agitation, reduced
frequency of such challenging behavior is the strong evidence of the efficacy of Montessori interventions.
Vance and Johns74 compared the stages of dementia to
Piagets distinct stages of cognitive development and provided multiple examples of Montessori-based activities appropriate for persons with differing severity of dementia.
Information from the seminal work of Vance and Johns74

TABLE 2

and Camp77 has been combined to provide readers with

examples of specific functional and recreational Montessori activities (Table 2) and the stage of dementia for which
these are appropriate. For example, an activity that may
be appropriate for a person with mild dementia (with an
Mini-Mental State Examination score between 15 and 25 of
30) would be Color Tiles.74 This activity relies on seriation
and requires a person to arrange tiles in a sequence ranging from lightest to darkest. This activity requires complex,
logical analysis and is similar to Piagets later operational
stage of development. From successful completion of such
an activity, a PWD can logically progress to tasks such as
sorting laundry into light and dark clothing. Similarly, a
person with moderate to moderately severe dementia
(Mini-Mental State Examination score between 5 and 15 of
30) can participate in pouring tasks. These tasks involve
pouring beans, rice, or other material into containers of
different sizes and shapes to illustrate the conservation of
volume, a key milestone in Piagets preoperational stage.
Successful performance on pouring tasks can then be utilized by engaging residents to assist with pouring drinks
in a social setting or in the dining room. For persons with
severe dementia, an appropriate activity would be the Discovery Bowl74 in which participants search for colorful
objects such as 3-dimensional shapes, hidden in a bowl of
rice. Such activities correspond with Piagets early sensorimotor stage and emphasize object permanence.
In most studies,74,75 researchers, clinicians, or professional caregivers facilitate Montessori activities and PWD
participate. However, some investigators have demonstrated the success of Resident-Assisted Montessori Programming (RAMP) approaches.46,78,79 In RAMP activities,
PDW themselves successfully lead others in Montessori

Montessori Activitiesa

Broad Activity Category

Stage of Dementia for

Which Usually Appropriate

Functional and Recreational Tasks

Sensory discrimination

Sound discrimination (eg, loud versus soft), color discrimination

(eg, red vs blue), weight discrimination, temperature discrimination, smelling jars

Late-stage or advanced
dementia

Scooping exercises

Scooping by hand (eg, discovery bowl),

scooping with tools (eg, pasta, grains)

Late stage dementia

Moderate dementia

Pouring activities

Pouring drinks

Moderate dementia

Seriation activities

Arranging items in a series (eg, measuring bowls, fabric swatches)

Moderate dementia

Squeezing activities

Using tongs or a garlic press, hole punching

Mild and moderate dementia

Fine motor activities

Stringing beads, lacing, painting, cutting with scissors

Mild and moderate dementia

Care of the environment

Arranging flowers, watering plants, place setting, polishing metal

Mild and moderate dementia

Care of the person

Folding and hanging clothes

Mild and moderate dementia

Matching activities

Sorting activities (eg, shapes, faces, light and dark clothing)

Mild and moderate dementia

Based on information from Camp77 and Vance and Johns.74

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activities. Persons with mild dementia have been effectively

trained to lead a Montessori activity called Memory Bingo
to preschool children46 and to small groups of persons with
more advanced dementia.78 Camp and Skrajner78 assessed
the feasibility of training persons with mild dementia to
lead others with more advanced dementia in Montessori
activities. They also documented social engagement and
pleasure in both the participants and the leaders. Their
findings demonstrate that PWD can be trained to effectively fill the role of activity staff, with little to no assistance
in carrying out the activities. Both participants and leaders
showed increased positive engagement and affect in the
Montessori-based activities, compared with their standard
activities. In another study, Skrajner and Camp79 successfully trained 6 participants with mild dementia to facilitate
a small group in reading activity for persons with more advanced dementia in an adult day health care setting and in a
skilled nursing facility. It is noteworthy that they documented better effect and engagement in residents participating
in peer-led Montessori activities than when participating in
routine programming. These authors78,79 posit that RAMP
interventions have a dual benefit for participants receiving interventions and for enhancing satisfaction and sense
of self-worth among residents who serve as facilitators or
leaders. Furthermore, these researchers have reported that
caregivers and facility staff view resident leaders differently
when witnessing them as activity leaders and regard them
as allies in assisting those with more advanced dementia.
Next, we discuss why MIs are effective for PWD.
Why do Montessori-based interventions work?
Multiple factors likely underlie the success of Montessori
principles for designing interventions for PWD. First, Montessori activities involve everyday practical tasks and engage the learning-by-doing system, thus relying on implicit
memory rather than explicit or declarative memory. This
provides an added advantage for PWD of the Alzheimer
type because many implicit, nondeclarative memory processes are relatively spared in AD.47,75,78 Next, based on
Vance and Porter,75 MIs are particularly effective for PWD,
because the use of novel and rich sensory stimuli within
structured learning experiences likely induces experience-dependent neuroplasticity. Another reason for the
success of MIs is likely based on the concept of reverse
ontogeny.74 Reverse ontogeny refers to the observations
that skills documented by Piaget to be acquired early in
child development are the same skills that are among the
last to be affected in AD.80 Therefore, Vance and Johns74
reason that novel cognitive activities that are based on
Piagetian concepts and incorporate Montessori principles can help persons with AD maintain and, perhaps,
even enhance their cognitive functioning. Furthermore,
stimuli routinely used in Montessori-based activities are

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tangible sensory materials (eg, real objects, colorful tokens, textured fabric swatches, etc) that are functional and
aesthetically pleasing, while emphasizing visual, auditory,
and tactile discrimination. Finally, Montessori activities are
designed with inbuilt controls to facilitate self-recognition
of errors in task completion. For example, persons with
moderate dementia may be assigned a task of sorting red
spoons and blue forks into a red and blue bin, respectively.
Because each item has a distinct primary color and must
match the color of the bin in which it is placed, a person
with dementia is more likely to complete this task successfully and be able to monitor his or her own performance
and self-correct errors.
Regarding candidacy for MIs, Mahendra et al47 recommend that suitable candidates for such interventions are
PWD who have some spared motor learning capacity, social skills, and ability to initiate verbal communication. Furthermore, ideally, candidates for Montessori interventions
will have mild to moderate severity of dementia, absence
of combative behavior, and functional hearing and vision
abilities to attend to sensory stimuli, understand task instructions, and participate in intervention sessions.

CONCLUSIONS
In summary, we have presented robust evidence for the
efficacy of 3 specific interventions for PWDSRT, memory
books and memory wallets, and MIs. This evidence provides a compelling foundation for clinicians, researchers,
and caregivers to change their perceptions about the restorative potential of PWD. Furthermore, on the back of
such empirical evidence, current standards of clinical care
must change to provide PWD optimal opportunities to
maintain and enhance cognitive and communicative function, thereby promoting their sense of self and preventing
excess disability, given a diagnosis of dementia.

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