Montessori-Based Programming for Dementia Certification - DOC

							  Montessori Methods for Dementia™:

A Focus on the Person & the Prepared Environment


            Certification Report
          Completed by: _______________

          Date: ______________________

          Email Address: ______________

          Mailing Address: ____________
          ____________________________
          ____________________________




1|Page
                              Contact Information :

                               Gail Elliot, BASc, MA
                                Assistant Director
                        Gilbrea Centre for Studies in Aging
                               McMaster University
                              1280 Main Street West
                                      KTH 204
                                   Hamilton, ON
                                     L8S 4M4


                                 duec@mcmaster.ca
                                         or
                                elliotg@mcmaster.ca

                            905 – 525 – 9140 Ext. 24449




If you have any questions don’t hesitate to contact Gail Elliot at elliotg@mcmaster.ca
or by phone at (905) 525-9140 ext. 24124.




2|Page
                      Case #1
  (Please use this format for the beginning of each
           case – but change the Case #)

Client Name (this does not have
to be the person’s real name)

Type and Stage of Dementia

Where did you implement your
programming (e.g. – in the
person’s home, in a Day
Program, in a nursing home or
somewhere else?)

Any other details that would be
important for the evaluator to
know.




3|Page
   Sight and Reading Ability Assessment
         (When printing copies of this form, remove this heading.)




           I am fine.
           How are you?

              What a nice day.

                       Tried and true.


                        Live, laugh and learn.



                    Smile and the world smiles with you.
4|Page
     Sight and Reading Ability Assessment
Client Name: ______________________ Phone Number: _______________

Address/Room Number: __________________________________________

INSTRUCTIONS:
First of all, you should try to find out the following before you begin.

    Could this person read prior to being diagnosed with dementia?
       o Yes
       o No

    What language(s) did he/she read?
       o English
       o French
       o Other __________________________________________________

    Does he/she need glasses:
       o For distance
       o For reading

    Are his/her glasses clean? If not, please clean them before you begin.

Ask this person if he/she would help you to determine the best size of print needed
for people to see. Point to one sentence at a time, starting at the top of the page, with
the largest size font. Use only the sheet with the six statements. Record your findings
after you have completed the assessment.

      Size of                                    Check if        If he/she didn’t read
       Font                                    he/she read       full sentence, circle
                                              full sentence       which words were
                                                                         seen.
   72 point        I am fine.                                  I am fine.
   48 point        How are you?                                How are you?
   36 point        What a nice day.                            What a nice day.
   24 point        Tried and true.                             Tried and true.
   16 point        Live, laugh and learn.                      Live, laugh and learn.
   12 point        Smile and the world                         Smile and the world
                   smiles with you.                            smiles with you.

Form completed by: ________________________ Date: __________________

If this is a re-test:
Form completed by: ________________________ Date: __________________
5|Page
                          Program Participant Profile
              A Focus on Knowing the Person Behind the Dementia
Date: ____________________ Form Completed by: ______________________

Name: _________________________________________________________

Address: _________________________________________________________

Date of Birth: ____________________ Place of Birth: _____________________

Where has she/he lived & for approximately how long?



Marital Status: ( ) Married   ( ) Widowed   ( ) Divorced ( ) Single

Name(s) of Partner(s): _____________________________________________

Employment/Volunteer History:




Languages spoken:
    ( ) English   ( ) French         ( ) Spanish        ( ) Other:

Children/Grandchildren (If you need more space attach a separate page.)
                                                       Details about their
                                                       relationship. (Do
Name               Age      Where do they live?        they visit or phone?
                                                       How often, when,
                                                       etc.)




6|Page
Important Friends:
Identify important friends that continue to be involved in this person’s life. If there are
friends this person likes to remember and talk about include that information too.




Health Status:
                     Cognitive                                        Physical

 Dementia                                        Abilities:
             Alzheimer’s
             Vascular                            Note:    Check off the appropriate column
             Frontal Lobe                                Not applicable
             Lewy Body                                   Independently
             Other:                                      With Assistance
                                                      
 Stage:                                                   Total Assistance Required

        Mild                                      Can walk                              Indepnt W assist Total
                                                                                    NA                    assist
        Moderate                                  Walker
        Advanced                                  Walks: ( ) needs cane
                                                   Wheelchair
Orientation to time, place & person:               Toileting
   Fully oriented                                 Needs help eating
   Oriented in familiar surroundings              Dressing
   Needs some orienting                           Bathing
   Needs orienting information most or all        Grooming: Hair
          of the time                              Grooming: Face & hands/nails
                                                   Transfers (to chair or bed)
Are there any situations that create heightened    Teeth
      levels of anxiety? If yes, elaborate.        General neatness/hygiene
                                                   Knows what to do with objects
                                                   Can handle own finances
                                                   Uses a phone
                                                   Uses a computer

      Memory Cueing recommended                  Other:
 Elaborate:



                                                  Does this person like to be helped?




7|Page
 Depression                                         Arthritis
   None                                             Identify limitations & describe what
   Some                                             needs to be done to ensure that function
   Significant                                      is maintained
Provide details about stage & treatment &
impact on engagement in life and motivation to
be involved in activities.
                                                      Ability re:            Excellent   Moderate   Poor

                                                      Reaching
                                                      Grasping
                                                      Manipulating
                                                      Objects
Delirium                                             What hand is used?
A sudden change in status has been checked            Right hand
to ensure a delirium has been treated.                Left hand
Follow up:

Pain                                                 Vision & Hearing
 Often in pain. Where?                               Sight & Reading Assessment
 Sometimes in pain.                                   completed: Date __________
 Seldom shows signs of being in pain.                Needs glasses to read
                                                      Needs glasses always
                                                        Size of font required: _________

Note: Always observe to make sure that pain is        Needs hearing aid
being treated. Pain may be contributing to             Date batteries last checked:
behaviour – make sure it is reported.
Motivation:                                          Communication Skills:
 Usually wants to be involved in activities          Able to hold a conversation
 Sometimes interested                                Some ability to hold a conversation
 Sometimes interested but needs                      Minimal ability to hold a conversation
  encouragement
 Never interested in activities but will observe
                                                     Enjoys talking about:
 Just wants to be left alone
  Comments:




Interests:
Identify the things that this person enjoys/ed.
Household tasks:               Social                                Reading:
      Cooking                        Visiting family               What does/did he/she like to
      Laundry                        Visiting friends              read?
      Cleaning                       Planning social functions
      Shopping                       Entertaining
      Doing dishes                   Reminiscing: Are there
      Decorating home               any topics of
      Home repairs                  preference/enjoys most?
      Other:




8|Page
Leisure Activities                Games:                           Sports/exercise:
    Travel                           Cards                             Hockey
    Games                            Board games                       Football
    Sports                           Puzzles                           Soccer
    Crafts                                                              Volleyball
    Reading                                                             Curling
    Photography                                                         Croquet
    Gardening                                                           Horseshoes
    Genealogy                                                           Shuffleboard
    Watching movies (what                                               Golf/mini golf
   kind?)                                                                Yoga
                                                                         Walking
                                                                         Jogging
                                                                         Dancing
                                                                         Other:
Culture, Religion &               Music:                           Crafts:
Spirituality                       Likes to listen to music             Knitting
Does he/she like to participate    Likes to play music                  Sewing
in:                                                                      Woodworking
     A religious service?        What kind of music?                    Painting
     Quiet prayer                                                       Sculpting
     Guided prayer               Did he/she play an instrument?         Ceramics
     Singing hymns                                                      Other:
     Other:
Pets                              General interests not            Room Environment:
Does he/she have a pet now?       included elsewhere:               Room feels like home
 Yes  No                            Fashion                      Room reflects former self
                                      Giving back to the           Phone is usable
Did he/she have a family pet?          community                    TV available (if interested)
Elaborate.                            Volunteering                 Radio (if interested)
                                      Helping family               Orienting info available
                                                                   Modifications Required:



Routines:
Routines are important in our lives. Identify routines & consider what can be done to
add routine to this person’s day. An important part of this is to ensure that the routine
is communicated and understood by the client, with the objective of adding meaning to
life.




Fears, losses, and tragic events. These can be important to know about. This
information may need to be taken into consideration when selecting activities. The
purpose is to be aware – but not necessarily to address these issues – unless you are
qualified to do so.



9|Page
Ask, “Is there anything you would like me to know?” or “Is there anything you would
like me to know about you?” This is a very open-ended question. There may be
something important that he/she wants to share with you have his/her life, health,
work and/or family.




Information collected from:
    Client/resident
    Family member(s) Please elaborate:_____________________________
    Friends
    Work or volunteer colleagues
    Client files
    Other:______________________________________________________

Form updated:
Date:_______________________ By: ________________________________
Date:_______________________ By: ________________________________
Date:_______________________ By: ________________________________
Date:_______________________ By: ________________________________
                            Additional Notes:




10 | P a g e
               Today’s Schedule
Today is:_____________________
                                      Check 
                                       when
 Time            Details   Location    done




11 | P a g e
        Client Name:____________________________ Form Completed by:______________
        Date:
A. Identify skills, abilities and interest by ranking or checking the appropriate boxes.
B. Decide what areas you want to focus on. Either check the boxes or number according
      to priority (e.g. 1 would be most important, 2 next important, etc.)
        Activities of Daily       Sensorial                 Cognitive        Culture & Social
              Living                                                          Connections
  A B                         A B   Discriminating:   A B               A B
  Walking                 Colour     Exploration of the         Grace & courtesy:
  Carrying objects        Shape      world, including:        Group activity
  Folding clothes         Sounds   History                  Roles
  Buttoning               Touch    Music                    Visiting
  Using zipper          (e.g. –      Art                       
  Dressing                soft/hard or Creativity                   Making connections
                              
                              rough/       Geography                  to the world around
  Opening & closing                                                   
    (drawers, bottles     smooth)      Science                    him/her:
    or screwing nuts    Size & shape Biology                  Activities that bring
    & bolts)            Taste                                     joy
  Using tools         Smells         Exploration can          Activities are
                                                                            connected to
    (including cutlery)                   be accomplished            personal interests
                                             through:                   
  Pouring                                                           
        




  Spooning                             Sorting                   
  Toileting                            Reading                    Environment offers:
  Personal care                        Games                    Social roles
  Hygiene                              Puzzles                  Opportunities for
                                                                            personal expression
  Attending to                                                        
                                             Includes                 Support (physical,
    personal finances                        accessing
                                             important                  social & emotional)
    (such as writing a
    cheque)                                information &            Interpersonal
                                                                          connections
  Eating                                 decision-making.
                                                                      Atmosphere of both
                                                     
                                               May need
                                               external cues to
                                                                          caring &
  
                                                                       being cared about
                                                      
                                               support decline
                                              in declarative                
                                           memory.                       
                                           Memory book
                                           Cue cards
                                           Daily schedule

Use the information from this chart to help you establish goals on the Montessori
Assessment Form.
 Activities & Goals




        12 | P a g e
                         Montessori Programming Form
               Connecting Observations to Goals and Interventions

 Client Name:
 Date:
 Form Completed by:
 Area of                                                             Activities, Roles, Routines
 Observation Strength/Skills/                Goals                   and Cueing
              Abilities                      Steps to meet goals     (Based on needs, interests,
                                                                     skills and abilities.)
 Practical Life Observations:                Goal(s)                  Activities:
 (Activities of
 Daily Living)                                                       Roles:
                Strength/Skills/Abilities    Steps to meet goal(s)
                                                                     Routines:
                 Interests:
                                                                     Cueing:
 Culture &   Observations:                   Goal(s)                 Activities:
 Social
 Connections                                                         Roles:
             Strength/Skills/Abilities       Steps to meet goal(s)
                                                                     Routines:

                 Interests:                                          Cueing:

 Sensorial       Observations:               Goal(s)                 Activities:

                                                                     Roles:
                 Strength/Skills/Abilities   Steps to meet goal(s)
                                                                     Routines:

                 Interests:                                          Cueing:

 Cognitive       Observations:               Goal(s)                 Activities:

                                                                     Roles:
                 Strength/Skills/Abilities   Steps to meet goal(s)
                                                                     Routines:

                 Interests:                                          Cueing:




13 | P a g e
                                           Roles
      NOTE:      Your report will be written after you have put your program plans into
      practice. Therefore your report will be written using past tense – making it very clear
      that you have already put these ideas into action and you are reporting on what you
      actually did.


      What roles did you assign to this client? (List the roles you identified
      and tried and provide details about the experience – what worked, adaptations
      that were required, etc.)




                                        Routines

      What routines did you develop and how did you put these
      routines into this person’s daily life? (Please provide examples of the
      schedules you created for your client. At least two examples must be included in
      the report. Be sure to included details about the format of the agenda/schedule.
      For example, did you laminate a partially filled in template and leave room for
      details to be changed according to the day?)




14 | P a g e
                                      MONTESSORI ACTIVITY RECORD KEEPING LOG
Client Name: _____________________________________ Date:______________________________________

                      Activity/role/routine    Activity/role/                                                               How long
                                                                How much of the time did              Participant            did the
                      was created based on    routine was the
                                                                he/she participate in the           enjoyed activity       participant
DATE    ACTIVITY       interests/skills of     right level of
                                                                        activity?                                           engage in    COMMENTS   STAFF
                           participant           difficulty                                                                 activity?               NAME
  &
                                                    Too Too All      None       Just observed All             Not At All
Time                  Yes No     Why Not      Yes             1 2 3 4 5              6        1 2 3 4             5
                                                                                                                           (# minutes)
                                                    Easy Hard




       15 | P a g e
Lessons Learned with (Client name) ______________________
Successes:




Things tried but not successful. Why not?




16 | P a g e