Katrina Clarke | June 3, 2013 | National Post
When Diana Adams first walked into the hospital room of a frail 88-year-old a month ago, she caught him in the midst of climbing off his stretcher. The distressed man had severe dementia, had been in the emergency room for four hours and was saying he wanted to go home.
But by the time Ms. Adams had helped him sit back and set up her materials, he was calm, focused and engaged in the task before him; clipping coloured clothespins to plastic buckets.
“He was engaged with this for 40 minutes,” she said. “After I left, he didn’t pull his ECG lines, he didn’t try to pull out his IV. He was calm.”
Activities like this are part of a new study Ms. Adams, a geriatric emergency management nurse, is leading at North York General Hospital through funding from the hospital’s Exploration Fund. Her research is looking at how Montessori Methods for Dementia, which uses a person-centred approach and multisensory activities, can calm and reassure an ER patient, preserve their abilities and improve their overall experience.
They don’t know where they are and it’s very frightening
A visit to the ER can be overwhelming enough for someone without cognitive impairment, but for someone with dementia or Alzheimer’s, the visit can be especially challenging.
“Imagine somebody you love and they’re in an emergency department and they’re in a stretcher screaming, they’re trying to climb off. It’s so heartbreaking,” said Ms. Adams after she exited the main ER area, where sick patients waited in the hallway on stretchers and nurses addressed concerns of anxious relatives.
“It’s a recipe for disaster. They don’t know where they are and it’s very frightening,” she said. Sometimes patients have to be sedated or restrained.
Patient distress can also make the already chaotic environment more stressful for staff, she said.
The method Ms. Adams uses is simple. She or one of her team members will sit down with a patient for 30 minutes or so, set up materials and allow the patient to interact with the items. There is no right or wrong way of engaging; pink clothespins can be clipped on blue buckets, or on top of other clips.
Her materials include plastic buckets and clothespins, sorting cards and a laminated book showing scenes the patient might encounter — a nurse in scrubs with a mask on her face or ECG wires on someone’s chest — and large print describing what each scene means.
The Montessori philosophy was first developed in the early 1900s by Italian educator Maria Montessori and was geared toward helping children learn through discovery, encouraging them to follow their interests. In the 1990s, American psychologist Cameron Camp adapted these methods when he discovered it could preserve ability in people with dementia. Later, now-retired McMaster University gerontologist Gail Elliot created Montessori Methods for Dementia. This approach looks at an individual’s needs, skills and abilities and then matches them with purposeful, stimulating activities.
Deborah O’Connor, director of the Centre for Research on Personhood in Dementia at UBC, said although there is need for more research on the effectiveness of Montessori Methods, she calls Ms. Adams’ ER study an “amazing idea.”
“We really need to be… making that experience so that it’s not quite so devastating to both the family member and the [patient],” she said.
Montessori Methods for Dementia is currently used at care facilities like Toronto’s L’Chaim Retirement Centre and Dementia Support day centre. There, staff determine what everyday things residents did throughout their live and what they are capable of doing now.
“You have to look into the person and find the person behind the dementia,” said Judy Cohen, founder of the facilities. For one older woman, the task of folding towels gives her a sense of purpose, improving her self-esteem, she said.
You have to look into the person and find the person behind the dementia
It was learning about success at these facilities that sparked Ms. Adams’ initial interest in Montessori.
At North York General Emergency Department, staff don’t have the luxury of determining what patients used to do, but they do try to judge levels of ability. Higher functioning patients with dementia are given travel books, for instance.
“Nobody has said this is baby-like,” Ms. Adams said. “This is the ability that they are at.”
Though Ms. Adams was initially skeptical of using these methods in the ER, she now says “they’re working.”
The study began in April and of the about 12 patients she’s worked with so far, 80% have responded successfully — they calmed down, stopped asking repetitive questions and climbing off their stretcher. Those for whom the methods didn’t work may have been too sick to focus, Ms. Adams said.
She aims to work with 30 to 40 patients in total and to gather all data by late fall 2013. This is the first known study of using Montessori Methods in an ER setting and her hope is that the results may help improve patient experiences throughout North America.