Both people with dementia and their family carers may suffer from the consequences of dementia such as confusion, disorientation and reduced language fluency. As a result, people with dementia may experience increasing difficulty in communicating their needs to family and professional caregivers for physical comfort, social engagement and meaningful activity. According to the unmet needs theory
], the resulting distress contributes to the behavioural and psychological symptoms of dementia (BPSD). The psychological symptoms include anxiety, depression, hallucinations and delusions. Behavioural symptoms include restlessness, aggression and calling out. BPSD reach a peak in the middle to late phases of dementia and greatly increase the likelihood of admission to an aged residential facility [2
]. Within facilities, rates of BPSD are often high. In 11 Sydney nursing homes, for example, 60% of residents had an affective disorder, 53% showed activity disturbance and 77% were aggressive [3
When BPSD stem from pain, co-morbid major depression or psychosis, treatment with analgesics, antidepressants or antipsychotics can bring relief. However, in cases where the causes of BPSD are less obvious, medications have variable efficacy and can lead to adverse effects such as worsened confusion and falls [4
]. More attention is being paid, therefore, to non-pharmacological interventions that better address the needs that underpin BPSD. In two recent systematic reviews, it was demonstrated that treatments such as music, recreation therapy and relaxation therapy significantly reduced BPSD with effect sizes ranging from 0.5 to 1.15 [6
]. The largest effects were found when treatments were tailored to individuals' own backgrounds, interests and skills.
Two studies conducted since the reviews suggested that Montessori-based activities significantly reduced agitated behaviours and increased positive mood and engagement [[8
], van der Ploeg ES, Eppingstall B, Camp CJ, Runci S, Taffe J, O'Connor DW. The effect of personalised, one-to-one interaction using Montessori-based activities on agitation, engagement and mood in aged care facility residents with dementia. Submitted]. Montessori-based activities follow the principles espoused by Maria Montessori and subsequent educational theorists who promoted engagement in learning by sequencing tasks from simple to complex; providing cues to successful completion; encouraging repetition, and carefully matching demands to individuals' interests and levels of competence [9
]. For people with dementia, Montessori-type programs entail detailed interviews with family carers about the resident's former interests and skills coupled with assessments of cognitive, language and motor skills. A range of activities are then presented, tested and refined. When dementia is advanced, the activities are simple (e.g. completing a jigsaw made from a family photograph). Facilitators present tasks deliberately, modelling them first and using little language if appropriate. The main objective is to engage participants' interest and involvement. Despite a growing evidence base, personalised one-to-one activities are rarely implemented in aged care facilities as they require extra time and resources that are often not available.
Dementia may also inflict negative consequences for family members of the individual with dementia [11
]. Frequently reported adverse consequences of caring for relatives with dementia include physical health problems, depression, social isolation and financial burden [12
]. These stresses might be expected to diminish following admission to a residential facility where care tasks are undertaken by paid staff. In reality, stress levels often remain high, with only a change in the source of burden [13
]. New stressors may include the practicalities of visiting, tension with staff regarding care roles, concerns about care and continuing costs [15
]. Carers possibly also experience guilt and difficulties relinquishing their role as primary supporter [16
]. In addition, visits to the facility can prove unsatisfying, especially if the resident is anxious, agitated and increasingly more confused. There are fewer opportunities for easy communication, shared activities and contentment in the relationship [18
]. Interventions to ease this transition have included carer education and support groups [20
]. While promising, they considered the family carer and resident separately, overlooking the loss of relationship between the two, particularly significant for spouses [15
]. Preserving and enhancing this relationship through meaningful activities can restore a sense of competence and self-determination for family carers [22
] and improve the well-being of both parties [23
]. An activity program delivered by family carers to relatives with dementia living in the community resulted in large increases in carers' confidence through perceived enhanced skills and personal control as well as enhanced engagement and mood of the individuals with dementia [24
Interventions to alleviate carer stress and BPSD have mostly treated carers and relatives separately rather than focusing on re-establishing and enhancing their relationship. Since one-to-one structured activities have been shown to reduce BPSD and also improve the caring experience, they seem an ideal intervention to bring people together and thus improve wellbeing for both carers and their relatives with dementia. The current study will investigate the effect of individualised activities based on the Montessori methodology administered by family carers in residential care on the wellbeing of carers. We hypothesise that family carers conducting Montessori-based activities will experience higher self-rated mastery, fewer depressive symptoms, and a better quality of life than carers in a waiting list period, as well as a better quality of visits and overall relationship with the resident.