Montessori-Based Interventions for Older Adults

The globally increasing life expectancy is leading to a rapid rise in the number of older adults. According to 2024 data from the United Nations, individuals aged 65 and older constitute 10.2% of the global population (United Nations, 2024). Similarly, according to the Turkish Statistical Institute (TÜİK) data, the proportion of the population aged 65 and over, which was 9.1% of the total population in 2019, increased to 10.6% in 2024 (TÜİK, 2024). These demographic shifts necessitate a more in-depth examination of the physical and mental health of older adults. Particularly during the aging process, the losses accompanying physical changes, the inability to fulfill independent roles, and cognitive impairments have emerged as significant public health issues within the scope of tertiary healthcare services in recent years (Latino \& Tafuri, 2024; Lisko et al., 2021).

Certain common characteristics associated with aging, such as alterations in perception, decreased cellular regeneration, prolonged physical and mental reaction times, and the loss of former physical strength, lead to changes in cognitive processes (Kim et al., 2015). During this process, a decline in productive capacity, weakened interest in environmental stimuli, delays in adapting to new situations, and a slowdown in cognitive functions such as memory, attention, and thinking are observed (Lisko et al., 2021). Cognitive decline is evaluated within a spectrum ranging from simple forgetfulness to dementia, causing various difficulties in individuals' social, occupational, and community lives. The onset of cognitive changes leads to a decrease in the level of independence in activities of daily living; this situation causes older adults to transition from an independent life to a semi-dependent or fully dependent one (Hewston et al., 2021). These changes pose even greater challenges, particularly for older adults residing in institutional care, which negatively affects their cognitive functioning and activities of daily living (Biazus-Sehn et al., 2020; Hewston et al., 2021).

Stimuli and activities customized according to the cognitive levels or personal experiences of older adults can significantly reduce agitation and problem behaviors associated with dementia (Feng et al., 2018; Van Mierlo et al., 2010). A study conducted by Kocaman et al. with older adults demonstrated that a regularly implemented exercise program has a positive effect on postural control, gait, and cognitive functions (Kocaman et al., 2020). Another study revealed that game-based physical activities provided significant improvements in the motor skills of older adults, and this effect was also reflected at the cognitive level (Karabulut, 2023). In a thesis study conducted by İnel Manav with older adults suffering from mild dementia, it was concluded that internet-based video group reminiscence therapy had a significant effect on the cognitive functional status of older adults with mild dementia (İnel Manav, 2018). In addition to these, visual and auditory interventions such as puzzles, chess, paper-and-pencil activities, dance, and music can also be beneficial for cognitive functions. In this context, one of the prominent approaches for older adults in recent years, particularly in dementia care, is Montessori-based interventions (Çınar et al., 2022; Mondini et al., 2016; Simon et al., 2020). Originally developed to support the cognitive and sensory development of children, the Montessori method has recently been adapted to preserve and support the remaining functional capacity of older adults living with dementia. This approach aims to increase engagement, reduce behavioral symptoms, and support the individual's quality of life by providing meaningful activities structured progressively in accordance with the individual's cognitive level (Camp, 2010; Feng et al., 2018).

Montessori-based interventions were first developed by Maria Montessori in 1907 for the education of children. This educational method was applied to equip children with cognitive, social, and functional skills by breaking tasks down into steps from simple to complex and from concrete to abstract. Thus, children were encouraged to step out of their comfort zones to develop their skills (Camp, 2010; Feng et al., 2018; Malone \& Camp, 2007; Sheppard, McArthur \& Hitzig, 2016). The initial steps towards applying Montessori-based interventions for individuals with dementia were taken by Dr. Cameron Camp in the 1990s (Camp, 2010). In older adults, Montessori-based interventions focus on the individual's strengths rather than their weaknesses, aiming to foster development through these strengths. This encourages the creation of personalized programs taking into account the individual's lifestyle, interests, likes, and dislikes (Brush, 2020; Rodrigues, 2023). Montessori-based interventions are founded on the principles of respect, dignity, autonomy, and equality, and are personalized according to the cognitive capacities of the individuals. In this approach, the use of familiar materials, the division of tasks into small, manageable steps, and the inclusion of repetitions progressing from simple to complex allow individuals to learn at their own pace and experience a sense of accomplishment. Furthermore, these interventions support engagement and independence by encouraging individuals to interact with their social and physical environments through purposeful and meaningful activities (Camp, 2010). In this context, Montessori-based interventions, rooted in person-centered care principles, offer an important theoretical foundation for supporting cognitive and functional capacity as well as activities of daily living. They aim to activate the individual's preserved implicit memory system through structured activities, environmental modifications, and guiding elements (Berkovic et al., 2024; Camp et al., 2018). Within this framework, to explain the effect of Montessori-based interventions, the cognitive decline processes that emerge with age and their reflections on activities of daily living must be evaluated together.

With advancing age, the problem of decline in cognitive functions due to neurodegeneration is frequently observed (Lv et al., 2025). In cognitive impairments, the explicit memory system is affected early on because its processes are dependent on the hippocampus. In contrast, procedural (implicit) learning and the repetition-based priming effect-which leads to an increase in the speed and accuracy of responses through the repeated presentation of stimuli-can operate independently of the hippocampus (Beaunieux et al., 2012; De Wit et al., 2022). This provides a theoretical basis for developing behavioral interventions targeting implicit memory to compensate for learning difficulties arising from hippocampal damage in cognitive impairments (De Wit et al., 2022). In this context, while Montessori activities support "explicit memory" through guiding and reminding elements in the individual's environment, they are structured to enable the use of the "implicit memory" system. This is achieved by reducing the need for language use and complex cognitive processing, dividing tasks into small and manageable steps, and supporting the individual's use of this preserved memory system through structured, repetitive practices and environmental cues (Camp, 2010; Giroux et al., 2010; Larson, 2010; Malone \& Camp, 2007; Mousavi et al., 2022). Additionally, these interventions incorporate an error control mechanism that allows the individual to evaluate their own success without needing external feedback. This error control process offers individuals the opportunity to experience a sense of achievement, generally leading to increased self-confidence and allowing them to participate in activities with a calmer and more engaged approach (Brenner \& Brenner, 2012; Rodrigues, 2023).

Loss of muscle strength, restricted mobility, and decline in sensory and cognitive functions that occur with age lead to a decrease in activities of daily living (ADLs) among older adults (Chang et al., 2025). Conversely, sensory-based and structured activities emerge as a fundamental approach that increases individuals' participation in activities when presented alongside individual guidance and a supportive environment. Such activities enhance motivation for participation by strengthening emotional expression and self-confidence; at the same time, they contribute to individuals maintaining their daily routines more independently in collaboration with their caregivers. Since ADL performance requires the coordination of motor, sensory, and cognitive processes, this holistic stimulation provided is considered a fundamental mechanism supporting functional capacity (Gambella et al., 2025; Liao et al., 2019; Sun et al., 2022). It has been reported that such interventions aimed at maintaining motor skills and flexibility increase independence in basic activities such as feeding, dressing, and personal care (Ljubič et al., 2023; Sun et al., 2022). Furthermore, a meta-analysis study demonstrated that sensory-based activities increased participation, thereby strengthening individuals' levels of emotional expression, self-confidence, and cooperation, indirectly improving ADL performance through this process (Sun et al., 2022). Based on these findings, it is considered that the integration of Montessori principles into geriatric care can support both the functional independence and cognitive performance of individuals through the cognitive, sensory, and psychomotor stimulation it provides. In this context, planning and implementing such non-pharmacological, independence-enhancing interventions to preserve the functional capacities of older adults and support their active aging directly align with the core professional responsibilities of public health nurses. Indeed, the primary roles of public health nursing include enhancing individuals' self-care capacities, guiding them in maintaining independent living skills, and creating adapted environments that promote health (Williams, 2021). In Montessori-based interventions, public health nurses are also expected to offer older adults the opportunity to utilize their own potential, supporting them cognitively, sensorially, and physically, thereby contributing to the goal of independence.

It has been demonstrated in the literature that Montessori-based interventions provide numerous benefits. Considering the participation of individuals with dementia in the process through a person-centered approach, it is emphasized that these interventions lead to positive changes, such as an increase in general quality of life and cognitive functions for both the individual with dementia and the caregiver (Booth et al., 2020; Brenner \& Brenner, 2012; Feng et al., 2018; Rodrigues, 2023; Sheppard, McArthur \& Hitzig, 2016). However, no study applying Montessori-based interventions to older adults has been found in our country. The aim of this study is to evaluate the effect of Montessori-based interventions, known as an evidence-based intervention method, on cognitive function and activities of daily living in older adults.