Cognitive Stimulation Therapy

(CST) for people with dementia

Ritchard LedgerdClinical Researcher

Acknowledgements: Dr Aimee Spector, Amy Streater

Aims of the Cognitive Stimulation Therapy (CST) studyTo combine elements of past research to create an

evidence-based group therapy programme for people with dementia.

To evaluate the effectiveness of this programme as a multi-centre Randomised Controlled Trial (RCT).

Size of trial, methodology and outcome measures to match that of the major drug trials.

CST development: literature reviewReality Orientation (RO, Folsom, 1966): “The presentation

and repetition of time, place and person related information”.

Made important impact in 1960s: one of first non-drug interventions for dementia.

More recent work described as ‘Cognitive Stimulation’ (Breuil et al, 1994): used techniques including maps, categorising words /objects, food, current affairs.

Evidence-base for its effectiveness in cognition and behaviour (Spector et al, 1998)

CST development: Literature reviewReminiscence Therapy (RT, Butler and Lewis, 1977): Discussion

about the past, often using prompts (e.g. pictures, objects, music) with groups or individuals (e.g. life review books).

Focuses on long-term memory, hence extremely popular - helps to avoid failure experiences, aids communication.

Cochrane review (Woods et al, 2005) showed limited evidence of effectiveness.

We also reviewed evidence on Validation Therapy (e.g. Feil, 1992) and Multisensory Stimulation (e.g. Baker et al, 2001).

Attempted to identify best features of each therapy and combine into a single programme.

What does CST do?Aims to be mentally stimulating, yet for people to feel empowered rather than de-skilledAlways encouraging new ideas / new thoughts / new associations.

Stimulate memory through:Using reminiscence as an aid to the here and now.Providing triggers to aid recall, e.g. multi-sensory cues, boardContinuity and consistency between sessions helps support memoryImplicit (rather than explicit) recallUsing orientation, but sensitively and implicitlyOpinion rather than facts (which supports idea of validation)

What does CST do?Stimulates language through:Naming of people and objects (e.g. in categorisation)

done in implicit wayThinking about word construction and word

association

Stimulates executive functioning through:Discussion of similarities and differencesPlanning and executing stages of a task (e.g. making a

cake)Word association, categorising objects

The CST intervention: Sessions1. Physical games2. Sound3. Childhood4. Food5. Current affairs6. Faces / scenes7. Word association

8. Being creative9. Categorising objects10. Orientation11. Using money12. Number games13. Word games14. Team quiz

Example – Famous Faces

Which is the odd one out? Why?

Mental StimulationNew ideas, thought and associationsUsing orientation, but sensitively and implicitlyOpinions rather than factsUsing reminiscence, and as an aid to the here and nowProviding triggers to aid recallContinuity and consistency between sessionsImplicit learningStimulating language

Stimulating executive functioningPerson centredRespectInvolvementInclusionChoiceFunMaximising potentialBuilding /strengthening relationships

CST key principles

The CST intervention

Pilot programme modified into 14 session programme, twice a week for 7 weeks

Named ‘CST’ as it was largely based on Breuil’s ‘Cognitive Stimulation’ (1994)

45 minute group sessions (5-8 per group)

Within broad themes there are flexible activities to cater for group’s needs and abilities

CST Trial (Spector et al, 2003)Multi-centre, single-blind, RCT

23 centres (18 residential care homes, 5 day centres)

201 participants who:Met DSM IV criteria for dementiaScored 10-24 on MMSE (mean = 14)Did not have significant visual or auditory impairmentsDid not have learning disability or major physical health

problemsWere not on dementia medication

CST Trial: ResultsBlind assessments in week prior to and week

following intervention.

Cognition:Significant improvement following CST in MMSE

(p = 0.04) and ADAS-Cog (p = 0.01).ADAS-Cog: trends in all subscales (memory,

language, praxis) but only significant subscale was language (including naming, word-finding and comprehension).

CST Trial: ResultsQuality of Life:Qol-AD (brief, self-rated measure covering 13 areas of

QoL): significant improvement following CST (p = 0.03)No significant change in functional ability (CAPE-BRS),

depression (Cornell) or anxiety (RAID)Communication (Holden): positive trends (p = 0.09)CST shown to be cost effective, in study run in

conjunction with LSE (Knapp et al, 2006)

Variation between centres in several outcome measuresLimitations included control group not being homogenous, different staff rating outcomes, no long-term follow-up

CST Trial: Comparison with cholinesterase inhibitorsNumbers needed to treat (NNT): number needed to be treated

for one favourable outcome. Comparisons made with CIs using previous studies (Livingston

and Katona, 2000)Showed that on one level, CST not quite as effective as most

CIs but on another, CST as effective as Galantamine or Tacrine and substantially better than Rivistigmine or low dose (5mg) Donepezil

Matsuda (2006): Cognitive Stimulation combined with Donepezil better than Donepezil alone.

CST: Cost EffectivenessCST is more cost-effective than usual activities using both outcome

measures:

• Incremental cost-effectiveness ratio: £75.32 (784.30 ) per additional point on MMSE, £22.82 (237.61 ) per point on QoL-AD

• Donepezil had considerably larger cost per incremental outcome gain (AD2000, 2004)

Conclusions: Small costs were outweighed by larger gains likely that decision makers will see CST as cost-effective.

Limitations – short time span, mainly focused on people in residential care

Neuropsychological mechanisms of change (Hall et al, 2012)34 participants given detailed neuropsychological

test battery before / after 7 weeks (14 sessions) of CST.

Significant improvements (p<0.05) in verbal memory, non-verbal memory, language comprehension and orientation.

No significant changes in executive function, praxis, attention/working memory, language expression.

Qualitative Research (Spector et al, 2011)34 participants (people with dementia, carers and staff)

participated in individual interviews and focus groups.Asked about experiences of CST – positive or negative.

Key themes emerging:

Positive experiences of being in group (e.g. supportive and non-threatening).

Changes generalised into everyday life: improvement in mood and confidence (finding talking easier), changes in concentration and alertness (wanting to attend to things more).

Maintenance CST (MCST), Orrell et al (2013)

Included 237 people with mild to moderate dementia who had previously received CST (14 sessions). A third of the sample was on acetylcholinestrase medication.

Intervention: weekly, 24-session programme of Maintenance CST (MCST) compared to TAU.

ITT analysis showed that MCST improved QoL at 3 and 6 months, and ADL at 3 months.

MCST continuedCognition was higher in MCST group but the difference

was not significant.

Sub-analysis indicated that MCST appeared to be effective irrespective of whether or not CI’s were prescribed, with greater improvements showed in the CI’s plus MCST group.

Conclusions: There is good evidence for the benefits of continuing CST beyond the initial programme. Whilst people are still willing and able, CST should be continued.

“People with mild / moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme. This should be commissioned and provided by a range of health and social care workers with training and supervision. This should be delivered irrespective of any anti-dementia drug received by the person with dementia”.

2006

The World Alzheimer’s Report (Alzheimer’s Disease International, 2012), stated that CST should routinely be given to people with early stage dementia.http://www.alz.co.uk/research/WorldAlzheimerReport2011.pdf

“An economic evaluation of alternatives to antipsychotic drugs for individuals living with dementia”.

Analysis focused on cost of providing CST.

Combining health care cost savings and QoL improvements, behavioural interventions generate a net benefit of nearly £54.9 million per year. October 2011

Many of the principles of CST, such as valuing the individual, the focus on wellbeing despite impairment, the importance of motivation and use of a group setting for intervention, will be familiar.

Occupational therapists may feel that they have been using most of the elements of CST for many years, though not necessarily in the highly structured way recommended for specific CST programmes. CST does provide an evidence base for intervention, and the recommended interventions should be followed to enable the clinician to measure impact and effectiveness. October 2011

Use of CST

National Memory Services Accreditation programme (NMSAP) audit (2013): CST used in 66% of UK memory clinics.

CST is being used in Australia, USA, South Africa, New Zealand, Germany, Canada, Chile, Italy, Japan, Nepal, the Philippines, the Netherlands, Tanzania, Brazil, China, Hong Kong, Indonesia, India, Ireland, Nigeria, Singapore, South Korea, Turkey and Portugal

Individual CST (iCST)Large trial currently running at UCL.

Involves one-to-one CST, led by home carers or professionals / volunteers.

Similar themes to group CST.

Results available in 2014.

How CST can be establishedPublished CST training manuals which include session-by-session

plan, equipment required, DVD etc. www.careinfo.org/books

Has been adapted e.g. to weekly sessions, outpatients, in community.

CST website: www.cstdementia.com

One-day training course to ensure delivery in standardised, person-centred and effective way.

For all references, see CST website