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Cognitive Stimulation Therapy: Making a Difference for People with Dementia

Disclosure StatementWe have no relevant financial relationships to disclose

PresentersJanice LundyBSW, MA, MHADirector of Social Work and Geriatric Case ManagementPerry County Memorial HospitalJlundy@pchmo.org

Debbie Hayden RN, BSN, OTR/LDirector of Occupational TherapyPerry County Memorial Hospitaldhayden@pchmo.org

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PresentersSue TebbPhD, MSW, RYT-500Professor School of Social WorkSaint Louis Universitytebbsc@slu.edu

Julia Henderson-KalbMS OTR/L Instructor Department of Occupational Science and Occupational TherapySaint Louis Universityjhenders@slu.edu

AcknowledgementsMax ZubatskyPhD, LMFTAssistant ProfessorDepartment of Family and Community MedicineMedical Family Therapy ProgramPhone: 314-977-2496 zubatskyjm@slu.edu

Developing and Implementing a CST Group

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What is Cognitive Stimulation Therapy?

An evidence based Psychosocial treatment for individuals with mild to moderate dementia

Focuses on the improvement and strengthening of cognitive functions

Maintenance of social and interaction skills

Potential to improve mood and quality of life

Development of CST

CST developed by Dr. Aimee Spector under the direction of Dr. Martin Orrell and his

team at University College London (UCL).

Introduction

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Outline of CST Train the Trainer Toolkit/Session

How to use the manual Evaluating culturally appropriate material How to set up sessions/classes Planning and facilitating groups (recruiting, marketing,

transportation, time of day, space) Co-leading groups Managing behaviors in group Maintenance of groups short-term/long-term

Outline of CST Train the Trainer Toolkit/Session (cont)

Forms used in CST groups Billing of group activities-how it is coded Offering CST on an individual basis Exercise option Caregiver support, understanding CST and use of CST

between sessions FAQ

Key Principles of CST1. Mental stimulation 2. New ideas, thoughts and

associations3. Using orientation, both

sensitively and implicitly4. Opinions rather than facts5. Using reminiscence as an aid to

the here-and-now6. Providing triggers to aid recall7. Continuity and consistency

between sessions8. Implicit (rather than explicit)

learning

9. Stimulating language10.Stimulating executive

functioning11. Person-centeredness12. Respect13. Involvement14. Inclusion15. Choice16. Fun17. Maximizing potential18. Building / strengthening

relationships

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Session Structure Introduction

Welcome every member individually Group name Soft ball toss ( warm up and orientation of members) Reference to day, weather, season (always on board as cue). Any discussion of important events in their lives since last session.

Theme Song Current Affairs ( Local and national). Main Activity Suggested activities for home (may include in take home

handout). Closure (discuss time, day, and activity for next session-get

opinions).

Videos on CSTShort version: 21/2 min

https://www.youtube.com/watch?v=ohM8WGo2gO4

Medium version:11 min.https://www.youtube.com/watch?v=kh3XqDEqVN4

Key Features of CST Program

14 CST sessions, usually twice a week 45 minutes to an hour, with exercise component will be longer. Ideally 5-8 participants in a group, run by two

therapists/facilitators. Each session has a choice of activities, to cater for interests

and abilities of group. Group members should ideally be at similar stages of

dementia, so activities can be pitched accordingly. Attention should be paid to gender mix.

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Who is appropriate for CST?Meet

criteria for dementia,

SLUMS greater

than 10?

Can s/he

have a “meaningful” conversation?

Can s/he hear well

enough to participate in a small

group discussion?

Is her/his vision good

enough to see most pictures?

Is s/helikely to

remain in a group

for 45 minutes?

YES

YES

YES

YES

YES

THIS PERSON MIGHT BE

INCLUDED IN THE GROUP

THIS PERSON SHOULD NOT BE INCLUDED IN THE GROUP

NO

NO

NO

NO

NO

Assessment of participants SLUMS

http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf QOL-AD

http://www.dementia-assessment.com.au/quality/qol_handout_guidelines_scale.pdf Cornell Scale for Depression in Dementia

http://www.amda.com/resources/2005_updates_ltc_teaching_kits/dementia.pdf TUGS

http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/timed_up_and_go_test.pdf http://www.rehabmeasures.org/PDF%2520Library/Timed%2520Up%2520and%2520Go%2520Test%2

520Instr.. Short Blessed

http://geriatrictoolkit.missouri.edu/cog/bomc.pdf Trailmaking A and B

http://doa.alaska.gov/dmv/akol/pdfs/uiowa_trailmaking.pdf AM-PAC mobility and daily activity

http://www.bu.edu/bostonroc/files/2013/10/AM-PAC-Short-Form-Manual_10.24.2013-SAMPLE.pdf

Strengths, sensitive areas, interests, literacy, hearing, etc.

Preparation to Begin Groups

Marketing/Recruitment Medical community, web sites, senior centers, LTC/RES

communities, churches, caregiver support groups, etc.

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Preparation to Begin Groups

Explaining nature and purpose of CST groups to participant and caregiver.

Organizing transportation, room, therapists/facilitators. Deciding on time of day (mornings if possible). Preparing material for each session (Being well prepared

is essential). Preparing send home information for each session.

ROLE PLAYING ACTIVITY

Co-Leading Groups

Essential that therapists/facilitators are a good match. Choose co-leaders carefully. good understanding of dementia symptoms and behaviors patience and ability to manage and redirect ability to emotionally connect with group members (group

members see you as leader but also part of the group) define roles prior to beginning groups

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Managing Groups Varying of cognitive abilities Attempt if possible to group according to cognitive abilities-not

always possible Attention to members not participating (draw them back in to

discussion) Attention to each members feelings at all times Attention to members who monopolize

o sometimes can be due to anxiety ( helping them feel at ease)o recognize their contribution and gently move discussion to

another member. Physical needs (toileting, ambulation, mobility)

Assure patients’ physical needs are met (co-facilitator)

Managing Groups

Examples for discussion of common issues that occur

1. It is very difficult to get some members to come to sessions, although once they are there they really seems to enjoy it. What could you do to encourage them?

2. When the caregiver is a spouse they sometimes can resent the closeness of the group. What can be done to help them feel a sense of inclusion?

3. Often you will have one or two members who will take over and repeat the same lengthy stories over and over again. Other members begin to notice and are becoming bored. How can you manage this?

Maintenance CST Groups

Community vs facility. Deciding on time. Incorporating new members into the group. Group name and song (can become confusing if adding

new members to an existing group) Managing size of the group and similar cognition How to handle when a member is no longer appropriate

for group. How to keep it interesting and from becoming stagnate

over time.

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Maintenance CST Groups

Monitoring progress Keeping records of progress Outcome measures, including:

SLUMS- measures cognitive changeQOL-AD- measures quality of lifeDepression screen

Feedback from group and caregivers Regular support and supervision is essential

Incorporating Exercise into CST Groups

Exercise Can Benefit Those With DementiaMeta-analysis found exercise helps in most domains 40 studies used broadly defined exercise interventions-

including flexibility, strength, balance, and aerobic activity

It assessed a range of outcomes including, cognition, behavior, function, endurance, balance, strength, flexibility

Found exercise helps people with dementia in most every physical and functional aspect-jury still out on cognition

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Guidelines for Exercise in Older Adults Aerobic Exercise

Moderate Intensity; 30 minutes/day; 5 days/week Vigorous Intensity; 20 minutes/day; 3 days/week

Resistance Exercise At least 2 nonconsecutive days/week Eight to ten exercises

Flexibility Exercise At least 2 days/week for at least 10 minutes

Balance ExerciseAmerican College of Sports Medicine and the American Heart Association

Types of Exercise

CDC Exercises for Older Adults

CDC Strength Training for Older Adults

Part I: strengthens the body slowly and gently, using only the person’s own body weigh

Part II: introduces dumbbells and ankle weights to increase strength

Part III: adds variety with new ways to boost strength even more.

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Providing Support for CST Participants’ Care Partners

Working with Caregivers of Dementia I. Exploring the Experiences and Journey of the Diagnosis

II. Determining the Individual’s Style of Caregiving

III. Assessing Resources and Support Systems

Exploring the Journey of the DiagnosisImportant areas to consider when exploring the lived experiences and narratives of new caregivers and support members: How was the diagnosis communicated to you? What meaning have you tried to make of the

diagnosis? Who was involved in your care team during the

initial stage of the diagnosis? How have you and your family handled the

caregiving responsibilities? (open to outside help or choosing to handle needs within the family system)

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Determining the Individual’s Style of Caregiving

In caregiving, there is truly no “one size fits all” approach. Individuals offer care to their loved ones in a variety of ways and have a unique routine that works in sync with the diagnosed member.

Caregivers must also balance the tasks of their personal family, work and social obligations with the increasing demands of caring for their loved one.

Providing encouragement and validating the strengths of caregivers in their roles is an important aspect in the early stages of caregiving.

Assessing Resources and Support System Many first time caregivers feel the need to solely

take on all caregiving tasks and assume full responsibility for their loved one.

It is important not only for caregivers to get a break from the caring role, but to also receive comfort and support in their own lives.

Alzheimer’s Disease is truly a systemic disease, one where changes in the physiology in one person, affects the physical, psychological and social aspects of others members within the family unit.

Questions?

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References Aguirre E, Spector A, Streater A, Hoe J, Woods B and Orrell M (2011). Making a Difference 2.

Hawker Publications: UK. Chapman, S. B., Aslan, S., Spence, J.S., DeFina, L. F., Keebler, M.W., Didehbani, N., Hanzhang, L.

(2013). Shorter term aerobic exercise improves brain, cognition, and cardiovascular fitness in aging. Frontiers in Aging Neuroscience, 12.

Heyn, P., Abreu, B.C., & Ottenbacher, K.J. (2004). The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis. Archives of Physical and Medicine Rehabilitation, 84(10), 1694-1704.

Khoo, Y.J., Schaik, P. & McKenna, J. (2014). The Happy Antics programme: Holistic exercise for people with dementia. Journal of Bodywork and Movement Therapies, doi: http://dx.doi.org/10.1016/j.jbmt.2014.02.008

Mozes, A. (June 5, 2014). Yoga, meditation may help dementia patients and caregivers alike. Consumer Health News. http://bi.galegroup.com.ezp.slu.edu/essentials/article/GALE/A370354293

Nelson, M. E., Rejeski, W. J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C., Macera, C.A., Castaneda-Sceppa, C., (2007). Physical activity and public health in older adults: Recommendation From the american college of sports medicine and the american heart association. Circulation, 116 (9),1094-1105.

Spector A, Thorgrimsen L, Woods B and Orrell M (2006). Making a difference: An evidence-based group programme to offer Cognitive Stimulation therapy (CST) to people with dementia. Hawker Publications: UK

Images retrieved from Google Images or taken during CST group at Perry County Hospital, Perryville MO