Cognitive Stimulation Therapy

(CST)

for people with dementia

Dr Aimee Spector

Senior Lecturer in Clinical Psychology

Research Department of Clinical, Education &

Health Psychology,

University College London

E-mail: a.spector@ucl.ac.uk

The context

No cure for dementia. Even when a cure is found, it may

take years to put into practice.

People live 3 - 11 years from diagnosis of dementia to

death (Xie et al, 2008). Priority is improving care and

quality of life for these people.

Drug treatments can be a lifeline, yet are not suitable for

all, have limited effectiveness and can have adverse

effects.

In the past 20 years, non-pharmacological treatments

have increasingly been part of the picture.

Background

Dementia primarily conceptualised from a

medical perspective (Lyman, 1989).

Considered an organic disease for which

assessment, diagnosis and treatment guided by

medical interventions.

Prior to the late 1990’s, no psychological

interventions with a robust evidence-base.

“Tacrine and psychological therapies in

dementia: No contest?” (British Journal of

psychiatry, Orrell & Woods, 1996)

What is CST? A brief, evidence-based group intervention for people

with mild to moderate dementia.

14 themed sessions, typically twice a week for 7 weeks.

Includes word association / categorisation, current

affairs, food, number games.

Key aims: to improve cognitive functioning through using

techniques that exercise different cognitive skills.

Achieved through a variety of means including executive

functioning tasks (e.g. categorisation), multi-sensory

stimulation and reminiscence as an aid to orientation.

Based on concept of ‘use it or lose it’: brain needs to be

exercised in order for skills to be retained.

Improved cognitive functioning is associated with

increased quality of life and independent living.

Aims of Cognitive Stimulation

Therapy (CST) study

To 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.

Project ran at UCL Department of Psychiatry and Behvavioural Sciences, led by Professor Martin Orrell.

Development of CST: the steps

Stage 1: Cochrane systematic reviews

Stage 2: Literature reviews to guide

development of intervention

Stage 3: Pilot study -> modification

Stage 4: RCT evaluating effectiveness of

CST (including i. cost-effectiveness

analysis and ii. direct comparison with

drugs).

Development of CST: the steps

Stage 5: Implementation work (website,

manuals, training, implementation

research)

Stage 6: Qualitative research

Stage 7: Long-term follow-up (MCST trial)

Stage 8: RCT evaluating individualised

CST (iCST)

Stage 1: Cochrane reviews Two key psychological interventions for dementia

identified in the literature: Reality Orientation and Reminiscence.

Reality Orientation: The presentation and repetition of time, place and person related information. Focuses on rehabilitation through improving orientation.

Cochrane review showed evidence for its effectiveness in cognition and behaviour (Spector et al, 1998).

Reminiscence: Discussion about the past, often using prompts (e.g. pictures, objects, music) with groups or individuals (e.g. life review). Focuses on long-term memory, relatively preserved in dementia.

Cochrane review(s) (Spector et al, 1998; Woods et al, 2005) showed evidence for effectiveness in cognition and mood.

Stage 2: Literature reviews to

develop intervention

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

Evaluated quality of research and focused on papers showing strongest methodology and outcomes.

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

Named ‘CST’ as it was largely based on Breuil’s

‘Cognitive Stimulation’ (1994)

Stage 3: Pilot study

Pilot programme evaluated with 27 people (17 treatment,

10 controls) in four settings (Spector et al, 2001).

Described 45 minute group sessions(5-8 per group)

Within broad themes there are flexible activities to cater

for group’s needs and abilities.

Positive trends in cognition, anxiety and depression.

Used outcomes to modify programme, including

increasing cognitive element.

Modified into 14 session programme, twice a week for 7

weeks.

Stage 4: RCT

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

201 participants with dementia in 23 centres (18 residential care homes, 5 day centres)

Results

Significant improvement in cognition using MMSE (p = 0.04) and ADAS-Cog (p = 0.01) (comparing CST with TAU).

ADAS-Cog: trends in all subscales (memory, language, praxis) but only significant subscale was language (including naming, word-finding and comprehension).

Stage 4: RCT Significant improvement in quality of Life using the Qol-

AD (brief, self-rated measure covering 13 areas of QoL) comparing CST to TAU (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 comparable to dementia medication (cholinesterase inhibitors – Rivastigmine, Galantamine, Donepezil) using a ‘numbers needed to treat’ analysis.

CST shown to be cost effective, in study run in conjunction with London School of Economics (LSE) (Knapp et al, 2006).

Stage 5: Implementation work

Published 3 manuals (Spector et al 2005,

Spector et al 2006, Aguirre et al 2012)

Developed CST website: www.cstdementia.com

Developed one-day CST training course.

Research trial on implementation (Streater et al,

2014) – looking at effects of manual, training and

outreach support on implementation.

The UK manuals

Stage 6: Qualitative Research

34 participants (people with dementia, carers and staff) participated in individual interviews and focus groups (Spector et al, 2011).

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).

Stage 7: Long-term follow-up

(MCST trial)

Big question: what happens next? (Orrell et al,

2014)

237 people with mild to moderate dementia who

had previously received CST (14 sessions).

Intervention: weekly, 24-session programme of

Maintenance CST (MCST) compared to TAU.

MCST group significantly improved in quality of

life at 3 and 6 months, and in activities of daily

living at 3 months.

Stage 7: Long-term follow-up

(MCST trial)

Cognition was higher in MCST group but the

difference was not significant.

Greatest improvements in the medication 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.

Stage 8: RCT evaluating

individualised CST (iCST)

iCST manual follows similar principles to group

CST manual.

Large trial at UCL, involving family carers and

health professionals.

Results out soon….

iCST manual will be available in November 2014

through Hawker Publications.

What is the outcome of all this

research?

NICE guidelines ( 2006)

“People with mild / moderate dementia should be given the opportunity to participate in a structured group cognitive stimulation programme.

Should be commissioned and provided by a range of health and social care workers with training and supervision.

Should be delivered irrespective of any anti-dementia drug received.”

NHS Institute for Innovation &

Improvement (Matrix Evidence, 2011)

“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 for NHS.

Use of CST in the UK

National Memory Services Accreditation

programme (NMSAP) audit (2013): CST

used in 66% of UK memory clinics.

CST training : around 104 courses, mainly

commissioned by NHS trusts, around

2400 people trained in CST.

Care home residents – the forgotten

people?

CST internationally

The World Alzheimer’s Report (Alzheimer’s Disease

International, 2012), stated that CST should routinely be

given to people with early stage dementia.

CST manual has been translated into several languages

including Japanese, Spanish, Italian, German,

Portuguese, Dutch, Norwegian and Swahili.

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, Nigeria, Portugal,

Singapore, South Korea and Turkey.

CST internationally

‘International research centre at UCL’ currently

being developed.

Our team recently published guidelines for

adapting CST to other cultures (Aguirre et al,

2014).

This draws from our work in Japan (Yamanaka

et al, 2013) Nigeria and Tanzania, and UK

translation into Swahili.

MRC framework for complex

interventions (Craig et al, 2008)

What does CST do?

Aims to be mentally stimulating, yet for people to feel empowered rather than de-skilled

Always 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, RO board

Continuity and consistency between sessions helps support memory

Implicit (rather than explicit) recall, e.g. famous faces

Using orientation, but sensitively and implicitly

Opinion 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 way

Thinking about word construction and word association

Stimulates executive functioning through:

Discussion of similarities and differences

Planning and executing stages of a task (e.g. making a cake)

Word association, categorising objects

Can be understood in the context of a Biopsychosocialmodel of dementia (Spector and Orrell, 2010), particularly when considering group factors influencing mood, QoL, social factors, person-centred care, working against a ‘Malignant Social Psychology’ (Kitwood, 1993)

Conclusions

Complex interventions should be developed and

evaluated considering theory, literature and

involve piloting and a full scale trial evaluating

effectiveness and cost-effectiveness.

Many interventions show effectiveness, yet do

not make a clinical impact due to insufficient

implementation.

For all references, see CST website:

www.cstdementia.com