1. Cognitive Stimulation Therapy (CST) for people with dementia
Ritchard Ledgerd
Clinical Researcher
Acknowledgements: Dr Aimee Spector, Amy Streater

2. Aims of the 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.

3. CST development: literature review
Reality 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)

4. CST development: Literature review
Reminiscence 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.

5. 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, board
Continuity and consistency between sessions helps support memory
Implicit (rather than explicit) recall
Using orientation, but sensitively and implicitly
Opinion rather than facts (which supports idea of validation)

6. 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

7. The CST intervention: Sessions
Physical games
Sound
Childhood
Food
Current affairs
Faces / scenes
Word association
Being creative
Categorising objects
Orientation
Using money
Number games
Word games
Team quiz

8. Example – Famous Faces
Which is the odd one out? Why?

9. CST key principles Mental Stimulation
New ideas, thought and associations
Using orientation, but sensitively and implicitly
Opinions rather than facts
Using reminiscence, and as an aid to the here and now
Providing triggers to aid recall
Continuity and consistency between sessions
Implicit learning
Stimulating language
Stimulating executive functioning
Person centred
Respect
Involvement
Inclusion
Choice
Fun
Maximising potential
Building /strengthening relationships

10. 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

11. 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 dementia
Scored on MMSE (mean = 14)
Did not have significant visual or auditory impairments
Did not have learning disability or major physical health problems
Were not on dementia medication

12. CST Trial: Results
Blind 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).

13. CST Trial: Results Quality 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 measures
Limitations included control group not being homogenous, different staff rating outcomes, no long-term follow-up

14. CST Trial: Comparison with cholinesterase inhibitors
Numbers 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.

15. CST: Cost Effectiveness
CST is more cost-effective than usual activities using both outcome measures:
Incremental cost-effectiveness ratio: £75.32 ( ) per additional point on MMSE, £22.82 ( ) 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

16. 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.

17. 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).

18. 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.
Randomised everyone for CST +
Randomised MCST
Intention to treat

19. MCST continued
Cognition 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.

20. “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.

21. Analysis focused on cost of providing CST.
“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

22. 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

23. 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

24. 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.

25. How CST can be established
Published CST training manuals which include session-by-session plan, equipment required, DVD etc.
Has been adapted e.g. to weekly sessions, outpatients, in community.
CST website:
One-day training course to ensure delivery in standardised, person-centred and effective way.
For all references, see CST website