Cognitive Stimulation Therapy for Dementia

History, Evolution and Internationalism

Lauren A. Yates, Jennifer Yates, Martin Orrell, Aimee Spector, Bob Woods, Lauren A. Yates, Jennifer Yates, Martin Orrell, Aimee Spector, Bob Woods

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351805469
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Cognitive Stimulation Therapy (CST) has made a huge global, clinical impact since its inception, and this landmark book is the first to draw all the published research together in one place. Edited by experts in the intervention, including members of the workgroup who initially developed the therapy, Cognitive Stimulation Therapy for Dementia features contributions from authors across the globe, providing a broad overview of the entire research programme.

The book demonstrates how CST can significantly improve cognition and quality of life for people with dementia, and offers insight on the theory and mechanisms of change, as well as discussion of the practical implementation of CST in a range of clinical settings. Drawing from several research studies, the book also includes a section on culturally adapting and translating CST, with case studies from countries such as Japan, New Zealand and Sub-Saharan Africa.

Cognitive Stimulation Therapy for Dementia will be essential reading for academics, researchers and postgraduate students involved in the study of dementia, gerontology and cognitive rehabilitation. It will also be of interest to health professionals, including psychologists, psychiatrists, occupational therapists, nurses and social workers.

Part I
Overview of CST and related approaches

Chapter 1
Introduction

Aimee Spector

CST: development of the initial concept

CST was effectively ‘conceived’ twenty years ago. A timely editorial entitled ‘Tacrine and psychological therapies in dementia – No contest?’ (Orrell and Woods, 1996), presented an invaluable snapshot of the time. At this point, Tacrine (a previously used drug for dementia) and other potential drug therapies were evaluated through large, robust randomised controlled trials (RCTs). In stark contrast, ‘psychological therapies’, which included specific programmes such as Reminiscence or environmental manipulation, just did not have the evidence base. Research was primarily small scale, uncontrolled, and riddled with methodological flaws; and there were no evidence-based treatments which also had a replicable treatment manual. As a result, clinicians and policy makers were focusing on pharmacological therapies, despite modest benefits and risks of adverse effects, stating that ‘gold-standard’ evidence was simply not available for psychosocial alternatives. The vision was to develop a novel ‘psychological therapy’ and evaluate it in a trial adhering to the same methodological expectations of any drug trial. The contest was on!

And this is precisely what happened. Orrell and Woods successfully secured funding to develop and evaluate probably the largest trial of any psychosocial intervention at that time and I was recruited as the lead researcher and PhD student. The aim was to build an intervention based on what we already knew, largely anecdotally, was working. We systematically reviewed the literature on two widely used psychological interventions: Reality Orientation (RO) and Reminiscence Therapy (Spector et al., 1998; Spector et al., 2000), as well as scoping the literature on all the key therapies available. In order to develop the intervention, the workgroup pulled out what appeared to be the best techniques from the more effective therapies, combining these together into one programme. Our work was most influenced by the largest, most scientifically robust, and effective study at the time. This randomised controlled trial (Breuil et al., 1994) was led by a team at the Hopital Broca in Paris, who described their therapeutic technique as ‘Cognitive Stimulation’. This differed from the more traditional ‘RO’, (‘the presentation and repetition of orientation-based information’), which previously dominated the literature. Whereas RO had a more repetitive element, Breuil’s Cognitive Stimulation approach seemed to have unique properties, more implicitly engaging people in enjoyable group cognitive tasks. Their trial included 56 people with dementia and found signifi-cant improvements in cognition when presenting them with tasks such as word association and object categorisation.

Table 1.1 CST sessions

Session 1:	Physical games	Session 8	Being creative
Session 2:	Sound	Session 9:	Categorising objects
Session 3:	Childhood	Session 10:	Orientation
Session 4:	Food	Session 11:	Using money
Session 5:	Current affairs	Session 12:	Number games
Session 6:	Faces/scenes	Session 13:	Word games
Session 7:	Associated words	Session 14:	Team games

Our examination of the literature led to the development of a 14-session programme, designed to run twice a week for seven weeks. This ‘dose’ of CST was determined by the past literature and by what was feasible within the confines of the research funding and timetable. Both the content and name of the current CST programme was largely based upon the foundations of Breuil et al.’s innovative work, while also including elements of RO, Reminiscence, and multi-sensory stimulation. Each session was given a theme, with a choice of activities within each to be adapted for the interests and abilities of the group. Table 1.1 provides a summary of the group CST sessions.

Twenty years on: the CST journey

The CST research programme and individual studies will be described throughout this book, but a brief summary follows. The initial CST study (Spector et al., 2003), described in Chapter 4, was a single-blind, multi-centre RCT including 201 participants. It demonstrated significant improvements in cognition and quality of life (QoL) for those participating in the 14-session programme when compared to those receiving usual care. Further, complex economic analysis, which considered the cost of running CST groups in addition to the differences in use of services between the treatment and control groups, showed that CST was cost-effective (Knapp et al., 2006). This early CST work led to many questioning whether such benefits could be maintained over a period beyond seven weeks. Consequently, we developed the ‘Maintenance CST’ (MCST) programme, consisting of 26 additional, weekly sessions designed to follow from the initial (more intensive) CST programme. This was evaluated through another RCT with 236 people with dementia. It demonstrated that QoL can continue to significantly improve for up to six months if people receive ongoing CST, and that activities of daily living can improve for three months (Orrell et al., 2014).

The qualitative effects of group CST, discussed in Chapter 8, have been evaluated through interviewing 38 people (those with dementia, family carers, and care staff) about the experience of CST groups (Spector et al., 2011). Results showed that positive experiences of being in the group (such as feeling able to talk in a non-threatening environment) were really valued, and that benefits in everyday life were evident, including noticeable improvements in concentration and alertness. The neuropsychological changes have been explored in more detail (Spector et al., 2010; Hall et al., 2013) – see Chapter 9, as have models of implementation (Streater et al., 2016), discussed in Chapter 6. Most recently, we have developed and evaluated a one-to-one, carer-led CST programme (iCST), Orgeta et al., 2015). This 25-week, 75-session programme led to significant improvements in carer QoL and in the relationship between the person with dementia and their carer. However, the primary outcomes (cognition and QoL for the person with dementia) did not change. Uptake of the intervention was low, with an average of 33 sessions being delivered and a quarter of the treatment participants receiving no sessions. This may well have impacted on the findings, which are discussed in Chapter 5.

CST in the UK: how does it feature?

The seminal CST study was possibly the largest published trial of any psychosocial intervention at the time and showed significant improvements in cognition and quality of life. The Department of Health’s ‘National Institute of Clinical Excellence’ (NICE) issued their guidelines for dementia in 2006, specifically referencing the 2003 CST study. NICE stated that

People with mild to 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 prescribed for the cognitive symptoms of dementia.

This was the only non-pharmacological treatment recommended for the cognitive symptoms of dementia, and crucially, there were no such recommendations prior to this. The additional economic analysis, led by colleagues at the London School of Economics (LSE), was novel and likely to have had an important impact on NICE’s recommendations. In fact, a recent review suggests that this and the more recent economic analysis accompanying the MCST trial (D’Amico et al., 2015) were the only trials of Cognitive Stimulation to formally analyse costs (Streater et al., 2016).

An important step to enable the widespread implementation of CST has been the publication of four training manuals. Following the initial publication of a manual in the United States entitled ‘Our time: an evidence based group program to offer cognitive stimulation to people with dementia – manual for group leaders’ (Spector et al., 2005), there have been three UK manuals published through Hawker Publications. ‘Making a difference’ (Spector et al., 2006) describes the initial, 14-session CST programme and ‘Making a Difference 2’ (Aguirre et al., 2012) includes the MCST programme and a training DVD. Crucially, the ‘key principles’ of CST (see Table 1.2) were more formally introduced in this second manual. This was driven by clinical feedback, suggesting that the techniques of CST and clarification of how it was both similar and different to other therapies, was needed. ‘Making a difference 3’ (Yates et al.,

Table 1.2 Key principles of CST

Key principle		Description/rationale	Applied example
1	Mental stimulation	Getting people’s minds actively engaged, pitching tasks at a level whereby people are suitably stretched yet do not feel deskilled.	Asking people to calculate their score in the ‘physical games’ session by adding numbers.
2	New ideas, thoughts, and associations	Continually encourage new ideas, thoughts, and associations through making new semantic links with material.	Asking people to think of similarities and differences when shown two or more faces in the ‘faces’ session.
3	Using orientation, but sensitively and implicitly	Integrating time, place, and person-related information into general discussion and activities.	Tasting seasonal fruit in the summer (‘food’ session), Christmas word games (‘word games’ session).
4	Opinions, rather than facts	Always asking for opinions before factual information. Opinions cannot be wrong and are more engaging to discuss.	Asking views on political or topical issues within the ‘current affairs’ session.
5	Using reminiscence as an aid to the here-and-now	Reminiscence itself promotes well-being, but it also ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• Contributors
• PART I Overview of CST and related approaches
• PART II The CST research findings
• PART III The CST process – how does it work?
• PART IV CST: an international perspective
• Index