Cognitive stimulation – an effective intervention to improve quality of life and cognition in people with mild to moderate dementia

Disgrifiad o Effaith

CST is recommended and widely used within the UK and internationally.
Current UK guidelines recommend the widespread implementation of CST. The National Institute
for Health and Clinical Excellence Guidelines (5.1), which set the standards for practice in the NHS
in England and Wales, state that CST groups should be made available to all people with mild to
moderate dementia, irrespective of any anti-dementia medication prescribed. This is the strongest
recommendation in the guideline relating to non-pharmacological therapies, and, as this was a joint
guideline with the Social Care Institute for Excellence, also applies to the social care context.
Although originally published in 2006, these guidelines have been reviewed in 2011-2012 and
continue to stand as current best practice. In Scotland, the Scottish Intercollegiate Guidelines
Network (5.2) national clinical guideline on dementia similarly recommends cognitive stimulation,
and in its booklet for patients with dementia (revised 2011) states: “You should be offered cognitive
stimulation as part of your treatment.” Other influential bodies that advocate CST include, in the UK, Alzheimer’s Research UK (5.3) and, at an international level, Alzheimer’s Disease
International (ADI). CST was strongly endorsed in ADI’s World Alzheimer’s Report (2011) for the
early stages of dementia (5.4). This report, available in English, Chinese, Arabic, German and
French, has far-reaching influence and impact and helps to influence health and social care policy
worldwide, increasing awareness of the challenge of Alzheimer’s disease and dementia to society.
CST is not a cure for dementia, but the small changes in cognitive function (especially in language)
and quality of life consistently identified in research studies can make a difference in everyday life:
“…CST was a lifeline for us – the group restored her confidence. She felt she was doing something
to help herself…” (Daughter of person with dementia attending CST groups – Mail on Sunday,
December 13, 2011). Our studies have shown that the differences in cognitive function are of the
same order of magnitude as those associated with the currently available medication. The costeffectiveness
of CST is a powerful argument for its implementation. Our primary economic
evaluation (3.5) indicated CST is more cost-effective than usual care when looking at benefits in
cognition and quality of life. Beyond this, the NHS Institute for Innovation and Improvement
published an economic evaluation in 2011, concluding that CST could save the NHS over £54.9
million per annum over the use of anti-psychotic medication (5.5).
A variety of measures show that CST is now in wide use.
A National Audit Office Report in 2007 (5.6; the most recent relevant report) stated that structured
group cognitive stimulation for dementia was used regularly by 36% of community mental health
teams in England in early stage dementia, by 33% in mid stage and by 20% in late stage dementia.
This translates to CST being used in 2013 by over 200 teams in England, assuming a modest 25%
growth over this period. CST is offered to people with dementia, for example, in NHS Trusts in
Camden and Islington, Cardiff, Cornwall, South Essex, Norfolk and Waveney, Northampton and
Nottingham amongst many others. The ‘Dementia Tsar’ for England (National Clinical Director for
Dementia, Department of Health), Professor Alistair Burns has commended cognitive stimulation
(5.7) for use in a variety of settings.
The “Making a Difference” CST manual (5.8) for group leaders is used in care homes, day care
centres, hospitals and community settings by family carers and staff carers, occupational therapists
and nurses involved in running activities for people with dementia. The manual has been translated
into a number of languages (e.g. Japanese, Spanish, Italian, German, Portugese, Dutch and
Swahili). ‘Making a Difference – 2’, a manual for maintenance cognitive stimulation groups was
published in 2011 by Hawker Publications. Over 5000 copies of the manuals have been sold (twothirds
since 2008). Training events are frequently held e.g. under the auspices of Dementia UK, in
London, for example (5.9) with over 300 people being trained since 2009.
CST is being used elsewhere internationally, for example in Australia, Hong Kong, Italy, Japan,
and New Zealand. Obtaining figures of how many people with dementia have benefitted from CST
is difficult, of course, as such statistics are not routinely collected. However, in one region of Italy,
Emilia Romagna, the annual report on the Regional Dementia Project indicates that 1,379 people
with dementia living at home took part in cognitive stimulation in the previous 12 months. This does
not include people with dementia taking part in groups in day centres or nursing homes (5.10).
Given that there are estimated to be 36 million people living with dementia globally (750,000 in the
UK), and that these figures are growing with the growth of the numbers of people surviving to live
into the ages of greatest risk (80 and above), the potential for CST to continue to influence the lives
of thousands of people is clear, even if it were only to reach a modest proportion of those affected.
We therefore consider an estimate of 50,000 beneficiaries between 2008-2013 to be conservative

Crynodeb Effaith ar gyfer y Cyhoedd

There are very few evidence-based psychological interventions for people with Alzheimer’s
disease and other dementias. Of these, cognitive stimulation has the strongest evidence-base.
Developed by Bob Woods (Bangor University) and Martin Orrell (UCL) in the late 1990s, the
approach has proven effective in maintaining both cognitive function and quality of life.
Recommended in guidelines around the world for use with people with mild to moderate dementia
as the major evidence-based non-pharmacological intervention, it has assisted literally thousands
of people with dementia and their carers globally to have a better quality of life both before and
since 2008.

Disgrifiad o'r ymchwil sylfaenol

Psychological interventions for people with dementia have been described for over 50 years, but
the research focus has been largely on developing pharmacological approaches. Studies of
psychological approaches have been very limited by comparison, with small sample sizes and a
lack of rigorous methodology making health service commissioners reluctant to fund their
implementation.
In 1996, Prof. Bob Woods moved to Bangor University from UCL to take up the first UK Chair in
Clinical Psychology with Older People. In a sustained collaboration with Prof. Martin Orrell (at
UCL), Woods’ programme of research set out to evaluate the effectiveness of psychological
interventions for people with dementia, producing evidence of comparable quality to that from trials
of the emerging pharmacological interventions. This joint programme of work has had several
components underpinning the impact achieved:
1) Intervention development: an intervention had to be designed and standardised so that it could
be delivered consistently and reliably, whilst maintaining respect and dignity. In order to build on
the best of what had gone before, we undertook two systematic reviews, published in 2000 by the
Cochrane Collaboration, on Reality Orientation (an early cognition-based approach from the USA)
[3.1] and Reminiscence Therapy. From the effective components of these, coupled with 20 years
of experience of these approaches brought to the team by Bob Woods, a new intervention called
‘cognitive stimulation therapy’ (CST) was developed, offering a standardised programme of group
sessions, within a person-centred framework of respect and individual choice.
2) Feasibility: the new approach was next tested for feasibility in a small-scale study, and the
programme and treatment manual adapted and adjusted accordingly in the light of patient and staff
feedback [3.2].
3) Outcome measures: to enable comparison with drug trials, standard cognitive function
measures were used. However, for the approach to be clinically useful it needed to also
demonstrate an impact on the person’s well-being and quality of life (QoL). Accordingly, we
evaluated the use of a then-new QoL self-report measure for people with dementia from the USA
[3.3] and showed its applicability and validity in the UK.
4) Effectiveness and cost effectiveness: following the previous steps, a rigorous randomised
controlled trial of CST, with a parallel health economic evaluation, could then be undertaken. At the
time this was one of the largest trials of such an approach in the world [3.4, 3.5]. It demonstrated
that CST produced potentially cost-effective improvements in QoL and cognitive function.
Impact case study (REF3b)
Page 2
5) Mechanisms: these positive results led to further exploration of mechanisms of change,
especially as QoL and cognitive function tend to be unrelated in people with dementia. Further
analyses indicated that cognition mediates the improvements in QoL [3.6] and highlighted areas of
cognition showing most change.
6) Wider implementation: in 2012, we completed the first Cochrane review of cognitive stimulation
with people with dementia [3.7], indicating that Bangor/UCL findings in relation to improved
cognition and well-being are replicable by research groups internationally.
7) Further development of CST continues, with National Institute for Health Research funded trials
of maintenance CST (the effects of 8 months of treatment) and of individual, family-care delivered
CST.

Statws effaith	Ar Gau
Dyddiad effaith	2006 → 2013
Categori effaith	Ansawdd Bywyd / Iechyd, Cymdeithasol, Polisi a Gwasanaethau Cyhoeddus
Lefel yr effaith	Budd