Cognitive Stimulation Therapy (CST) for dementia

Professor Martin OrrellUniversity College London and

North East London Foundation Trust

Bob Woods, Aimee Spector, Elisa Aguirre, Amy Streater, Juanita Hoe, Zoe Hoare, Ian Russell, Charlotte Gardner,

Vasiliki Orgeta, Fara Hamidi, Phoung Leung, Lauren Yates

new generation psychosocial interventions in dementia

Nine principles:• Theory of action and model• Evidence used in development• High quality evaluation – major RCT/systematic review• Unitary intervention – clearly defined• Evidence of effectiveness on key outcomes • Appropriate outcomes (cognition, behaviour, mood, ADL

institutionalisation, quality of life)• Cost effectiveness• Scalable – training/manual/resources• Transferable – across care systems/countries

NICE-SCIE guidance (2006) www.nice.org.uk

• People with mild/moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme … provided by workers with training and supervision … irrespective of any anti-dementia drug received …’

Cognitive Stimulation • Distinguish from cognitive training and cognitive

rehabilitation (Clare & Woods, 2004)

• Cognitive stimulation: – Targets cognitive and social function

– Has a social element – usually in a group or with a family care-giver

– Cognitive activities do not primarily consist of practice on specific cognitive modalities

CST Background• ‘Reality Orientation’ (RO) marked a breakthrough in dementia

care• Criticism of RO: applied in a rote, uninspired way, (Dietch,

Hewitt and Jones, 1989), insensitive to individual needs (Powell-Proctor & Miller, 1982)

• RO Cochrane Review (Spector et al., 2000)- Meta-analysis of 6 RCTs, (125 participants)- Significant improvement in cognition and behaviour following RO,

compared to no treatment or alternative treatment- Need for a treatment which is evidence-based, replicable, cost-

effective and follows principles of person-centred care

The programme1) 14, 45 minute sessions (2 x week, 7 weeks)

2) Participants asked to give a group name

3) RO board

4) Sessions begin with warm up exercise

5) Bridging between sessions, consistency in time, place, participants and facilitators

6) Presenting sessions in a fun and stimulating way

CST trial (Spector et al., 2003)

CST Key Principles

• Orientating people sensitively / when appropriate

• Information processing and opinion rather than factual

knowledge -> implicit learning

• Multi-sensory stimulation

• Flexible activities to cater for group’s needs and abilities

• Using reminiscence (as an aid to here-and-now)

• Building / strengthening relationships

Attrition Rate: n= 201, n=168 at follow up

Significant improvement in the primary outcome measures cognition and quality of life

Improvement in QoL mediated by improvement in cognitive function

Numbers needed to treat for cognition = 6similar to AChEIs

CST trial (Spector et al., 2003)

•23 centres ( 18 residential care and 5 day care)•A multicentre Randomised Controlled Trial (RCT)

Treatment and Control Groups - differences between baseline and

follow up: Cognition (n=201)

MMSEp=0.04

ADASp=0.01

-1

0

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2

3

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ge treatment control

Treatment and Control Groups - differences between baseline and follow up: Quality of Life (n=201)

p=0.03-1

-0.50

0.51

1.5

1

QOL

chan

ge treatment control

No significant results were found for the secondary outcome measures

- Functional ability (CAPE-BRS)- Depression (Cornell)- Anxiety (RAID)

QoL improved more for women than men

Improvement in QoL mediated by improvement in cognitive function

Numbers needed to treat for cognition = 6similar to AChEIs

CST trial: Other results

Cost- effectivenessFew studies have evaluated cost-effectiveness of apsychosocial intervention

Service use was recorded 8 weeks prior to, and during the 8-week intervention and costs calculated

Incremental cost-effectiveness ratio: balancing mean cost difference Between CST and usual activities with changes in

a) Cognition and b) QoLService use levels generally very modest and remained

stable over time

Cost-effectiveness acceptability curve: probability group is cost-effective for a range of values of decision-makers’ willingness to

pay for one point improvements on MMSE/QoL-AD.

0

0.1

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0.3

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0 50 100 150 200

Willingness to pay for additional point on MMSE/QoL scales (£)

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MMSE QoL

Cost-effectiveness (Knapp et al., 2006)

CST is more cost-effective than usual activities using both outcome measures:

• Incremental cost-effectiveness ratio: £75.32 per additional point on MMSE (111 euros), £22.82 per point on QoL-AD (33.2 euros)

• 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

• Need to evaluate potential longer-term effects of CST• Cochrane review no clear evidence of longer-term effects

• Follow on from 7 week/14 session programme

• 16 session weekly programme (45 mins)

• 35 people with dementia

• 2 residential homes had MCST + controls

• 2 residential homes had CST only +controls

Pilot - Maintenance CST (Orrell et al., 2005)

Maintenance CST - MMSE Results(Orrell et al., 2005)

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CST

Baseline7 weeks23 weeks

Pilot - Maintenance CST

• Over 23 weeks people with dementia receiving MCST continued to show cognitive improvements

• Cognition declined in CST only and control groups

• Interpretation limited as it was a pilot study - Groups no randomised - Small sample

• Large multicentre trial is required

Development of the MCST trial programme

Maintenance CST development

• Extract features of research trials which had demonstrated effectiveness

• New included themes : Useful tips (caring from oneself, memory tips, use of calendars, alarms) and Visual Clips from Requena (2007) and Olazaran (2004)

• Development of the evidence-based programme, 24 sessions of maintenance based on the CST and MCST pilot programme sessions plus new identified studies

• Presentation of the draft version 1 in a consensus conference to develop draft version 2 of the manual.

Modelling the programme9 Focus Groups(Aguirre et al., 2010)

• 17 people with dementia, 13 staff and 18 family carers • Inductive thematic analysis to examine user perceptions of the

Maintenance CST programme • Mental stimulating highly valued by PWD, finding it vital in

order to keep them healthy and active.• Most family carers and staff very positive attitudes towards

cognitive stimulation programmes BUT some concerns were raised:

- When use it or lose it doesn’t apply - Concerns with regards lose of confidence, anxiety or sense of

inferiority.

• Positive agreement was found among 14 themes and suggestions were made for the 5 remaining themes.

• Carers and staff rated using money and current affairs very low - felt that using money could be a sensitive topic and current affairs was a theme that people with dementia wouldn't relate to

• In contrast people with dementia expressed a great interest in the using money theme and in the news

Focus Groups results(Aguirre et al., 2010)

RCT of Maintenance CST• Need sample size of 230 people with mild/moderate

dementia. (60 Alzheimer’s Type plus Donepezil)

• 50% sample to be recruited from community and 50% from care homes

• People with dementia will be recruited into CST groups (8 to 10 per group).

• Complete initial CST programme - x2 weekly 45 min sessions for 7 weeks

• Primary outcome measures -cognition and quality of life

Maintenance CST vs. CST

8 to 10 ParticipantsCST group A

8 to 10 participantsTAU

Randomised 236

BASELINE ASSESSMENT

7 WEEKS CST

Twice a week (14 session)

BASELINE ASSESSMENT 2

3 MONTH Follow Up

24 WEEKS MCST

Once a week (24 session)

6 MONTH Follow Up

8 to 10 ParticipantsCST group B

8 to 10 participantsMCST

Randomised 272

CST Predictors of change

• 272 recruited to CST groups as first stage of Maintenance CST Trial and 236 completed 7 weeks

• Improvement 1.09 MMSE points (p < 0.001), ADAS-Cog 2.34 points (p< 0.001)

• Improvement 1.85 DEMQOL points (p < 0.003)• Female gender was associated with higher

improvement • use of ACHEIs did not alter improvement

Maintenance CST Trial – first results

• 236 participants (123 MCST/123 CST only)• After 6 months MCST

– Quality of life better QoL-AD p = 0.04 • After 3 months MCST

– Quality of life better (proxy) DEMQOL p = 0.04, QoL-AD = 0.008

– ADCS-ADL better p = 0.05• MMSE improved in MCST group 0.85 points

• Qualitative study investigating experiences of the people attending CST groups, their carers and group facilitators (N=34)

• Data analysed using Framework Analysis

• Two main themes:' Positive experiences of being in the group’ & ‘Changes experienced in everyday life’

• Experience of CST seen as being emotionally positive

• Most reported some cognitive changes.

• Findings support the mechanisms of change suggested by the previous RCT of CST.

CST mechanisms of change

CST in practice

• Past research in dementia care training have shown variable and limited findings.

• Most studies showing that staff training does not lead to any lasting change.

Method• Survey of 152 people who had attended a one-day CST training

course (50% - 76 responded) after 3 months +• Questionnaire on starting CST groups and obstacles

Measures • Attitude towards dementia (ADQ)• Job satisfaction (JS) • Learning transfer (LTSI)

CST in practice• 27 took up CST (36%) and 49 did not (64%)

• CST group scored significantly better on work environment and ability / enabling on LTSI

• No differences between groups on the other measures

• No relationship between job title, place of work, gender, age or ethnicity and starting CST group

• Individuals with better learning characteristics may be more likely to take up CST following training

• Simple factors such as a lack of staff time and resources may prevent people from doing CST

CST in practice(Spector, Aguirre and Orrell 2010)

• Delivered by carer 2 times a week for 20-30 minutes

• 75 individual CST sessions

• 25 week programme

• Themed activities eg: Number Games

• Manuals and resource workbook

What is the Individual CST programme?

Field testing - Support• Weekly support calls

• Majority of carers have not requested help or advice about the programme, technique, or activities

• Support outside weekly scheduled calls: 2 requests

Barriers

2Health of carer and person

with dementiaMotivation

1Finding the time to

do sessions

Positive outcomes for carersThe programme

has given me more tolerance

We’ve had some nice enjoyable times doing the

activities together

The programme has given me ideas I never would have

thought of

I feel like I have a purpose when

spending time with dad

I’m glad we have iCST, it has given

us a lot of help

It made us realise that parts of mum’s memory work, and

others don’t

It has taught us how to work on the things

that matter, and ignore the things

that don’t

I cannot say how much of a difference this has made to my relationship with my

mother

Positive outcomes for people with dementia

My dad’s mood is lifted during

sessions

My mum seems more confident and like her old

self

Mum is more alert after sessions

Mum’s conversational skills seem to

have improved

Mum is enjoying the activities

Recruit N= 306 participants

Baseline data collectionRemote

randomisationN= 153 individual

CSTN= 153 TAU

Outcome measures at 13 weeks

Follow up at 26 weeks N= 260

Methods / Design of Main RCT

Cochrane Review 2012Woods, Aguirre, Orrell, Spector

• 15 trials, 407 treatment and 311 controls participants• Length of intervention varied: 1 to 24 months• MMSE difference at follow up = 1.74 points (Z = 5.57, p

< 0.00001)• Holden Communication Scale SMD = 0.47 (Z = 3.22, p =

0.001) • Wellbeing/QoL SMD = 0.38 (Z = 2.76, p = 0.006)• Depression (GDS) SMD = 0.34 (Z = 1.88, p = 0.06)• No benefits to ADL, behaviour, or carers measures

Future CST work• ADI World Alzheimer Report recommends CST• Training evaluation part of the SHIELD programme• Defining cognitive change - neuropsychology of CST• Individualised CST for family carers: home-based work

CST website: www.cstdementia.com

Join the CST Network - email a.spector@ucl.ac.uk