3.1 What is Cognitive Stimulation Therapy?

Aim

The traditional non-pharmacological or behavioural interventions for people with dementia will be briefly described and Cognitive Stimulation Therapy will be extensively analysed.

Learning outcomes

After completing the module, you will be able to:

• Recognize the different non-pharmacological therapies that are available, including CST,
• Understand what CST is.

Introduction

Dementia has become one of the most challenging global health problems ^[1]. Non-pharmacological interventions in combination with pharmacotherapies have been widely used for the management of dementia. More specifically, the non-pharmacological or behavioural interventions aim to improve or at least maintain the individual’s cognitive function, enable the person to continue to perform usual activities of daily living, and/or address behavioural symptoms that often accompany memory impairment (e.g. depression, sleep, agitation, aggression, etc) ^[2].

Cognitive Stimulation Therapy (CST) is a psychosocial intervention that offers mental stimulation and enjoyable activities to people with dementia.

3.1.1 Non-Pharmacological interventions for dementia

There are many non-drug interventions to help people with dementia improve their memory and thinking skills and deal with memory loss. One of the psychosocial therapies is Cognitive Stimulation Therapy (CST), which has the best evidence-base for improving some of the cognitive symptoms of dementia and for also improving the quality of life. However, before the extended analysis of the CST, it is worth having a brief review of the best known non-pharmacological treatment options for cognitive impairment.

• Reality Orientation (RO) is one of the first non-drug interventions that aim to decrease confusion and behavioural symptoms in people with dementia by orienting the individual to time, place, and person-related information. RO can be of a continuous 24-hour type, whereby staff orientates the patients to reality, or of a ‘classroom’ type, where groups of elderly people meet regularly to engage in orientation-related activities. A prominent focus of this classroom is often the ‘Reality Orientation board’, which typically displays information such as the day, date, weather, name of next meal, and location etc. Specific topics included on the board consist of using money, word games, use of maps, categorizing words/items, puzzles, present-day information, and famous faces. The therapy focuses on repeatedly reminding patients of specific information using themes (such as childhood and food) to create continuity between different bits of information.

Review: There is some evidence for its effectiveness but this intervention is rarely used in practice nowadays. More specifically, a Cochrane review found that RO was associated with significant improvements in both cognition and behaviour, but also identified the need for large, well-designed, multi-centre trials ^[3,4].

• Reminiscence Therapy elicits recall of past events, activities, and memories through the use of tangible aids such as pictures, familiar objects from the person’s past, music, and movies. While remembering recent memories (e.g. what one had for dinner) may prove difficult for individuals with dementia, long-held memories of personal importance can remain easily accessible. Reminiscence therapy works by encouraging people to revisit moments from their past.

Review: Whilst the criticism has shown that reminiscence therapy can improve outcomes in cognitive function, interaction, quality of life, and mood, its effects are inconsistent, often small in size, and differ considerably across settings and modalities ^[5,6].

• Validation Therapy is a form of “therapy for communicating with persons diagnosed with Alzheimer’s disease and related dementia”. Focused on the emotional meaning of what people say or do, validation therapy suggests that individuals with dementia experience confusion in order to avoid stress, boredom, loneliness, and often as an escape from reality. Validation therapy is found to alleviate stress, promote contentment and empathic listening, and decrease behavioural disturbances. This therapy pays less attention to what is right or not and more so to validate the person’s feelings and emotions in their moment of confusion.

Review: There is a lack of evidence ^[6,7].

• Multisensory Stimulation, previously known as snoezelen, is an approach aiming to stimulate all the senses through sound, touch, taste, smell, and visual images. The clinical application of snoezelen has been extended from the field of learning disability to dementia care over the past decade. The rationale for its use lies in providing a sensory environment that places fewer demands on intellectual abilities but capitalizes on the residual sensorimotor abilities of people with dementia. A typical snoezelen room consists of calming music, visual stimulation from fibre optics and lava lamps, aromatherapy, etc.

Review: Some evidence-bases show immediate effects on mood during the sessions, which however are not maintained over time. Too much stimulation can be unhelpful or distressing. This intervention can be incorporated into other techniques ^[8,9].

3.1.2 Cognitive Stimulation Therapy (CST) – What it is?

Cognitive Stimulation Therapy (CST) is a brief, non-pharmacological and evidence-based intervention for people with mild to moderate dementia. CST was designed in UK by Dr. Aimee Spector and several dementia experts following extensive evaluation of research evidence. It was designed using the theoretical concept of Reality Orientation Therapy, which through the systematic reviews was found to have the most significant results and the best-defined intervention. More precisely, among the alternative therapies available, it is generally accepted that CST has the best evidence base for improving some of the cognitive symptoms of dementia and also the quality of life of the person living with dementia.

The aim of CST is to improve cognitive function through themed activities, usually carried out for several weeks in small groups or individually, led by a trained professional, a therapist, or a carer. Every session covers a different topic and is designed to improve mental abilities and stimulate skills including memory, language, and executive function through tasks such as word association, categorization, and discussion of current affairs.

CST is important because not only does it stimulate the mind but also the group sessions offer the opportunity to share experiences and talk with other people with dementia in a relaxed and supportive environment. Being part of the group helps participants to build their self-esteem, so they feel better about themselves and more confident to join in conversations and activities. CST is a guided practice based on a set of standard tasks designed to reflect particular cognitive functions with a range of difficulty levels to suit the individual’s level of ability.

The intervention is usually conducted in a group involving 14 sessions of activities such as current affairs, word associations, and categorizing objects. They are designed to be relaxed, fun and to create opportunities for people to gain knowledge, express their views and work with others in a sociable setting. More specifically, the intervention does not aim to test factual answers but to encourage participants to give their opinions and thus to actively stimulate and engage them in an optimal learning environment with several social benefits ^[12].

Synopsis

Key points:

• CST is considered as the non-pharmacological therapy with the strongest evidence-base.
• CST has been found to help the memory and thinking (cognitive) skills of people with mild to moderate dementia.