3.3 Development of CST

Aim

In this topic, you will learn about CST design, pilot implementation, evaluation, and its main results.

Learning outcomes

After completing the module, you will:

• Learn how CST was designed and evaluated,
• Understand the CST trial and the results,
• Comprehend what Individual Cognitive Stimulation Therapy is.

Introduction

CST for dementia is nowadays an accepted and increasingly implemented approach not only in the UK but all over the world. However, you may be surprised to learn that it has taken about 60 years, with some considerable ups and downs along the way, to reach this point. The most effective elements of different therapies, and especially from Reality Orientation Therapy, have been combined to create the CST method. This topic will discuss curtly the steps leading to the development of CST.

A framework has been developed by the Medical Research Council for the development and evaluation of complex interventions to establish clear evidence of the effectiveness of interventions, on which CST design relies. The phases that the MRC framework distinguishes are (1) Phase I: development of an intervention, (2) Phase II: piloting, (3) Phase III: evaluation, (4) Phase IV: implementation (Figure 1) ^[1].

Figure 1: Framework for the development of complex interventions ^[1].

3.3.1 First steps

The first step in creating what was to become CST was to identify the best features of the different therapies, combine them into a single program, which were modified following a pilot study. A total of 28 studies, including studies on orientation, reminiscence, and validation, provided enough details on activities used in the first CST intervention. The decision was taken to initially develop a group-based program, given the apparent effectiveness of Reality Orientation sessions, which was associated with significant improvements in both cognition and behaviour, but also identified the need for large, well-designed, multi-centre trials. It was named ‘CST’ as it was largely based on Breuil’s ‘Cognitive Stimulation’.

Five basic principles were followed while designing the CST program:

• Experiential learning using all five senses to promote cognitive stimulation and memory processes.
• Focused psychological interventions were relevant to the difficulties of everyday living.
• Acknowledgment of the emotional lives and enhancement of the cognitive skills of people with dementia.
• Implicit learning, rather than explicit ‘teaching’. Extensive rehearsal and consolidation of essential information about themselves and their world.
• The reciprocal, psychological process (involving cognitive and emotional states) in which people with dementia and those who care for them learn more about each other’s capabilities and vulnerabilities.

A 14-session program was designed with four phases:

• The senses e.g. sound and music
• Remembering the past e.g. childhood
• People and objects e.g. cookery, famous faces
• Everyday practical issues e.g. money ^[2].

Sessions were planned to last 45 minutes, commencing with a 10-minute opening phase where the group was to be welcomed, the ‘theme song’ sung, current information discussed around a board, and tea and biscuits consumed. This was to be followed by a 25-minute session focusing on the main activity of the day, with the session ending with 10 minutes of consolidation where the discussion and ideas could be summarised, the theme song again, and farewells said.

Having developed the initial CST program, its feasibility needed to be evaluated in practice. This step was performed first on a small scale aiming to shed light on the first results and possible failures that will occur to the full trial and were essential to be avoided. Accordingly, the CST program began with feasibility and pilot study conducted in one day centre and three care homes. The results from the feasibility/pilot study contributed remarkably to the improvement of the CST program. This phase helped to calculate what sample size would be required in the full trial and showed up significant criteria that should be accounted for the improvement of the final implementation of research (choice of participants, levels of activities, feasibility in real-life practice, etc).

Based on these findings, the effects of CST groups on cognition, mood, communication, functioning, and quality of life (QoL) for people with dementia were investigated in a larger scale, single-blind, multi-centre, randomized controlled trial (RCT). A total of 201 people with dementia took part in the RCT within eighteen residential homes and five-day centres in the Greater London area, making a total of 23 groups ^[2,3].

The results of the trial showed that CST led to a significant impact on people’s cognitive functioning, as measured by the Mini-Mental State Examination (MMSE) and the ADAS-COG. These tests primarily investigate memory and orientation, but also language and visuospatial abilities. Further research showed that CST made a significant benefit on language skills including naming, word-finding, and comprehension.

The Cochrane Collaboration, which is viewed internationally as the authoritative source for evidence-based medicine practice, considered regarding the CST that: ‘there was consistent evidence from multiple trials that cognitive stimulation programs benefit cognition in people with mild to moderate dementia, with studies from several countries adding to the evidence base. The implementation of CST was also aided by its recommendation in the NICE-SCIE guidelines (NICE: the National Institute for Health and Clinical Excellence and SCIE: the Social Care Institute for Excellence) on the management of dementia: ‘People with mild/moderate dementia of all types should be allowed to participate in a structured group cognitive stimulation program. . . provided by workers with training and supervision . . . irrespective of any anti-dementia drug received’ ^[5]. Later it was included in the influential Royal College of Psychiatrists’ Memory Services National Accreditation Programme (MSNAP). Finally, it is worth noting that when 34 participants (people with dementia, carers, and staff) were asked about their experiences of CST, they answered that they had positive experiences of being in a group (supportive and non-threatening) and that this program changed their everyday life by improving their mood and confidence (finding talking easier), as well as by changing their concentration and alertness (wanting to attend more activities) ^[4,5].

3.3.2 Individual Cognitive Stimulation Therapy (iCST)

Individual Cognitive Stimulation Therapy (iCST) is a cognitive and psychosocial one-to-one intervention offering mental stimulation and enjoyable activities to people with dementia. With the increasing evidence for the benefits of CST and its uptake in routine services, the need to offer CST through different avenues became apparent. It was acknowledged that CST is not always accessible for those who are either unwilling or unable to attend groups. Taking their needs and wishes in consideration, the individual version of CST (iCST) was developed. Unlike CST, iCST is home based and is facilitated by an informal carer (eg, a family member, friend, or anyone who is close to the person with dementia) or a paid carer (eg, home support worker).

As already seen, CST is recommended by organizations such as Alzheimer’s Disease International and the UK National Institute for Health and Care Excellence. It is based on the evidence-based group Cognitive Stimulation Therapy for people with mild to moderate dementia. iCST provides an opportunity for family carers to be involved in the CST procedure, enhance the caregiving quality, and improve their well-being ^[6].

iCST intervention consists of structured activities, like CST, and follows approximately the same principles of group CST (Figure 2) ^[7].

Figure 2: iCST Key Principles ^[8]

3.3.3 Virtual Cognitive Stimulation Therapy (VCST)

During the Covid-19 pandemic, CST in groups or individual sessions is not feasible. Therefore, home-based CST and iCST were developed. More precisely, online virtual CST/iCST sessions were designed, which are applied according to the pre-existing guidelines and key principles of in-person/group CST.

However, there are some special considerations for virtual CST/iCST. The virtual CST/iCST program is delivered by a person who is familiar with the technology involved in running the virtual sessions and who can also assist the person with dementia (relative or carer) with applying the technology required in their home. The role of a participants’ carer/supporter can vary depending on the people with dementia’s cognitive ability and prior skills with the technology. Carers/supporters input should be valued and encouraged in supporting the participants’ attendance and technological set-up. In addition, they should provide participants with privacy and autonomy once the sessions begin, as would be customary in face-to-face CST.

Any video-conferencing application can be used. Some of the most commonly used platforms are Zoom, Skype etc due to theirs ease of use and low to zero cost. The group format follows the original evidence-based CST or iCST protocol as closely as possible and normally lasts 45-60 minutes plus time to organize (15 minutes). The optimum number of group members for vCST is five; this could be increased as familiarity with the system increases. All activities normally used in CST/iCST sessions may need some adjustment for online use ^[9].

Synopsis

Key points:

• CST was developed through systematic reviews of literature and pilot studies.
• CST has its basis in Reality Orientation Therapy.
• iCST involves one-to-one CST, led by home carers or professionals, and has similar themes to group CST.
• iCST improves the relationship between the person and their carer (rated by the carer) and carer quality of life.
• New challenges to dementia care were created during COVID-19. Virtual CST is an innovation in remote delivery of group/individual CST.