3.3 Development of CST
In this topic, you will learn about CST design, pilot implementation, evaluation, and its main results.
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.
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 lay out the steps leading to the development of CST.
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.
Five basic principles were followed while designing the CST program:
- Experiential learning using all five senses.
- Focused psychological interventions were relevant to everyday living.
- Acknowledgment of the emotional lives and enhancement of the cognitive skills of people with dementia.
- Implicit learning, rather than explicit ‘teaching’.
- The reciprocal, psychological process 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 .
Having developed the initial CST program, its practical feasibility needed to be evaluated. This was tested at first on a small scale to get some initial results and indicate possible failures that could occur to the full trial. Accordingly, the CST program began with feasibility and pilot study conducted in one day centre and three care homes. Then, it was evaluated as a multi-centre randomized controlled trial (RCT) in 23 centres (residential homes and day centres).
The results of the trials showed that CST led to a significant impact on people’s cognitive functioning, mood, quality of life, and 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’ . 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 a person living 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 mentioned, 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 .
iCST intervention consists of structured activities, like CST, and follows approximately the same principles of group CST (Figure 2) .
Figure 2: iCST Key Principles 
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 their 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 .
- 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.
1.List of references
- Medical Research Council. (2000). A framework for the development and evaluation of RCTs for complex interventions to improve health. MRC.
- Woods, B. (2019). Development process In: Yates, A., YatesJ., Orrell M., et al (editors). Cognitive stimulation therapy for dementia: history, evolution, and internationalism. 1st edition. Oxford: Routledge.
- Orrell, M., Forrester, L. T., A. (2019). Group cognitive stimulation therapy. Clinical trials. In: Yates, A., YatesJ., Orrell M., et al (editors). Cognitive stimulation therapy for dementia: history, evolution, and internationalism. 1st edition. Oxford: Routledge.
- Woods, B., Aguirre, E., Spector, A., Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews, 2, CD005562. DOI:10.1002/14651858.CD005562.pub2.
- NICE-SCIE (2006) Dementia: supporting people with dementia and their carers. Guideline - draft for consultation. NICE-SCIE.
- UCL, (2021). Why was the study of iCST done? https://www.ucl.ac.uk/individual-cognitive-stimulation-therapy/why-was-study-icst-done
- Rai, H., Yates, L., Orell, M. (2018). Cognitive stimulation therapy for dementia. https://core.ac.uk/download/pdf/161100598.pdf
- Yates, L. (2019). iCST In: Yates, A., YatesJ., Orrell M., et al (editors). Cognitive stimulation therapy for dementia: history, evolution, and internationalism. 1st edition. Oxford: Routledge.
- UCL, (2020). Interim Guidelines for Virtual Cognitive Stimulation Therapy (vCST). https://www.ucl.ac.uk/pals/sites/pals/files/vcst_interim_guidelines_august2020.pdf
2. Further reading
- https://discovery.ucl.ac.uk/id/eprint/1378587/1/Aguirre.1378587.Redacted_Final_PhD_Thesis_Vol1.pdf (p.28-34)