- Martin Orrell, professor of ageing and mental health12,
- Bob Woods, professor of clinical psychology of older people3,
- Aimee Spector, senior lecturer in clinical psychology24
- 1UCL Mental Health Sciences Unit, University College London, London, UK
- 2North East London Foundation Trust, Goodmayes Hospital, Ilford, UK
- 3Dementia Services Development Centre, Bangor University, Bangor, UK
- 4Department of Clinical, Educational and Health Psychology, University College London
- Correspondence to: M Orrell
- Accepted 29 November 2011
Interest is growing in the potential for mental exercises and activities to maintain and improve cognitive function, especially for patients attending memory clinics. However, a recent six week study of online brain training1—using cognitive tasks designed to improve reasoning, memory, planning, visuospatial skills, and attention—found that although specific improvements occurred in each domain, these effects did not transfer to untrained tasks.
Psychological therapies targeting cognitive function in dementia have been in widespread use for several decades. These approaches may involve personalised interventions, such as cognitive rehabilitation (which focuses on coping with deficits and enhancing remaining cognitive skills)2 or cognitive training (which aims to enhance cognitive skills such as memory and attention through practice). More generic approaches include reminiscence, reality orientation, and cognitive stimulation therapy (box).3 Reality orientation, which involved re-teaching information related to orientation to everyday life (such as date, location, and current events), has now been superseded by cognitive stimulation, which uses more implicit methods, with activities including categorisation and word association. Group based cognitive stimulation therapy is now a well established, evidence based, and cost effective approach that can improve cognition and quality of life in people with dementia.3 4
Description of cognitive stimulation therapy
Cognitive stimulation therapy (www.cstdementia.com) is an intervention for people with mild to moderate dementia that is usually delivered by specifically trained staff, who may include occupational therapists and mental health nurses
It can be conducted individually or (more usually) in groups of five to eight people, in settings including care homes, memory clinics, and day centres
Sessions include structured discussions about topics such as current affairs, word associations, and money
The technique 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, usually with the social benefits of a group
A systematic review in the 2011 World Alzheimer Report concluded that cognitive stimulation had the “strongest evidence by far” for cognitive benefits,5 although more research is needed on longer term outcomes, including whether this approach reduces admission to care homes. In the UK, around a third of community mental health services for older people use group cognitive stimulation therapy. However, many people with dementia may be unable to take part in group therapy because they are unsuitable (for example, owing to severe sensory impairments), unwilling to participate, or unable to get to groups, or because they have no access to local groups. Evidence for the ability of other individual psychological interventions (such as cognitive training and cognitive rehabilitation) to improve cognition in dementia is weak. One small single centre randomised controlled trial found that cognitive rehabilitation improved attainment of individually relevant goals in early Alzheimer’s disease6. An updated Cochrane review of cognitive training2 found a lack of evidence of benefit, and the World Alzheimer Report5 concluded that structured cognitive training was ineffective. The recent updated Cochrane review of cognitive stimulation7 found robust evidence for improved cognition, but this finding mostly applied to group treatment, since the review only included one study of individual treatment. Since around 70% of people with dementia living at home also have a family carer, this suggests that individual cognitive simulation training (delivered with the help of a family carer), if found to be effective, should be made widely available.
What is the evidence of the uncertainty?
We searched PubMed for systematic reviews of psychological interventions in dementia using the search terms systematic review, dementia or Alzheimer’s, cognition, psychological, psychosocial, and interventions, from 2004 onwards. We also carried out a search through the Cochrane Collaboration for randomised controlled clinical trials. The search terms cognitive stimulation, reality orientation, memory therapy, memory support, and memory stimulation were used to search the Cochrane Dementia and Cognitive Improvement Group’s specialised register. Four recent systematic reviews5 7 8 9 were identified (table⇓), but only one review looked at individual and group approaches separately.9 The recently updated Cochrane Review 7 included only one randomised controlled trial of individual cognitive stimulation (described as reality orientation in the paper) that was of sufficient quality to be included10 (table). The participants in this trial were people with Alzheimer’s disease on cholinesterase inhibitors who were living at home. The intervention was a standardised programme delivered in the participant’s own home by trained family carers for 30 minutes three times a week over 25 weeks, compared with usual care, and the principal outcome was cognition. Carers were given manual and specific schedules for each session. The study was well designed and multicentre, but follow-up was limited to only six months, and the family carers’ adherence to the intervention was not measured, making it difficult to assess a possible dose effect based on the number of sessions actually received.
Is ongoing research likely to provide relevant evidence?
We searched the European Clinical Trials Database (Eudract), the Clinical Trials database (clinicaltrials.gov), the Current Controlled Trials Database (ISRCTN Register), and the Cochrane Central Register of Controlled Trials. One trial for people with dementia in an acute hospital setting looked at the effects of individual cognitive stimulation on the severity and duration of episodes of delirium, compared with usual care. However, we found no randomised controlled trials of community based individual cognitive stimulation to improve cognition (compared with usual care) except for our own multicentre, pragmatic, single blind, 26 week study (www.controlled-trials.com/ISRCTN65945963). This trial will investigate whether individual home based cognitive stimulation delivered by a family carer to people with dementia improves cognitive function and quality of life, compared with usual treatment. Although it will provide evidence on the potential benefits of individual cognitive stimulation therapy, a longer follow-up than the initial six months would be worthwhile to better understand the longer term effects on cognition, care home admissions, and cost effectiveness. Future studies should also look at the potential for people other than family members to deliver individual cognitive stimulation therapy, including home care staff and the voluntary sector.
What should we do in the light of the uncertainty?
The NICE/Social Care Institute for Excellence guidance on dementia11 recommends that “people with mild-to-moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme . . . irrespective of any drug prescribed for the treatment of cognitive symptoms of dementia.” However, participation may be difficult for people with severe sensory problems. Developing evidence suggests that individual cognitive stimulation therapy (usually carer led) may be promising, but it may be premature to recommend this treatment routinely in dementia care until better evidence from large scale multicentre randomised controlled trials is available.
Recommendation for further research
Population: patients with dementia living in the community supported by a family carer
Intervention and comparison: family carer delivered individual cognitive stimulation therapy sessions compared with usual care
Outcome: cognition, quality of life, and costs
Cite this as: BMJ 2012;344:e633
This is one of a series of occasional articles that highlight areas of practice where management lacks convincing supporting evidence. The series adviser is David Tovey, editor in chief, the Cochrane Library. To suggest a topic for this series, please email us at.
Contributors: MO devised and drafted the article. MO and AS completed the searches of literature and trials. MO, AS, and BW were all involved in editing and revising the article. MO is guarantor.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; MO, BW, and AS receive royalties (departmentally) from the sale of the cognitive stimulation therapy manual Making a Difference (Hawker Publications) and are grantholders for the Health Technology Association funded study “Individual Cognitive Stimulation Therapy for dementia (iCST Trial) 08/116/06”; AS runs regular training courses for staff on how to deliver cognitive stimulation therapy.
Provenance and peer review: Commissioned, externally peer reviewed.