Experiences of cognitive stimulation therapy (CST) in Brazil: a qualitative study of people with dementia and their caregivers

OBJECTIVES

There is a lack of investment in psychosocial treatments for people with dementia in Brazil. Cognitive Stimulation Therapy (CST) is a group-based intervention that has shown to have benefits on activities of daily living and mood for people with dementia in Brazil. This study aims to explore the experiences and perceived changes following CST groups.

METHODS

Individual interviews were conducted with the participants of the group (n = 12) and their caregivers (n = 11). Framework analysis was used to inspect the data.

RESULTS

Two main themes have emerged: 'Personal benefits of being part of the group', containing two subthemes: 'Benefits for caregivers' and 'Benefits for person with dementia' and 'Day-to-day changes', containing seven subthemes; 'Memory', Sociability', 'Language', 'Mood', 'Orientation', 'Everyday activities' and 'Behavioural and psychological symptoms'.

CONCLUSION

Results suggest that CST groups led to perceived personal benefits for the people with dementia and caregivers and that there are perceived changes for the participants of the groups.

The Impact of Exercise and Cognitive Stimulation Therapy on Intrinsic Capacity Composite Score in Pre-Frail Older Adults: A Pre-Post Intervention Study

Intrinsic capacity(IC) is a measure of physical, cognitive, vitality, psychological, and sensory abilities which determines functional ability. Decline in IC has been shown to accelerate the trajectory of frailty. We aim to show the impact of exercise (Ex) and cognitive stimulation therapy (CST) on (i) IC domains and composite score (ii) frailty and functional ability in pre-frail older adults. Secondary analysis of data from a pre-post intervention study of pre-frail older adults ≥ 65 years attending primary care clinic. Control (CON) and 2 intervention groups ((i) Ex 6 months (ii) CST 3 months with Ex 6 months (Ex+CST)) were recruited. Pre-frailty was determined using the FRAIL scale. Questionnaires (on demographics, functional ability, and depression) were administered and physical function assessment (gait speed (GS), short physical performance battery (SPPB) test, handgrip strength, five times sit-to-stand (5x-STS)) was conducted at 0, 3, 6 and 12 months. Four domains of IC were evaluated: locomotion (GS and 5x-STS), vitality (nutrition and muscle mass), cognition (MoCA and subjective cognitive decline) and psychological (depression and anxiety). Each domain was scored from 0 to 2 (no decline) with total IC score ranging from 0 to 8. 187 participants completed baseline and 3 months assessments, 109 (58.3%) were allocated to CON, 37 (19.8%) to Ex and 41 (21.9%) to Ex + CST groups. At 3 months, both Ex and Ex +CST showed improvement in IC composite scores, locomotion, and psychological domain scores but improvement in cognition domain only in Ex + CST group. At 6 months, there were improvements in total IC score, locomotion, vitality, and psychological domain in both Ex and Ex + CST groups. At 12 months, significant improvement was evident in total IC score for Ex and Ex+CST groups, vitality when fatigue (in addition to muscle mass and nutrition) was added and instrumental activities of daily living. Multidomain intervention incorporating exercise and CST resulted in significant improvement in IC composite scores, locomotion, vitality, cognition, and psychological domains.

Comparisons of Cognitive Stimulation Therapy Between Community Versus Hospital-Based Settings: A Multi-Site Study

BACKGROUND

Non-pharmacological interventions such as Cognitive Stimulation Therapy (CST) have been shown to help persons living with dementia in improving cognitive function and recall. While previous CST interventions have been conducted largely with community populations, none have explored the outcomes of CST in larger healthcare settings. Our study explored differences of cognitive function, mood, and quality-of-life from CST groups both community and residential-based groups.

METHOD

Participants (N = 258) from academic and rural, hospital-based settings in Missouri engaged in 14-session psychosocial groups to aid reminiscence for enhanced cognitive function and recall.

RESULTS

Post-intervention cognitive function improvements occurred for community (t = -7.48, p < .001) and residential samples (t = -2.46, p < .05). Community groups showed significant improvement in overall mood related to their dementia (t = 6.37, p < .001).

CONCLUSION

Healthcare providers should consider CST as a supplemental intervention for older patients receiving usual care for dementia-related symptoms.

Impact of Exercise and Cognitive Stimulation Therapy on Physical Function, Cognition and Muscle Mass in Pre-Frail Older Adults in the Primary Care Setting: A Cluster Randomized Controlled Trial

OBJECTIVES

Multicomponent exercise program have shown to improve function and cognition in older adults but studies on pre-frail older adults in the primary care setting are limited. This study aimed i) to evaluate impact of 6 months exercise (Ex) versus complementary effect of 3 months of cognitive stimulation therapy (CST) to 6 months of Ex (Ex+CST) on physical function, muscle mass and cognition versus control group at 3, 6 and 12 months ii) inflammatory biomarkers such as Interleukin-6 (IL-6) and Tumor Necrosis Factor Alpha (TNF-α).

DESIGN

Cluster randomised control trial.

SETTING AND INTERVENTION

Pre-frail older adults ≥ 65 years attending primary care clinic. Two intervention groups i) Ex 6 months ii) CST 3 months with Ex 6 months.

MEASUREMENTS

At 0, 3, 6 and 12 months, questionnaires (on demographics, physical function, cognition, and depression) were administered and physical function assessment (gait speed, short physical performance battery (SPPB) test, handgrip strength, five times sit-to-stand (5x-STS)) was conducted. Muscle mass and its surrogates such as phase angle and body cell mass were measured using bioelectrical impedance analysis machine. Inflammatory biomarkers were measured at 0 and 3 months.

RESULTS

Data from 190 participants was analysed at 3 months (111 control, 37 Ex and 41 Ex+CST). At 3 months, significant improvement in cognition was seen only in the Ex+CST group whereas improvements in depression, gait speed, SPPB and 5x-STS were seen in both the Ex and Ex+CST groups. At 6 months, the Ex+CST group improved in cognition and depression whereas improvement in frailty and muscle mass indices were seen in both the interventions groups. At 12 months, both the interventions groups had better perceived health, gait speed and less decline in muscle mass compared with control groups. Both the Ex and Ex+CST had significant association with TNF-α at 3 months (β -2.71 (95% CI -4.80 - -0.62); p = 0.012 and β -1.74 (95% CI -3.43 - -0.06); p = 0.043 respectively).

CONCLUSION

Combined Ex+CST had significant improvement in cognition whereas the intervention groups improved in depression, physical function, muscle mass, frailty, perceived health and TNF-α levels. With growing evidence of the benefits of multicomponent interventions at primary care level, incorporating it into mainstream care with action plans on long-term sustainability and scalability should be a priority for every country.

Cultural Adaptation of Cognitive Stimulation Therapy (CST) for Portuguese People with Dementia

OBJECTIVES

Portugal is one of the most aged countries in the world and dementia is increasing among the Portuguese population. It is estimated to affect around 200,000 people in Portugal. There is a clear need for non-pharmacological interventions to ameliorate the symptoms of dementia and improve the quality of life. Cognitive Stimulation Therapy (CST), a worldwide well-known program developed in the United Kingdom (UK), is recognized as a cost-effective intervention, with benefits both in cognitive function and quality of life of people with mild to moderate dementia. We tested the feasibility and cultural appropriateness and adapted CST to Portuguese people with dementia.

METHODS

The Formative Method for Adapting Psychotherapy (FMAP) model for cultural adaptation was used. A focus group discussion with health professionals and caregivers provided the basis for cultural adaptation, as well as feedback from participants, caregivers, and facilitators after a pilot study.

RESULTS

Some modifications were required, especially related to linguistic issues, in 11 of the 14 CST sessions. The adapted program was found to be acceptable and enjoyable in a small sample of people with dementia in a rehabilitation context.

CONCLUSIONS

CST seems feasible and culturally appropriate in Portugal. A systematically developed and culturally adapted manual is ready to be used in a large-scale implementation and validation of CST in Portugal.

CLINICAL IMPLICATIONS

CST is a valid program for the Portuguese culture, contributes to the availability of a structured and effective clinical intervention for PwD in Portugal and to the possibility of comparing programs across countries.

What are the current and projected future cost and health-related quality of life implications of scaling up cognitive stimulation therapy?

OBJECTIVES

Cognitive stimulation therapy (CST) is one of the few non-pharmacological interventions for people living with dementia shown to be effective and cost-effective. What are the current and future cost and health-related quality of life implications of scaling-up CST to eligible new cases of dementia in England?

METHODS/DESIGN

Data from trials were combined with microsimulation and macrosimulation modelling to project future prevalence, needs and costs. Health and social costs, unpaid care costs and quality-adjusted life years (QALYs) were compared with and without scaling-up of CST and follow-on maintenance CST (MCST).

RESULTS

Scaling-up group CST requires year-on-year increases in expenditure (mainly on staff), but these would be partially offset by reductions in health and care costs. Unpaid care costs would increase. Scaling-up MCST would also require additional expenditure, but without generating savings elsewhere. There would be improvements in general cognitive functioning and health-related quality of life, summarised in terms of QALY gains. Cost per QALY for CST alone would increase from £12,596 in 2015 to £19,573 by 2040, which is below the threshold for cost-effectiveness used by the National Institute for Health and Care Excellence (NICE). Cost per QALY for CST and MCST combined would grow from £19,883 in 2015 to £30,906 by 2040, making it less likely to be recommended by NICE on cost-effectiveness grounds.

CONCLUSIONS

Scaling-up CST England for people with incident dementia can improve lives in an affordable, cost-effective manner. Adding MCST also improves health-related quality of life, but the economic evidence is less compelling.

Comparative Effectiveness of 3 Settings of Cognitive Stimulation Therapy on Cognition and Quality of Life for People With Dementia: A Systematic Review and Network

OBJECTIVE

To compare and rank the effectiveness of group cognitive stimulation therapy (group CST), maintenance cognitive stimulation therapy (MCST), and individual cognitive stimulation therapy (iCST) on cognition and quality of life (QoL) in people with dementia.

DESIGN

Systematic review and network meta-analysis (NMA).

SETTING AND PARTICIPANTS

All published randomized controlled trials (RCTs) that compared the differences among 3 different settings of CST or a control group in treating people with dementia.

METHODS

Relevant electronic databases, including PubMed, Embase, Cochrane Library for clinical trials, Web of Science, CINAHL, PsycINFO, Chinese National Knowledge Infrastructure (CNKI), and Wanfang Data were systematically searched from inception to March 2021. RCTs that compared the differences among 3 different settings of CST or a control group in treating people with dementia were included. Then, a pairwise and network meta-analysis was conducted to evaluate the relative effects and rank probability of different CST settings. PRISMA guidelines were used for abstracting data, and the Cochrane Risk of Bias tool was used to assess data quality.

RESULTS

In total, 17 studies were included, which enrolled 1680 participants. Compared with the control group, MSCT [standardized mean difference (SMD) = 1.39, 95% CI 0.86, 1.91; low-quality evidence] and group CST (SMD 0.62, 95% CI 0.39, 0.84; very low-quality evidence) could significantly improve cognitive function. MCST (SMD 1.00, 95% CI 0.16, 1.85; low-quality evidence) and group CST (SMD 0.53, 95% CI 0.13, 0.92; low-quality evidence) demonstrated a statistically significant effect in improving the QoL, whereas iCST was not significantly inferior to the control condition. None of the treatments were significantly different from each other with respect to acceptability.

CONCLUSIONS AND IMPLICATIONS

For people with dementia, group CST and MCST seems to promote more consistent benefits in terms of cognition and QoL than the iCST, and MCST was likely to be the most effective CST setting. Further RCTs with respect to the MCST and iCST efficacy are needed.

A multicomponent psychosocial intervention among people with early-stage dementia involving physical exercise, cognitive stimulation therapy, psychoeducation and counselling: Results from a mixed-methods study

BACKGROUND

There is increasing awareness of the benefits of both physical and psychosocial interventions to empower and benefit people with dementia and their caregivers. However, the potential additional benefits of combining physical and psychosocial interventions have only been sparsely explored. The aim of this pilot study was to investigate the acceptability and potential impact of a multicomponent intervention comprising physical exercise, cognitive stimulation therapy (CST), psychoeducation and counselling for people with early-stage dementia.

DESIGN

A 15-week multicomponent group-based intervention was offered to people with early-stage dementia in Denmark (N = 44). A mixed-methods design combining interviews, observations, tests of cognitive and physical functioning and an interviewer-assisted questionnaire on quality of life was applied to (1) investigate acceptability of the intervention, including whether people with dementia and their caregivers found the intervention meaningful and (2) to explore and assess changes in participants' physical and cognitive functioning and quality of life. The study was conducted between June 2018 and August 2019.

RESULTS

The pilot study demonstrated that the multicomponent intervention was acceptable for people with early-stage dementia and their caregivers. Test results did not show significant changes in measures of participants' physical and cognitive functioning or quality of life. However, qualitative data revealed that participants perceived the intervention as meaningful and found that it had a positive influence on their physical and social well-being. In addition, interaction and support from peers and staff members was considered important and rewarding.

CONCLUSION

This multicomponent intervention constitutes a meaningful and beneficial activity for people with early-stage dementia and their caregivers. It provides an opportunity to engage in social interactions with peers and experience professional support. The study also underlines the importance of providing prolonged and sustainable interventions for people with dementia to maintain personal and social benefits.

Exploring the feasibility of an individual cognitive stimulation therapy application and related technology for use by people with dementia and carers in Indonesia: A mixed-method study

BACKGROUND

Cognitive stimulation therapy (CST) is a psychosocial intervention for people with dementia and can benefit cognition and quality of life. A touch-screen individualised CST (iCST) application has been developed to improve on accessibility and provide increased interactivity. This study aimed to explore the attitudes of people with dementia, carers and healthcare professionals in Indonesia towards the iCST application and related technology.

METHODS

Four focus groups were organised: one comprising family carers (n = 3), two comprising people with dementia and family carers (n = 12) and one made up of family carers and home care workers (n = 3). Participants discussed the uses of technology, tried out the iCST application and completed a usability and acceptability questionnaire. Furthermore, 21 healthcare professionals attended an expert meeting to discuss the potential of implementing the iCST application in the community.

RESULTS

Attitudes towards technology were positive but lack of experience, difficulties with operating devices and a limited infrastructure to support technology were described as barriers. The iCST application was seen as an interesting tool to support mental stimulation. Compared with people with dementia, carers were more willing to use the application and rated its usability higher. Healthcare professionals were positive about the interactive features of the application and judged that it could be useful within the family context.

DISCUSSION

Low-cost and low-infrastructure technology like iCST can meet the needs for stimulation of people with dementia in Indonesia and other countries. By understanding the attitudes of people with dementia and carers towards IT and their willingness to adopt technology like the iCST application, we are better placed to overcome potential obstacles to its implementation. It appears that systemic changes are needed to facilitate wider use of IT particularly in dementia care. These include needs to empower end users, strengthen access and connectivity to technology, and improve diagnostic support.

An Individual Cognitive Stimulation Therapy App for People With Dementia and Their Carers: Protocol for a Feasibility Randomized Controlled Trial

Background

There is a need for more resources to support the cognition and quality of life of people with dementia. The individual cognitive stimulation therapy (iCST) app aims to provide cognitive stimulation and social interaction to people with dementia and carers through interactive touchscreen technology. The iCST app has been developed according to the principles of CST and iCST, which have previously shown to improve the cognition and quality of life of people with dementia and benefit the relationship between the person with dementia and his/her carer. The iCST app has also shown to improve the quality of the carer’s life.

Objective

The aim of this study is to evaluate the usability of the iCST app intervention and the feasibility of conducting a full-scale randomized controlled trial (RCT) to assess the clinical effectiveness of the iCST app intervention compared to that of treatment-as-usual for people with mild-to-moderate dementia.

Methods

We aim to recruit 60 people with mild-to-moderate dementia and their informal carers as dyads in a multi-center feasibility RCT with a treatment-as-usual control group. Both parties must be able to provide informed consent and participate in the intervention. Dyads will complete a baseline assessment that will include cognition and quality of life measures and they will subsequently be randomized (1:1) to the iCST app intervention in addition to usual care or to usual care only. All participants will be followed up at 5 weeks and at 11 weeks after the baseline assessments. A range of feasibility outcomes will be assessed, including recruitment and retention rates, intervention fidelity and usability, and acceptability of the outcome measures. A sample of the experimental group will be invited to a semistructured posttrial interview to further examine the experience of using the iCST app.

Results

This study received funding in May 2015 and obtained ethical approval in March 2018. Data collection began in November 2018 and was completed in March 2020 with a total of 61 dyads recruited. Data analyses are in progress and the final results are expected to be available in the spring of 2021.

Conclusions

This study will investigate whether it is feasible to conduct a full-scale RCT to evaluate the clinical effectiveness of the iCST app in comparison to that of usual care alone. In addition, this study will examine the usability of the iCST app. The data will provide information on potential modifications to be made to the intervention, study design, and study process.

Trial Registration

ClinicalTrials.gov NCT03282877; https://clinicaltrials.gov/ct2/show/NCT03282877

International Registered Report Identifier (IRRID)

DERR1-10.2196/24628

Toward a theory-based specification of non-pharmacological treatments in aging and dementia: Focused reviews and methodological recommendations

INTRODUCTION

Non-pharmacological treatments (NPTs) have the potential to improve meaningful outcomes for older people at risk of, or living with dementia, but research often lacks methodological rigor and continues to produce mixed results.

METHODS

In the current position paper, experts in NPT research have specified treatment targets, aims, and ingredients using an umbrella framework, the Rehabilitation Treatment Specification System.

RESULTS

Experts provided a snapshot and an authoritative summary of the evidence for different NPTs based on the best synthesis efforts, identified main gaps in knowledge and relevant barriers, and provided directions for future research. Experts in trial methodology provide best practice principles and recommendations for those working in this area, underscoring the importance of prespecified protocols.

DISCUSSION

We conclude that the evidence strongly supports various NPTs in relation to their primary targets, and discuss opportunities and challenges associated with a unifying theoretical framework to guide future efforts in this area.

An Age-Friendly Health System

BACKGROUND/OBJECTIVES

To describe a screening and intervention program for geriatric syndromes instituted at a rural healthcare system that utilizes the 4Ms of an age-friendly health system, and to provide exercise and cognitive stimulation therapy (CST) as part of an age-friendly health program.

DESIGN

Retrospective evaluation of clinical data.

SETTING

Rural primary healthcare system.

PARTICIPANTS

Older adults aged 65 years and older in Perry County, Missouri.

MEASUREMENTS

Screening for geriatric syndromes was done using the Rapid Geriatric Assessment (RGA), which includes the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS). Outcomes for exercise and CST included the Five Times Sit to Stand (FTSS) and Timed Up and Go (TUG) tests, Cornell Scale for Depression in Dementia (CSDD), Saint Louis University Mental Status Examination (SLUMS), and Quality of Life in Alzheimer's Disease (QoL-AD) measures.

RESULTS

The RGA was administered to 1,326 individuals of which 36.5% were frail, 42.1% were sarcopenic, 26.1% were at risk for anorexia, and 20.8% had dementia. Of these receiving exercise therapy, both the FTSS and the TUG were improved at 3 months and 12 to 24 months. In the CST group, SLUMS, QoL-AD, and CSDD were improved at 7 weeks and 6 to 12 months.

CONCLUSION

It is feasible to introduce a screening program for geriatric syndromes and respond to the results with successful exercise and cognitive stimulation therapy programs.

An Individual Cognitive Stimulation Therapy App for People With Dementia: Development and Usability Study of Thinkability

BACKGROUND

There is a lack of technological resources for the mental stimulation and communication of people with dementia, which can be helpful in improving cognition and quality of life. Paper-based individual cognitive stimulation therapy (iCST) for people with dementia has the potential to be adapted to a touchscreen format. This can improve accessibility and provide mental stimulation using interactive features. There is a need for a rigorous and systematic approach toward development, leading to improved suitability and implementation of the intervention, so that more people can benefit from its use.

OBJECTIVE

This study aims to develop and investigate the usability of Thinkability, an iCST app that can be used by people with dementia and carers on touchscreen tablets.

METHODS

The Medical Research Council framework for evaluating complex interventions and the Centre for eHealth Research roadmap served as frameworks for the stages of intervention and technology development. The development of the iCST app itself adopted an agile approach with elements from action research. Hence, it was developed in 3 successive sprints and was evaluated by relevant stakeholders at each sprint. Sprint 1 included 2 patient and public involvement (PPI) consultation meetings, sprint 2 included 1 PPI consultation meeting, and 4 focus groups and 10 individual interviews were organized in sprint 3. A feasibility trial is currently underway.

RESULTS

The findings from each sprint were used to inform the development. Sprint 1 helped to identify the relevant evidence base and explored the attitudes of people with dementia and carers toward a potential iCST app. In sprint 2, an initial prototype was evaluated in a small PPI consultation meeting. In sprint 3, feedback was gathered through a qualitative study on the quality and perceived effectiveness of the iCST app. It was well received by people with dementia and carers. A need for more updated and personalized content was highlighted.

CONCLUSIONS

This study proves that an agile approach toward technology development involving all relevant stakeholders is effective in creating suitable technology. Adding to our previous knowledge of noncomputerized cognitive stimulation therapy, the release of the iCST app will make this psychosocial intervention accessible to more users worldwide.

Cognitive stimulation therapy for brazilian people with dementia: examination of implementation' issues and cultural adaptation

Objectives: The prevalence of dementia has been increasing particularly in developing countries. However, people with dementia (PwD) in Brazil are currently offered no psychosocial treatment upon diagnosis. Cognitive stimulation therapy (CST) that originated in the UK has proven benefits on cognition and quality of life in PwD. We investigate the possible issues for the implementation of CST for the Brazilian population and its cultural appropriateness. Method: Individual interviews and focus groups were conducted with PwD, their caregivers and health professionals (n = 37). Data were recorded and transcribed, before being analyzed using Framework Analysis. Results: Regarding the issues for implementation of CST in the Brazilian population, two main themes emerged, 'Barriers' and 'Facilitators', along with nine subthemes. Overall, the activities and materials were seen as being appropriate for use with the Brazilian population, some minor changes were suggested. Conclusions: The results indicate that CST is appropriate for use in the Brazilian population, only some cultural adaptations are necessary. In the stakeholders' opinions, CTS intervention is needed in Brazil, due to the lack of treatment options for PwD in developing countries.

Managing dementia in rural Nigeria: feasibility of cognitive stimulation therapy and exploration of clinical improvements

Objectives: We investigated the feasibility and clinical impact of a psychosocial intervention, Cognitive Stimulation Therapy (CST), to help manage dementia in a rural setting in Nigeria. Method: People with dementia were identified from a prevalence study in Lalupon in the south-west of Nigeria. Prior to this feasibility study CST was adapted for the setting and pilot by our team. Fourteen sessions of CST were provided over a 7-week period by a trained nurse specialist and occupational therapist. Change in quality of life was the main outcome. Results: Nine people were enrolled in CST. Significant improvements in cognitive function, quality of life (physical, psychosocial and environmental domains), physical function, neuro-psychiatric symptoms and carer burden were seen. Conclusions: CST appears to be feasible in this setting, although adaptation for low literacy levels, uncorrected visual and hearing impairment and work and social practices is needed. The clinical improvements seen were encouraging.

Different durations of cognitive stimulation therapy for Alzheimer's disease: a systematic review and meta-analysis

Objective

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of cognitive stimulation therapy (CST) of different durations for Alzheimer’s disease (AD).

Methods

A comprehensive search was carried out in three databases. The primary outcome was Mini-Mental State Examination (MMSE) score. We conducted a meta-analysis with Review Manager, version 5.3 and assessed the methodological quality of the included studies using the Cochrane Collaboration Recommendations assessment tool.

Results

Treatment effects from the meta-analysis showed that CST plus acetylcholinesterase inhibitors (ChEIs) was better than the control assessed by MMSE. In addition, the meta-analysis indicated that long-term CST was better than short-term or maintenance CST.

Conclusion

Our study confirmed that the combination of CST and drug treatment for AD is effective in AD, regardless of whether short-term CST, maintenance CST, or long-term CST is used. The long-term CST appears to be more effective.

The effects of an expanded cognitive stimulation therapy model on the improvement of cognitive ability of elderly with mild stage Dementia living in a community - a randomized waitlist controlled trial

OBJECTIVE

This research study aims to evaluate the effectiveness of an expanded cognitive stimulation therapy (CST) model that combines a CST group and tai chi on improving the cognitive ability of community-dwelling Chinese elderly with mild stage dementia (EwMD).

METHOD

A randomized waitlist controlled trial design was adopted in this study. The treatment group participated in a structured CST group followed by tai chi twice a week, with a total of 14 sessions throughout the study period. The waitlist control group received treatment as usual at the initial stage and expanded CST model at a later stage. The Chinese Mattis Dementia Rating Scale (DRS) and the Chinese Mini Mental State Examination (MMSE) were used to assess the cognitive ability of EwMD in the pre- and post- treatment periods.

RESULTS

At baseline, the treatment group (n = 51) and control group (n = 50) did not differ significantly in any demographic or clinical variables. Overall, the participants had a mean baseline MMSE score of 20.67 (SD = 2.30). The 2 × 2 repeated measures ANCOVA demonstrated that the treatment group was significantly more effective than the control group in improving the MMSE score (F = 12.31, p< .01) with a moderate effect size (partial eta square = .11) after controlling for group difference in age, gender, education, and having a diagnosis of dementia.

CONCLUSION

The present study demonstrates the effectiveness of the expanded CST model on the improvement of cognitive ability of community-dwelling EwMD. More research is needed to further investigate this intervention model across cultures and societies.

Individual cognitive stimulation therapy for people with intellectual disability and dementia: protocol of a feasibility randomised controlled trial

INTRODUCTION

Cognitive stimulation therapy (CST) is a psychosocial intervention for dementia. Group CST is effective in reducing cognitive decline and improving quality of life in patients with dementia. There is some evidence that individual CST (iCST) may be beneficial in reducing cognitive decline. People with intellectual disability (ID) have an increased risk of dementia. However, there are no published studies of CST in people with ID and dementia. This protocol describes the feasibility and acceptability of a randomised controlled trial of iCST delivered by carers to people with ID and dementia, compared with treatment as usual (TAU). The results of this study will inform the design of a future definitive randomised controlled trial.

METHODS AND ANALYSIS

The iCST intervention has been adapted for this trial. Forty dyads (individuals with ID and their carer) will be randomised to either iCST or TAU. The manualised intervention comprises 40 iCST sessions delivered by a carer for 30 min, twice a week, over 20 weeks. The primary outcome will be process measures assessing the feasibility and acceptability of the intervention and trial procedures. The secondary outcome will be changes in the scores of outcome measures (cognition, functional ability and quality of life in individuals with ID, and caregiver burden, competence in managing dementia, and anxiety and depression in carers). Data will be collected at baseline, 11 weeks and at 21 weeks. A process evaluation will examine adherence to iCST and will include qualitative interviews with participants to identify aspects of the intervention that were or were not successful.

ETHICS AND DISSEMINATION

The study has received ethical approval. The results of the study will be presented at conferences and submitted to a peer reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN18312288; Pre-results.

Multicomponent intervention combining a cognitive stimulation group and tai chi to reduce cognitive decline among community-dwelling older adults with probable dementia: A multi-center, randomized controlled trial

OBJECTIVE

This research study aims to evaluate the effectiveness of a multicomponent intervention that combines a cognitive stimulation group and tai chi to reduce cognitive decline among community-dwelling Chinese older adults with probable dementia.

METHODS

A multi-center, randomized controlled trial design was adopted in this study. In addition to treat as usual, the treatment group (n = 41) participated in a structured cognitive stimulation group followed by tai chi twice a week, with a total of 14 sessions held during the study period. The control group (n = 39) received treat as usual. Mattis Dementia Rating Scale and Mini-Mental State Examination were used for assessing the cognitive abilities of participants in the pre- and post-treatment periods.

RESULTS

A 2 × 2 repeated measures analysis of covariance demonstrated that the treatment group was more effective than the control group on improving Dementia Rating Scale score (F = 7.45, p < .01) with a moderate effect size (partial eta square = .09) and Mini-Mental State Examination score (F = 9.96, p < .01) with a moderate to large effect size (partial eta square = .12) after controlling for age, gender, educational level, marital status, and number of physical illnesses.

CONCLUSION

The present study demonstrates the effectiveness of the multicomponent intervention on improving cognitive ability among community-dwelling older adults with probable dementia, suggesting that the multicomponent intervention can facilitate early identification, assessment, and treatment for community-dwelling older adults with probable dementia.

Going back to school - An opportunity for lifelong learning for people with dementia in Denmark (Innovative practice)

The provision of lifelong learning for older people is often promoted as a way of engaging socially and maintaining cognitive function. The concept is also used with people with dementia, but is often limited to short-term programmes. Innovative practice from Denmark takes this concept further, offering people with early stage dementia the opportunity to return to school to attend classes in cognitive training, music, art and woodcraft. A pilot study conducted by the school of teaching and communication (Voksenskolen For Undervisning og Kommunikation) offers evidence for the benefits of prolonged educational programmes for people with dementia in maintaining decision-making, cognitive function and social interactions, with limited evidence of the impact on memory. Further evidence is required to understand the impact of a person with dementia attending school as a student and to understand if this concept is transferrable to a different cultural setting.

Cognitive stimulation therapy in dementia care: exploring the views and experiences of service providers on the barriers and facilitators to implementation in practice using Normalization Process Theory

BACKGROUND

Cognitive stimulation therapy (CST) is an evidence-based, cost-effective psychosocial intervention for people with dementia but is currently not a standard part of post-diagnostic care. This qualitative study explored the views and experiences of dementia care providers on the barriers and facilitators to its implementation in usual care.

METHOD

Thirty four semi-structured interviews (24 participants) were conducted across four dementia care sites in the North of England; ten were follow-up interviews. Data were analyzed using thematic analysis and then mapped to the Normalization Process Theory framework.

RESULTS

Participants considered CST a "good fit" with their "preferred" ways of working and goals of dementia care namely the provision of person-centered services. For facilitators delivering the intervention, compared to other behavioral interventions, CST was seen to offer benefits to their work and was easy to understand as an intervention. Training in CST and seeing benefits for clients were important motivators. Time and resources were crucial for the successful implementation of CST. Participants were keen to objectively measure benefits to participants but unsure how to do this.

CONCLUSIONS

CST is a cost-effective psychosocial intervention for people with dementia, recommended by national guidance. Despite our findings which show that, using the NPT framework, there are more facilitators than barriers to the implementation of CST, it is still not a standard part of post-diagnostic dementia care. Further research is needed to explore the reasons for this implementation gap in ensuring evidence-based care in translated into practice.

Cognitive Stimulation Therapy for Dementia: Pilot Studies of Acceptability and Feasibility of Cultural Adaptation for India

OBJECTIVE

This study aims to culturally adapt, translate, and test the feasibility and acceptability of delivering cognitive stimulation therapy (CST) for persons with mild to moderate dementia in Chennai, India.

METHODS

The adaptation followed a five-stage process in accordance with the formative method for adapting psychotherapy. Focus-group discussions with experts and feedback from participants, carers, and facilitators after two consecutive pilot studies provided the basis for adaptation.

RESULTS

Substantial modifications were required. The adapted program was found to be an acceptable, enjoyable, and constructive by participants and carers alike.

CONCLUSION

CST was successfully adapted for use in South India. Translations into other Indian languages using the adapted manual are required for nation-wide implementation. Large-scale clinical trials are required to replicate global reports on the efficacy and cost-effectiveness of CST in India across different settings.

Cognitive stimulation therapy as a sustainable intervention for dementia in sub-Saharan Africa: feasibility and clinical efficacy using a stepped-wedge design

BACKGROUND

Cognitive stimulation therapy (CST) is a psychosocial group-based intervention for dementia shown to improve cognition and quality of life with a similar efficacy to cholinesterase inhibitors. Since CST can be delivered by non-specialist healthcare workers, it has potential for use in low-resource environments, such as sub-Saharan Africa (SSA). We aimed to assess the feasibility and clinical effectiveness of CST in rural Tanzania using a stepped-wedge design.

METHODS

Participants and their carers were recruited through a community dementia screening program. Inclusion criteria were DSM-IV diagnosis of dementia of mild/moderate severity following detailed assessment. No participant had a previous diagnosis of dementia and none were taking a cholinesterase inhibitor. Primary outcomes related to the feasibility of conducting CST in this setting. Key clinical outcomes were changes in quality of life and cognition. The assessing team was blind to treatment group membership.

RESULTS

Thirty four participants with mild/moderate dementia were allocated to four CST groups. Attendance rates were high (85%) and we were able to complete all 14 sessions for each group within the seven week timeframe. Substantial improvements in cognition, anxiety, and behavioral symptoms were noted following CST, with smaller improvements in quality of life measures. The number needed to treat was two for a four-point cognitive (adapted Alzheimer's Disease Assessment Scale-Cognitive) improvement.

CONCLUSIONS

This intervention has the potential to be low-cost, sustainable, and adaptable to other settings across SSA, particularly if it can be delivered by non-specialist health workers.

Cognitive stimulation therapy in the Italian context: its efficacy in cognitive and non-cognitive measures in older adults with dementia

OBJECTIVE

Cognitive stimulation therapy (CST) has been shown to have significant benefits in enhancing cognitive functioning and improving the quality of life of people with mild to moderate dementia. The present study examines the efficacy of the Italian version of the therapy (CST-IT).

METHODS

Older adults with mild to moderate dementia (n = 39) were randomly assigned to two programs: one group participated in the CST-IT, consisting of 14 sessions (twice a week for 7 weeks) and the active control group took part in alternative general activities. The outcome measures were cognitive functioning (measured by the Mini-Mental State Examination-MMSE-, the Alzheimer's Disease Assessment scale-cognitive subscale, the backward digit span test, and a narrative language test); quality of life (Quality of life--Alzheimer's Disease scale); mood (Cornell scale for depression in dementia and the social and emotional loneliness scale); functional activities in daily living (Disability Assessment for Dementia); and behavior (neuropsychiatric inventory).

RESULTS

After the intervention, only the CST-IT group maintained its MMSE score, while the control group displayed deterioration. The CST-IT group also performed better in some of the cognitive measures (Alzheimer's Disease Assessment Scale-Cognitive subscale and narrative language), mood measures (Cornell scale, social and emotional loneliness scale with a decrease in reported loneliness), and the Quality of life--Alzheimer's Disease scale. No other treatment effect was observed.

CONCLUSIONS

The findings confirm the efficacy, at least in the short term, of the CST in sustaining cognitive functions and perceived quality of life in older adults with dementia in the Italian care setting as well.

Mindfulness in the Maintenance of Cognitive Capacities in Alzheimer's Disease: A Randomized Clinical Trial

BACKGROUND

The Canary Islands longitudinal study on non-pharmacological treatments showed the overall effectiveness of mindfulness in Alzheimer's disease (AD). However, no specific data on the maintenance of cognitive capacities were presented.

OBJECTIVE

To determine whether the practice of mindfulness modifies the course of cognitive impairment in AD.

METHODS

DESIGN

Longitudinal, non-inferiority and equivalence, randomized clinical trial, repeated-measures design, with three experimental groups and one control group.

PARTICIPANTS

Patients with AD who voluntarily attended the Lidia García Foundation (n = 502). Only those who were treated with donepezil and MMSE ≥18 were included (n = 120).

INTERVENTION

Over a two-year period, each group carried out three weekly sessions of stimulation based on mindfulness, cognitive stimulation therapy, and progressive muscle relaxation.

MEASURES

Cognitive assessment CAMDEX-R (MMSE and CAMCOG).

STATISTICAL ANALYSIS

Repeated-measures ANOVA (p <  0.05) and the effect size Cohen's d were performed.

RESULTS

The mindfulness group showed significant scores compared with the control and muscle relaxation groups (p <  0.05), while mindfulness and cognitive stimulation therapy were equivalent (p≥0.05). Group cognitive stimulation evolved better than the control (p <  0.05) group but not better than the muscle relaxation group (p≥0.05). The effect size compared over two years was large for the mindfulness group (p≥0.80), moderate for the relaxation group (p≥0.50), and low for the cognitive stimulation group (p≥0.20).

CONCLUSION

The practice of mindfulness maintained cognitive function over a period of two years. This longitudinal study suggests that mindfulness can be used as a non-pharmacological treatment to slow cognitive impairment in AD.

Does the Well-Being of Individuals with Down Syndrome and Dementia Improve When Using Life Story Books and Rummage Boxes? A Randomized Single Case Series Experiment

BACKGROUND

This study investigated whether a personalized life story book and rummage box enhanced well-being and led to changes in behaviour for people with Down syndrome (DS) who have dementia.

MATERIALS AND METHODS

A randomized single case series design was used with five participants who had DS and a diagnosis of dementia. Participants were invited to take part in three conditions at random (i) life story book, (ii) rummage box and (iii) no-intervention condition.

RESULTS

The two reminiscence conditions were significantly associated with enhanced well-being as compared to the no-intervention condition. However, for one participant, the life story book was associated with significantly higher well-being, while for another participant, the rummage box was associated with significantly higher well-being, suggesting some participants may prefer one method over another.

CONCLUSIONS

Personalized life story books and rummage boxes are associated with higher levels of well-being for people with DS and dementia.

Cognitive stimulation therapy: training, maintenance and implementation in clinical trials

There are around 35 million people worldwide with dementia, more than half of whom have Alzheimer’s disease (AD). Presently there are only four licensed pharmacological treatments available for treating the neuropsychological symptoms of AD. These include cholinesterase inhibitors, licensed for the treatment of people with mild to moderate AD, and an N-methyl-D-aspartate antagonist (memantine) licensed for the treatment of people with moderate to severe AD. These treatment options have modest symptomatic benefits for at least 6 months and possibly for 2 years or longer. Increasing evidence from randomized controlled trials has shown the potential value of cognitive training and cognitive rehabilitation in people with AD. There is a good evidence base to support the use of cognitive stimulation as a nonpharmacological treatment approach for people with AD, of which the most promising is cognitive stimulation therapy (CST). CST has shown benefits for cognition and well-being in people with dementia across a number of randomized controlled trials. There are important key issues related to the use of CST for people with AD, such as long-term benefits, implementation of individualized CST, adjunctive benefits with pharmacological treatments, and optimizing overall implementation of CST. Some of these key issues are already being addressed by ongoing clinical trials. Nevertheless, the strength of the current evidence from randomized controlled trials gives strong support to clinical implementation of CST in practice. Ongoing clinical trials will help to refine and optimize the use of CST in clinical practice.