Cognitive Stimulation Therapy – a review
BY Jennifer Bray, Association of Dementia Studies, University of Worcester
Back in 2006, the National Institute for Health and Care Excellence (NICE) and Social Care Institute for Excellence (SCIE) guidance (NICE, 2006) recommended that people with mild to moderate dementia should be offered the opportunity to take part in group Cognitive Stimulation Therapy (CST). This recommendation remained when the guidance was updated in 2018 as one of the ‘interventions to promote cognition, independence and wellbeing’ (NICE, 2018). CST is often described as an evidence-based treatment, but what actually is it and what might people with dementia and their family carers get out of it?
A review of the evidence base for CST was carried out and is available here but the main findings are presented below.
What is CST?
CST is a psychosocial intervention, meaning that rather than being a medication-based treatment it focuses on addressing the psychological and social factors affecting people with dementia. While there are a couple of versions of CST, by far the most commonly recognised and implemented – and also the one recommended in the NICE SCIE guidance – is a structured intervention developed around the turn of the 21st century. This CST intervention is well-defined with an accompanying manual and training being available. It has been implemented in at least 34 countries across the world and is offered by at least 66% of memory clinics in the UK. When people talk about CST, the version outlined here is what they are referring to.
CST comprises a series of 14 group sessions over a seven-week period, making it a relatively short-term intervention. Each session lasts 45 minutes and is delivered to groups of approximately eight people with dementia. Carers do not generally take part in the sessions. Each session has a different topic such as food, physical games, or being creative, but there is a consistent approach and format across the sessions, particularly in terms of the time, place, participants and facilitators.
CST targets the cognitive and social functioning of people with mild to moderate dementia, meaning that aims to improve and stimulate their memory, thinking skills and language skills as well as having a social element. Sessions involve discussions, music, singing, word games, practical activities that stimulate the brain, such as baking where you have to measure ingredients and follow a recipe, providing multi-sensory stimulation. There is also a focus on activities that encourage the sharing of opinions, rather than requiring participants to ‘know’ information or facts. The overall ethos is to deliver sessions in a fun environment, which help to strengthen people’s abilities and social relationships.
You may also hear about or be able to access two other variations of CST which have been developed from this ‘core’ version to help in different circumstances. Firstly, there’s Maintenance CST, which is a longer term follow up to CST, and essentially continues delivering CST in a series of 24 weekly sessions. Secondly, Individual CST (iCST) is one-to-one rather than group sessions, where a 30-minute session is delivered three times a week for 25 weeks. The sessions tend to be delivered by a family carer, but could also be run by a paid carer or other professional. iCST is a way of involving the carer in CST, or reaching people with dementia who may not be willing or able to access a group-based intervention. iCST may also be a better option for people with dementia who may benefit from one-to-one attention.
How can CST benefit a person with mild to moderate dementia?
There has been a lot of research into CST, both in the UK and across the world, and it has been consistently found that CST has a measurable positive effect on a person with dementia’s cognition and quality of life. Even in cases where no changes have been found, CST still appears to be beneficial as the progressive nature of dementia means that we would normally expect to see a decline. Although more difficult to measure, a number of other benefits have been seen as a result of attending CST sessions. These include improving memory, building self-esteem and increasing confidence to join in conversations and other activities. CST has helped people with mild to moderate dementia to feel relaxed, supported and socially connected, and while this may not sound like much to some people, it can have a big impact. For example, as a result of their CST experiences some people with dementia have felt able to engage with other groups and activities.
CST has not been found to make a difference on behavioural aspects of dementia that carers may have difficulty with. However, no negative effects of taking part in CST have been seen, suggesting that even if a person with dementia doesn’t see an improvement, they are highly unlikely to experience any decline beyond their normal dementia progression. It should be noted though that only limited research has been carried out so far to look at the impact of CST on people with different types of dementia. The existing research has still shown that CST can benefit people with different types of dementia, but the particular type or level of impact may differ depending on the individual, the type and stage of their dementia, and indeed their personality.
Some places may offer CST, but actually deliver it in a slightly different way to the manual. For example, for practical or pragmatic reasons, CST sessions could be delivered once rather than twice a week. While people with dementia can still benefit from this, and still get enjoyment from the sessions, the level of cognitive improvement tends to be lower that with the intended version of CST. If this is the only option you’re offered, don’t worry, but maybe manage your expectations about the impact that it may have.
How can CST benefit a family carer?
While CST sessions are delivered for people with dementia and are unlikely to include carers, carers have still reported benefits as a result of the person with dementia attending the sessions. In addition to the brief periods of respite that CST sessions offer, levels of carer distress have also been seen to reduce. Additionally, conversations and communication between a carer and the person they are caring for have improved as a result of the person with dementia’s language and verbal skills improving, which in turn makes them feel more confident and willing to have conversations.
With Maintenance CST particularly, carers enjoyed seeing the difference in the person with dementia over time, and found that it changed their attitudes in terms of what they felt the individuals were still able to do. Combined with the person with dementia’s increased confidence levels, this has encouraged some carers to feel more able to suggest taking part in other social groups and activities, mirroring some of the findings for CST. iCST has been found to be the most beneficial form of CST for carers, although it is less effective for the person with dementia. By being directly involved in the delivery of iCST sessions, carers have shown fewer depressive symptoms and it has also been found to improve the carer’s quality of life and enhance the caring relationship. iCST also gives carers a purpose when spending time with the person with dementia, giving them a common purpose and an opportunity to spend enjoyable time together. Additionally, it helps carers to see beyond the person’s dementia, providing an insight into the individual’s abilities and interests and also a better understanding of dementia and how the memory works. This in turn can make carers more tolerant in their interactions with the person with dementia which benefits all involved
CST is a well-defined, relatively short-term group psychosocial intervention with a focus on cognitive and social functions. While it is not a cure for dementia, CST does appear to support people with mild to moderate dementia to live well. A number of positive cognitive, social and emotional benefits of CST have been identified, although it does not appear to be have any impact on the behavioural aspects of dementia that carers may find difficult to address. The level and type of impact may however depend on the individual themselves, partly in terms of the form of dementia they have and partly in terms of their own personality and preferences.
From a carer’s perspective, CST has a number of indirect benefits due to its impact on the person with dementia’s language, conversational skills and confidence, all of which can improve interactions and the caring relationship. While iCST appears to be more beneficial for carers due to their greater level of involvement in its delivery, it is less effective for people with dementia, partly due to the lack of group social interaction.
Overall, CST has a better evidence base than many other interventions or approaches. This evidence base shows that CST has a positive impact for the person with dementia and, to a lesser extent, their carers. Furthermore, the fun, supportive environment in which it is delivered make it an enjoyable experience for those involved. It is also important to note that even when no changes have been measured, this can still be viewed positively as the progressive nature of dementia means that a decline would normally be expected. Finally, no negative impacts have been reported, so there do not appear to be any disadvantages to taking part in CST sessions.