There is some evidence to support the use of cognitive stimulation in dementia care but important questions about its effectiveness remain unanswered.
Author: Carmel Thomason is senior publishing manager, evidence resources, National Institute for Health and Clinical Excellence.
- Adapted from Eyes on Evidence (May 2012), a bulletin produced by the National Institute for Health and Clinical Excellence.
- Reproduced with permission
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Cognitive stimulation is an intervention for people with dementia that offers a range of enjoyable activities providing general stimulation for thinking, concentration and memory, usually in a social setting such as a small group. It is aimed at general enhancement of cognitive and social functioning, and family caregivers can be trained to provide cognitive stimulation on a one-to-one basis.
The World Alzheimer Report (Alzheimer’s Disease International, 2011) recommended that cognitive stimulation should be routinely offered to people with early stage dementia. However, in recent years, increased interest in its use in dementia has provoked concern about its effectiveness and potential negative effects on wellbeing.
The National Institute for Health and Clinical Excellence (2006) 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. This should be commissioned and provided by a range of health and social care staff with training and supervision, and offered irrespective of any drug prescribed for the treatment of cognitive symptoms of dementia.
The guidance also raised a need for more research into both the clinical and cost effectiveness of cognitive stimulation, both compared to and in combination with acetylcholinesterase inhibitors (donepezil, galantamine or rivastigmine).
NICE has a pathway on dementia (pathways.nice.org.uk/pathways/dementia) that brings together all related NICE guidance and associated products on the condition in a set of interactive topic-based diagrams.
A Cochrane review evaluated the effectiveness and impact of cognitive stimulation interventions aimed at improving cognition for people with dementia, including any negative effects (Woods et al, 2012).
The review included 15 randomised controlled trials involving 718 people with mild-to-moderate dementia, mainly in the form of Alzheimer’s disease or vascular dementia. Participants were treated in small groups and involved in different activities, including discussion of past and present events and topics of interest, word games, puzzles, music and practical activities like baking or indoor gardening. All activities were designed to stimulate thinking and memory. Improvements following cognitive stimulation were compared with those seen without treatment and with “standard treatments”, which could include medicine, day care or visits from community mental health workers or, in some cases, alternative activities such as watching TV and physical therapy.
Those who received cognitive stimulation interventions scored significantly higher in cognitive function tests. These benefits were still observed 1-3 months after treatment. In addition, positive effects on social interaction, communication and quality of life or wellbeing were observed in a smaller number of the trials, based on self-reported or carer-reported measures.
Where family members were trained to deliver cognitive stimulation on a one-to-one basis, no additional strain or burden on caregivers was reported.
Box 1. Commentary
David Anderson, Consultant in Old Age Psychiatry with Merseycare NHS Trust and honorary senior lecturer at the University of Liverpool.
The caveat to the findings of this Cochrane review is that many of the studies were of low quality and had a small sample size. Study populations varied and the protocols and content of therapy quite diverse. Cognitive stimulation therapy is not an easily defined intervention. Disappointingly, there is no evidence for an effect on function, mood or difficult behaviour.
Important questions remain: is there a need for maintenance sessions to sustain benefit beyond three months? What “dose” of stimulation is needed? What is the active ingredient(s)? How much therapist training is needed and are the benefits clinically meaningful? Is it cost effective?
Despite the limitations, there is evidence here to support the principle of “use it or lose it”. That one study achieved this by using family carers as therapists, without detriment to them, could help carers with the question “What can I do?” and to deal with their frustration of feeling powerless.
For professional carers, there is a message to develop a culture of stimulation for people with dementia in their care and keep people’s brains active if we want to do the best for them. There is more to supporting people with dementia than just administering care.
Alzheimer’s Disease International (2011) World Alzheimer Report. London: Alzheimer’s Disease International.
National Institute for Health and Clinical Excellence (2006) Dementia: Supporting People with Dementia and their Carers in Health and Social Care. Clinical Guideline CG42. London: NICE.
Woods B et al (2012) Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews; Issue 2, Art No: CD005562.