Overview: Cognitive stimulation is an intervention for people with dementia which offers a range of enjoyable activities providing general stimulation for thinking, concentration and memory usually in a social setting, such as a small group, aimed at general enhancement of cognitive and social functioning. Family caregivers can be trained to provide cognitive stimulation on a one-to-one basis.
In 2011, the World Alzheimer’s Report
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.
Current advice: NICE 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 appropriate 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
, which brings together all related NICE guidance and associated products on the condition in a set of interactive topic-based diagrams.
New evidence: 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.
Results showed that those who received cognitive stimulation interventions scored significantly higher in cognitive function tests. These benefits were still observed 1 to 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 care givers was reported.
Commentary: “The caveat to the findings of this Cochrane review is that many of the studies were low quality and with 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 3 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.” – David Anderson, Consultant in Old Age Psychiatry with Merseycare NHS Trust and Honorary Senior Lecturer at the University of Liverpool.