Tools and skills to facilitate running Cognitive Stimulation Therapy (CST) groups effectively. Amy Streater & Elisa Aguirre Research Assistants & PhD students OC077

Conflict of Interest Disclosure Amy Streater & Elisa Aguirre, MPhil. Has no real or apparent conflicts of interest to report.

Overview CST for dementia  Background  CST principles / structure / sessions Practicalities of running CST groups  Settings  Facilitation  Evaluation

NICE-SCIE guidance (2006) People with mild/moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme … irrespective of any anti- dementia drug received …’

CST Background ‘ Reality Orientation’ (RO) marked a breakthrough in dementia care Criticism of RO: applied in a rote, uninspired way, (Dietch, Hewitt and Jones, 1989), insensitive to individual needs (Powell-Proctor & Miller, 1982) RO Cochrane Review (Spector et al., 2000)

CST trial (Spector et al., 2003) multicentre Randomised Control Trial (RCT) n= 201 BL / 168 FU, 23 centres Found a significant improvement in the primary outcome measures: cognition and quality of life. No significant results were found for the secondary outcome measures: mood (depression and anxiety) & activities of daily living. CST shown to be more cost-effective than usual activities and compared favourably with anti- dementia drugs (Knapp et al., 2005).

Maintenance CST Pilot Maintenance CST (Orrell et al., 2005) found that maintenance CST led to continuous cognitive benefits. Whereas, CST only led to a gradual decline. -Pilot involved 16 weekly session following CST programme -Piloted in 2 experimental homes, 2 control homes Limitations: Small sample (35), homes volunteered Currently a multicentre RCT of Maintenance CST is being carried out by UCL / NELFT

Cognitive Stimulation Cognitive Stimulation Therapy… ★ Targets cognitive and social function ★ Social element enhanced by having in a group environment or with the family caregiver. ★ Cognitive activities do not primarily consist of practice on specific cognitive modalities

Concepts of CST sessions Aim to be mentally stimulating, yet for people to feel empowered rather than de-skilled 45 minutes / 14 sessions Group name Theme song Warm-up activities Roles for members RO board

CST Key Principles Orientating people sensitively / when appropriate Information processing and opinion rather than factual knowledge  implicit learning Multi-sensory stimulation Flexibility in the activities to cater to the groups needs Using reminiscence (as an aid to here-and-now) Building / strengthening relationships Empowering for staff running groups

CSTPilot MCST ThemeMCST 18Physical games8 27Sound7 31My life1 & 23 4Food3 & & 3Current affairs2 & Faces/ Scenes15 711Associated Words, discussion18 8Being creative4 99Categorising objects9 10Orientation19 11Using Money20 125Number game5 1316Word game16 146Team games. Quiz6 NEWUseful tips11 & 24 NEW12 & 13Thinking cards12 & 22 NEW14Art Discussion14 NEWVisual Clips Discussion13 NEW4 & 10Household Treasures10 CST/MCST Sessions

Household Treasures

Session Structure  Introduction  Theme Song  Current Affairs  Main Activity  Closure

Setting up the group Ideally 5-8 people in groups, run by two facilitators Each session has choice of activities, to cater for interests and abilities of group Group members should ideally be at similar stages of dementia, so activities can be pitched accordingly Attention should be paid to gender mix

Inclusion Criteria THIS PERSON SHOULD NOT BE INCLUDED IN THE GROUP Diagnosis of dementia (DSM IV) with CDR 0.5 / 2 Can s/he have a “meaningful” conversation? Can s/he hear well enough to participate in a small group discussion? Is her/his vision good enough to see most pictures? Is s/he likely to remain in in a group for 45 minutes? YES NONO NONO NONO NONO NONO THIS PERSON CAN BE INCLUDED IN THE GROUP YESYES

Preparing for the groups Assessment of individuals – strengths, sensitive areas, interests, literacy, etc Explaining nature and purpose of CST groups. Discussing continued assent – that people can withdraw at any time, with no negative consequences. Organising transport, a room, staff. Preparing folders for group members.

Monitoring Progress Keeping records of attendance, notes following all sessions Monitoring progress form included in the CST manual Outcome measures, including: ★ MMSE - to measure cognitive change ★ QoL-AD - to measure quality of life Feedback from group Regular supervision is essential

Future of CST Development and evaluation of the Maintenance CST programme. An evaluation and comparison of the effectiveness of two different CST training approaches and its implementation in practice. Individual CST (iCST)

Useful resources Speechmark Publishers Winslow The Robert Opie Collection (reminiscence) Toy museum

Thank you for listening

Knapp M, Thorgrimsen L, Patel A, Spector A, Hallam A, Woods B and Orrell M (2006). Cognitive Stimulation Therapy for people with dementia: Cost Effectiveness Analysis. British Journal of Psychiatry, 188: Orrell M, Spector A, Thorgrimsen L & Woods B (2005). A pilot Study examining the effectiveness of maintenance Cognitive Stimulation Therapy (MCST) for people with dementia. International Journal of Geriatric Psychiatry, 20: Spector A, Orrell M, Davies S & Woods B (2000). A systematic Review of the use of Reality Orientation in dementia. The Gerontologist, 40 (2): References

Spector A, Thorgrimsen L, Woods B & Orrell M (2005). Making a difference…An evidence-based group programme to offer cognitive stimulation therapy (CST) to people with dementia. UK: Hawker Publications. Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M & Orrell M (2003). Efficacy of an evidence-based Cognitive stimulation therapy programme for people with dementia: Randomised controlled trial. British Journal of Psychiatry, 183: CST website:

Maintenance Cognitive Stimulation Programme (ISRCTN )) is part of the Support at Home - Interventions to Enhance Life in Dementia (SHIELD) project (Application No. RP-PG ) which is funded by the NIHR Programme Grants for Applied Research funding scheme. The grantholders are Professors Orrell (UCL), Woods (Bangor), Challis (Manchester), Moniz-Cook (Hull), Russell (Swansea), Knapp (LSE) and Dr Charlesworth (UCL). This report/article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research sheme (RP-PG ). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Acknowledgements