1. Cognitive Stimulation Therapy on an Acute Psychogeriatric Ward
M Parker Senior Occupational Therapist
Helen Plesner Occupational Therapy Assistant
Kingsley Mortimer Unit , North Shore Hospital, Waitemata DHB

2. Aim
Explain the rationale for adapting CST in an acute psychogeriatric setting.
Report on observations of patient enjoyment, communication, interest and mood over 14 weeks from June- October 2015.
Report on patient feedback that was collected.
Comment on issues and adaptability of CST approach to a mixed inpatient unit.

3. Cognitive Stimulation Therapy (CST)
CST is an evidence based approach for persons with mild to moderate dementia (Woods et al 2012).
It improves outcomes in cognition, communication and quality of life (QOL) for the person with dementia.
A pilot study in New Zealand (Cheung and Peri, 2014) replicated the results found in the literature.
The World Alzheimer Report 2011,4 in a systematic review of psychosocial approaches for dementia care, concluded that cognitive stimulation had the “strongest evidence by far” for cognitive benefits in dementia.

4. Cognitive Stimulation Therapy (CST)
CST is a structured group treatment of 14 sessions over 7 weeks.
Uses an orientation and reminiscence approach with activities and social interactions.
Twice weekly groups for seven weeks.
Closed group of 6 to 8 people with dementia in a community setting or residential facility.

5. Clinical Context
Waitemata DHB serves 600,000 people with 75,000 over 65 years of age.
Estimated number with Mental Health conditions over 65 years of age ~14,000.
Highest Life expectancy (86 years) yet lowest institutionalisation rate.
The DHB has an estimated 7,700 persons with dementia.
Largest cohort of persons with dementia live in new Zealand live in Waitemata DHB ~ 1/7 persons with dementia ex. Double that of CMDHB

6. Kingsley Mortimer Unit
Kingsley Mortimer Unit (Ward 12) is a 19 bed Older Adults Mental Health Unit.
Mental Health Services for Older Adults -ward and four community teams.
Allied Health staff OT, OTA, PT, SW and psychologists.
It has a through-put of 160 patients with an average LOS of ~ 37 days.
(West, North and Rodney) and the Sub Acute Treatment and Rehab team (STaR)

7. Ward 12 Clinical Conditions
Major Depressive Episode +/-psychosis, +/-suicidal ideation or attempt.
Anxiety - severe +/- cognitive impairment.
Bipolar Affective Disorder (BPAD).
Dementia with behavioural and psychological symptoms of dementia (BPSD).
Mental Health issues overlaid on Parkinson’s Disease + Stroke.
60-70% usually having some cognitive impairments.
The rationale for choosing CST approach was due to the high percentage of patients with cognitive impairment. They may initially present with severe depression or anxiety but once treated cognitive impairments become apparent

8. Rationale for using CST
Large number of persons with cognitive impairment.
Initially present with severe depression or anxiety but, once treated, cognitive impairments become apparent.
Wanting evidence based approaches used for group therapy inputs.
Part of OT role development in 2015.

9. Issues using CST Open group required due to admissions and discharges.
Number of sessions provided would vary so variable CST dosage
Higher and lower functioning patient cohorts mixed on ward.
Average LOS is less than 7 weeks

10. What we did
Ran an open group using CST approach four times weekly on Kingsley Mortimer unit from June 2015.
Reviewed by CST trainer, September 2015.
Patient observations kept for 42 sessions (June- October).
Collected patient feedback (46 patient comments from 12 groups).
OT trained at CST workshop May 2015 trained OTA with manual and demonstration.
Comments – a) name badges, b) reduce busyness in group c) ask for opinions rather than questions cannot answer.
June 15 3 sessions July sessions
August 18 sessions Sept 12 sessions 4 October 5 sessions observed.

11. Patient Cohort 51 patients attended CST groups Attendance 1-14 groups
Dementia 43%
Depression 25%
Depression + psychosis 11%
Anxiety 11%
BPAD 10%
Schizophrenia and Schizoaffective Disorder 7%
Psychotic disorder 13%
Attendance - dependent on length of admission and willingness to attend.
Total comes to 120% as 20% patients had dementia/ Cognitive impairment as a secondary diagnosis though were admitted with another diagnosis

12. Results Patient observations by staff attending group (42 sessions).
Rated enjoyment, communication, interest and mood (1-5).
Despite large cohort of depressed patients most scored ‘3’ or above in, interest (84%), communication(86%), mood(77%) and enjoyment(76%).
Low mood (20%) correlated with Low enjoyment (19%)
Surprising result as often acutely unwell.
Ratings were observational
a) observing patient interactions and comments in the group b) asking them re group enjoyment c) Presenter and facilitator jointly agreed when both present
b) liekhart scale 1-5
c) Large cohort of depressed patients some acutely unwell as well as dementia patients- most were able to communicate and show interest in group activities and topics.

13. Results

14. Results

15. Results

16. Results

17. Patient Feedback Themes
46 patient comments from 12 groups.
Themes
Interesting variety
Active minds
Learning things
Fun
Activities were interesting and had variety which kept most patients stimulated in the group sessions
Theme of cognitive simulation present “Kept our minds active” “kept our brains working”
Learning – that patients enjoyed hearing and learning about new things eg where group member's had holidayed
Support of group felt was important
Two neutral comments It was ok and one negative “ played game but too close to lunch”

18. Theme-Fun
Group Names.
Song- changed every three weeks at patient request.
Mystery objects- to prompt reminiscence theme.
News items - numerous topical items (e.g.) Gangs in NZ, flag changes, children's health
Ways we have trided to design a fun’ element into the programme.
Clever clogs, The Remarkable, Dolphins, Ravens Phenomenal thinkers, Brain Trust and Green Mascots have all been group names suggested by participants
Songs- Do ra Me, Bridge over troubled Water, edelweiss, Jamaican farewell have been chosen by group vote
Mystery Objects- Cast Iron Griddle, Kauri Snail, Door Mincer, Old milk bottles , replica reed boat and other items have

19. Cultural Adaptations
CST has adapted well to several cultures -Tanzania Nigeria India and Japan.
Japanese CST-J pilot with similar results on original studies in Great Britain (Yamanaka et al 2013).
Guideline for adaptation to different cultures completed. Steps include programme trial, manual translation and revision by cultural stakeholders (Aguirre et al 2014).

20. Maori Language Week
OTA designed module completed in Maori language week.
a) Maori Greetings /mihi
b)Maori proverbs/whakatauki , meaning
c) Simple nouns (e.g) maunga (hill) nui (big)
d) Maori place names beginning with “ T”
e) Location of Iwi on map
f)Maori word to English word matching quiz
OTA ran modules for Maori language group with mostly Pakeha patients- later found out about literature for CST being culturally adapted
Discussion reminisce exposure to Te Reo at school

21. Theme 1:Adaptability of CST approach
Not a ‘precious’ approach.
Due to increased frequency of group, staff had to introduce more activities not in manual.
Followed use of structure and principles.
“Improvise - the programme is not meant to be rigid but to stimulate your own creativity, ideas and thinking” p47 (Spector et al 2006).
This is the main theme I want to emphasise CST is not a “precious approach” that you have to activity x on day 5 of the programme rather
there can be some improvisation of activities if the structure and principles are followed
New activities included
Art- artists they knew, famous paintings and galleries they had visited Activity on Toys form their youth, and a classic toy display was provided by Helen Plenser
Chickens- reminisce rearing chickens, chicken types, chicken care
Collage on creativity Spring poem, making a group programme

22. Activities Adapted
Art- artists they knew, famous paintings and galleries they had visited.
Activity on Toys from their youth, and a classic toy display was provided by occupational therapy assistant.
Chickens- reminiscence about rearing chickens, chicken types, chicken care.
Travel stories with large wall map.
Spring poem, making a group poem.
Just some of the activities that were introduced by OTA Helen Plesner.

23. Staff Themes/ Programme strengths
Unexpected reminiscence.
Helpful maintaining mood.
Higher functioning usually very supportive
Confidence to staff using evidence based principles to run groups.
Ability to adapt to level of impairments of group.
CST overdose- no negative effects.
1) As people were introduced to topic themes or objects from the past this triggered further memories which they were able to share with the group and affirmed the persons remaining strengths
Topics opened up unexpected reminisce for participants and facilitators- eg one man talking about cycling to Wellsford on a gravel road as a young man, another reminisce recently on the stories of their engagement rings
2) Frequently higher functioning persons without cognitive impairment attended often supported those with dementia by guiding peers towards the group room , turn taking allowing time for responses
3) Not running around ‘making it up as I go’ but that applying EBP to groups- this increased the confidence in the main group facilitator Helen Plesner
4) Adaptability of group can be targeted to level of ability of group particpants

24. Weaknesses
Never designed as a robust study with before and after outcome measures.
Kept observations as a way to validate approach for ward as a quality improvement.
A NZ first and may be first anywhere to use CST on mixed clinical cohort of Mental Health diagnoses as well as persons with dementia.
Ideally could be trialled in different settings using robust outcome measures in QOL and cognition.
A little aside contacted Dr Aimee Spector about the cultural adaptations and use with other conditions.
She cautioned against use with depressed patients as not validated approach . Oopsee we’ve already been doing this for 14 months with positive feedback from patients

25. Going Forward CST approach used DHB wide.
CST as a front end approach to maintain cognition and function for persons with mild-moderate dementia.
As CST improves QOL, may eventually reduce the incidence of BPSD in some patients dosed regularly with CST.
Front end approach- instead of waiting for things to progress and get worse can aid living well with dementia
Though not tested in literature we have found those patients able to participate in groups with moderate dementia can aid improved behaviour. Even at late stages of dementia the social niceties in a group setting can sometimes be followed
Waitemata DHB supports CST on ward and in three community settings. As the largest DHB with the largest number of dementia patients this is an approach that can maintain QOL and functional ability and may reduce the presentations of BPSD in crisis mode at a later stage.

26. Going Forward
Adaptability of approach, both culturally, with new activities and to level of person with dementia.
Trial CST Maori language modules with stakeholder inputs for revision.
World Alzheimer Report stated that cognitive stimulation had the “strongest evidence by far” for cognitive benefits in dementia.
Thank You
Plan to present CST module to DHB Kaumatua for stakeholder feedback and adapting for use with Kuia/Kaumatua who speak Te Reo.
The World Alzheimer Report 2011,4 in a systematic review of psychosocial approaches for dementia care,

27. References
Aguirre E., Spector A., Orrell M., (2014) Guidelines for adapting cognitive stimulation therapy to other cultures . Clinical Interventions in Aging –1007
Cheung, G. and Peri, K., (2014) Cognitive stimulation therapy: A New Zealand pilot. Auckland: Te Pou o Te Whakaaro Nui.
Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M, (2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. British Journal of Psychiatry 2003;183:248–54.
Spector A, Thorgrimsen L, Woods RT, Orrell M. Making a Difference: An Evidence-Based Group Programme to Offer Cognitive Stimulation Therapy (CST) to People With Dementia. London: Hawker Publications; 2006.
Woods B, Aguirre E, Spector A.E, Orrell M. (2012) Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD DOI: / CD pub2.
Yamanaka K., Kawano Y., Noguchi D. , Nakaaki S., Watanabe N. , Amano T.,& Spector A. (2013): Effects of cognitive stimulation therapy Japanese version (CST-J) for people with dementia: a single blind, controlled clinical trial, Aging & Mental Health, DOI: /