Cognitive stimulation therapy for people with dementia: cost-effectiveness analysis
Knapp M, Thorgrimsen L, Patel A, Spector A, Hallam A, Woods B, et al.;
Commented by , 25 Jul 2006
Background
Psychological therapies for people with dementia are developing, but have rarely been rigorously evaluated, with the exception of Cognitive Stimulation Therapy (CST). This was developed in 1998 from the findings of two Cochrane reviews, incorporating aspects of psychological therapies that demonstrably improve cognition and behaviour. A previous study published in 2003, by the same authors, suggested CST improves quality of life and cognitive abilities.
Aims
To investigate the cost-effectiveness of a CST programme for people with dementia as part of a randomized controlled trial.
Method
Recruitment
The managers of 169 possible care homes and day centres around the north of London were approached, and asked to identify possible participants able to give informed consent who were then screened by researchers. The main inclusion criteria were MMSE score 10 – 24, and ability to engage in a group process. Participants were randomized to receive either CST or "usual activities" (which often comprised doing nothing).
Intervention
CST groups ran for 7 weeks, twice weekly for 45 minutes. Each group consisted of 5 participants, the therapist, and one member of the care staff team, using principles of reality orientation and reminiscence therapy. A detailed description of the programme is in (ref. 1). The outcome measures were repeated in week 8, after the CST intervention had ceased.
Cost-Effectiveness Analysis
Each session was costed at £90, with 5 people in a group, the cost of the intervention per person per week was £31.50. A cost-effectiveness analysis was performed comparing the above costing with changes in the primary outcome measure (the MMSE), and the secondary outcome measure (quality of life as measured by QoL-AD).
Results
23 centres were recruited; of 292 people screened, 201 were included. Previous analysis of the outcome showed modest improvement in MMSE and QoL-AD for people receiving CST compared to controls. There was a trend for decreased use of hospital services, and decreased use of medication, in the intervention group. Building these factors into the cost-effectiveness calculation, CST was calculated to be cost-effective for both outcome measures: MMSE score and quality of life.
Dr Seymour's comments
Psychotherapeutic interventions in the field of dementia care are shifting from carers to the index person with (early) dementia. To evaluate their effectiveness, interventions need to be developed that are evidence-based, consistent, reproducible, quantifiable, and acceptable to people with dementia. Cognitive stimulation therapy is promising in several of these parameters.
This study sought to build on the authors' previous findings that CST leads to modest improvements in cognition, quality of life and behaviour in people with dementia. They sought to establish that the intervention was cost-effective, though over an 8 week period, their findings were not very convincing.
The study thus highlights the limitations of crude health economic analyses applied to complex illnesses, where outcome is dependent on multiple interacting social, medical and psychological factors. Cognitive stimulation therapy may be cost-effective, but this study does not prove it.
Reference
1. Spector A, Orrell M, Davies S, Woods B. Can reality orientation be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people with dementia. Psychology Press 2001, 3-4 (11); 377-397