Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia
Spector A., Thorgrimsen L, Woods B, et al.;
Commented by , 25 Sep 2003
Aim of the Study
To test whether providing cognitive stimulation therapy to older people with mild-moderate dementia in residential homes and day centres would benefit cognition and quality of life.
Method
A single-blind, multi-centre randomised controlled trial recruited 201 older people with dementia to participate in a cognitive-stimulation group process.
Participants
169 day centres and residential homes in the public and private sectors from the North East London area were contacted. A minimum of 8 eligible participants was required at each centre. Inclusion criteria were DSM-IV diagnosis of dementia (in the absence of learning disability); ability to communicate/participate; no accompanying major mental or physical illness compromising participation; and Mini Mental State Examination (MMSE) score 10-24.
Study Design and Programme
18 residential homes and 5 days centres participated; of 292 people screened, 201 entered the study (115 treatment, 86 control). The 14-session programme ran twice per week, 45 minutes per session, using reality orientation and cognitive stimulation. It was based on the programme previously developed by Breuil and Spector; a systematic review had found this programme gave the best results.
Participants were randomly allocated to treatment or control groups. Control groups underwent ‘activities as usual’, in reality this was often ‘nothing’.
Outcome Measures
The primary outcome measure was the MMSE, a secondary measure was the Quality of Life – Alzheimer’s Disease scale.
Results
Of 97/115 participants in the treatment group and 70/86 in the control group were assessed at follow up. Mean attendance was 11.6 sessions. There were no significant demographic or other baselines differences such as severity of dementia between treatment group and controls, though centres varied quite widely.
Data was analysed using ANCOVA. The main finding was that at follow up, the treatment group had significantly higher scores on MMSE and the quality of life scale than controls with women showing a particular benefit.
A number needed to treat (NNT) analysis suggested that 6 people needed to be treated in order for one to benefit, a NNT that the authors says compares with cognitive enhancers and many other treatments in medicine.
Discussion
The improvements in cognition with a programme of reality orientation and cognitive stimulation are consistent with previous literature on the benefits of reality orientation (cf. the Cochrane Review published in 1998), and this study demonstrated a particular impact on quality of life, for women in particular.
There was a significant variation between participating centres. Not surprisingly, centres that were “institutionalised” with poor staff-patient relationships did less well; the authors postulate that the effects of the group intervention were not strong enough to overcome the debilitating effects of a negative environment.
It can be seen from the number of exclusions that this study was on a selected group and may not be generalisable. The single-blind methodology meant that staff ratings may have had an element of bias. Further, the duration of the groups (14 weeks in this study) could not delineate whether improvements would be sustained over time.
Overall, this study provides further evidence that group stimulation helps improve cognition in people with moderate dementia. In most areas of psychiatry, the drugs vs psychotherapy debate is now a sterile one, as in many cases, drugs and psychotherapy are complimentary. Are cognitive enhancers and reality orientation complimentary in moderate Alzheimer’s disease? This research is awaited.