Cognitive Stimulation Therapy (CST) Intervention in the Community

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1 Cognitive Stimulation Therapy (CST) Intervention in the Community Janice Lundy, BSW, MA, MHA Debbie Hayden, RN BSN, OTR-L Disclosures We have no relevant financial relationships to disclose CST Intervention in the Community Background What is Cognitive Stimulation Therapy How was CST developed Evidence-base CST in practice Our results Why CST works an OT perspective Questions 1

2 Background Initial interest in CST Research (financial reimbursement) Establishing OT support Funding Medical Community Education and referral Fall 2014 attended training and interview with Dr. Spector (UCL) London What is Cognitive Stimulation Therapy? An evidence based Psychosocial treatment for individuals with mild to moderate dementia Focuses on the improvement and strengthening of cognitive functions Maintenance of social and interaction skills Potential to improve mood and quality of life Development of CST CST developed by Dr. Aimee Spector under the direction of Dr. Martin Orrell and his team at UCL. 2

3 How was the CST Program Developed? Systematic review of the literature on the main nonpharmacological therapies. Reality Orientation Reminiscence Therapy Validation Therapy Multisensory Stimulation Spector et al (2000); Spector et al (2001); Woods et al (2005) Evidence Based CST Program For People With Dementia Spector et al 2003, Br Jr Psychiatry UK Randomized Control Trial (n=201) 14 sessions program ran twice a week for 45mins Sessions in residential homes & day centers Study measured group intervention program against usual activities which was described as usually nothing CST Study (Spector et al 2003) Found that ADAS cog scores, MMSE scores and QOL improved following CST CST results showed CST improved cognition, to those reported with effects similar to the currently available anti-dementia drugs 3

4 Additional Benefits of CST Significant impact on language skills including: Naming Word finding Comprehension (Spector et al. 20) No reported side-effects Has been determined to be cost-effective (Knapp et al. 2005) CST: Expanded Maintenance Cognitive Stimulation Therapy (MCST) Single-blind RCT Longer-term MCST (24 wks) Led to continuous benefits in quality of life (Orrell, Aquirre, Spector et al (2014) Individual Cognitive Stimulation Therapy (icst) Taught to caregivers by trained CST providers The UK Government NICE Guidelines on Dementia The only government recognized nonpharmacological treatment for dementia Government NICE guidelines recommend the use of group Cognitive Stimulation Therapy for people with mild to moderate dementia, irrespective of drug treatments received National Institute for Health and Clinical Excellence (2006) 4

5 World Alzheimer s Report (2012) The World Alzheimer s Report (Alzheimer s Disease International), stated that CST should routinely be given to people with early stage dementia. sreport2011.pdf Key Features of CST Program 14 CST sessions, usually twice a week 45 minutes to an hour Ideally 5-8 participants in a group, run by two therapists/facilitators Each session has a 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 Who is appropriate for CST? Meet criteria for dementia, SLUMS greater than? N O YES Can s/he have a meaningful conversation? N O YES Can s/he hear well enough to participate in a small group discussion N O YES Is her/his vision good enough to see most pictures? N O THIS PERSON SHOULD NOT BE INCLUDED IN THE GROUP YES Is s/he likely to remain in a group for 45 minutes? N Y O E THIS S PERSON MIGHT BE INCLUDED IN THE GROUP 5

6 Key Principles of CST 1. Mental stimulation 2. New ideas, thoughts and associations 3. Using orientation, both sensitively and implicitly 4. Opinions rather than facts 5. Using reminiscence as an aid to the here-and-now 6. Providing triggers to aid recall 7. Continuity and consistency between sessions 8. Implicit (rather than explicit) learning 9. Stimulating language. Stimulating executive functioning 11. Person-centeredness 12. Respect 13. Involvement 14. Inclusion 15. Choice 16. Fun 17. Maximizing potential 18. Building / strengthening relationships Session Structure Introduction Welcome every member individually Group name Soft ball toss ( warm up and orientation of members) Reference to day, weather, season (always on board as cue). Any discussion of important events in their lives since last session Theme Group Song Current Affairs (Local and national). Main Activity Suggested activities for home (may include in take home handout). Closure (discuss time, day, and activity for next session-get opinions) CST SCREENINGS SLUMS Self DP CG DP Self QOL AD CG QOL AD Pre Post 6

CST SLUMS VARIANCE 40 36.5 38.5 39.2 36.6 35 30 25 21.6 25.7 31.7 25 33 31.8 29.75 28 26.5 26 20 15 5 7.5 16.1 18.1 14 8.6 6.4 5.25 2.65 2.3 18.8 14.4 15.3 7.

7 CST SLUMS VARIANCE SLUMS SLUMS Self DP Self DP CG DP CG DP Self QOL Self QOL CG QOL CG QOL AD AD AD AD Pre test Post test Pre test Post test Pre test Post test Pre test Post test Pre test Post test SLUM < SLUMS 19 SLUMS Gender: mean Pre SLUMS Post SLUMS Pre Self DP Post Self DP Pre CG DP Post CG DP Pre Self QOL AD Post self QOL AD Pre CG QOL AD Post CG QOL AD Male n =6 Female n=13 CST Success Cognition-SLUMS:75% Depression-Cornell: 80% Quality- QOL-AD: 90% MCST: 70% 7

8 CST PROVISION CST:14 sessions, twice a week Maintenance CST (MCST): weekly Individual CST (icst) An OT Perspective on Participant Goals For CST Initially looked at ADL performance, however, saw limited progress in most clients. (Canadian article) Areas of Progress Identified: 1. Increased presence or engagement in life 2. More aware and interactive in conversations activities in the home. 3. Increased interest in activities (playing cards) 4. Improved mood and behavior (less irritability and anxiety, more cooperative and happier). 5. Improved memory and recall requiring less prompting and cuing. Why Does CST Work : An OT Perspective Short Term Memory- How many pieces of information you can hold onto for short period of time. Information comes in from auditory and visual systems primarily. Long Term Memory- If value is placed on information in short term will move to long term. Intensity about information helps it stick. Working Memory- Taking information from short and long term and assimilating or manipulating it. Basis for higher executive function. CST guides participants through prompting memories and thoughts to stimulate working memory for assimilation and manipulation of thoughts. Turning the lights on. 8

9 Affect of Stress on Memory HPA axis (slide ) Hippocampus along with several other areas of the brain is responsible for telling hypothalamus to turn off the cortisol producing mechanism (feedback system) once levels reach a certain level Hippocampus is structure in brain that helps connect new information with what we already know- basis of learning. Everything we learn, read, do and understand relies on hippocampus. Brains production on new neurons and laying down connections to others takes place in the hippocampus (neurogenesis). Retention of memories relies on neuronal activity. Hippocampus-area susceptible to damage from cortisol levels. High levels of cortisol result in damage to hippocampus and lead to decreased feedback system and more cortisol production. Older persons often have lost 20-25% of cells in their hippocampus which causes even more cortisol production. Degenerative Cascade. (Brain Longevity, Dharma Singh Khalsa, M.D.) Benefit of CST: Low Stress Environment Participants perceive as an enjoyable experience more likely to continue to participate Provides for controlling anxiety and therefore the HPA axis cycle activation by avoiding placing participant in an uncomfortable or anxious position this in turn allows for memory recall and learning to take place Sense of belonging, sense of achievement and getting physiological rib cage expansion with slow release all aide in serotonin release Improves overall self-esteem QUESTIONS? 9

10 References Goosens KA, Sapolsky RM. Stress and Glucocorticoid Contributions to Normal and Pathological Aging. In: Riddle DR, editor. Brain Aging: Models, Methods, and Mechanisms. Boca Raton (FL): CRC Press; Chapter 13. Hall L, Orrell M, Stott J, and Spector A (2013). Cognitive stimulation therapy (CST): neuropsychological mechanisms of change. International Psychogeriatrics, 25, pp National Institute for Health and Clinical Excellence (2006). Dementia: supporting people with dementia and their carers in health and social care. NICE clinical guideline 42, November Orrell et al.: Individual Cognitive Stimulation Therapy for dementia (icst): study protocol for a randomized controlled trial. Trials :172. References Orrell M, Aguirre E, Spector A, Hoare Z, Woods RT, Streater A, Donovan H, Hoe J, Knapp M, Whitaker C, Russell I (2014) Maintenance cognitive stimulation therapy for dementia: single-blind, multicentre,pragmatic randomised controlled trial. Br J Psychiatry Jun;204(6): Spector A, Orrell M. (20). Using a biopsychosocial model of dementia as a tool to guide clinical practice. International Psychogeriatrics 22(6): Spector A, Orrell M, Davies S and Woods B (2000). "Reality Orientation for dementia: A review of the evidence of effectiveness from randomised controlled trails." The Gerontologist, 40 (2), Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M and Orrell M (2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: Randomised Controlled Trial. British Journal of Psychiatry, 183: References Woods R, Spector A, Jones C, Orrell M and Davies S (2005). Reminiscence therapy for dementia: A review of the evidence of effectiveness from randomised controlled trails. In The Cochrane Library, 2,

INTRODUCTION Cognitive stimulation is defined as engagement in a range of activities and discussions

INTRODUCTION Cognitive stimulation is defined as engagement in a range of activities and discussions Protocol: The effect of individual Cognitive Stimulation Therapy delivered by trained volunteers on cognition and quality of life in people with mild to moderate dementia: A pilot randomized controlled