Cognitive Stimulation Therapy - New Zealand and an International Perspective

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1 Cognitive Stimulation Therapy - New Zealand and an International Perspective Dr Kathy Peri School of Nursing University of Auckland

3 Cognitive Changes over time

4 Non pharmacological approaches in Dementia Physical exercise Cognitive Intervention (individual or group) 1. Aerobic exercise 2. Strength exercise 1. Cognitive training (CT) individual approach practice of standard tasks; a range of difficulty levels within the standard set of tasks to suit individual s level of ability 2. Cognitive stimulation (CS) usually group stimulation - engagement of activities and discussions aimed at enhancing cognitive and social functioning 3. Cognitive rehabilitation (CR) individual approach emphasis based on improving performance in everyday life rather than on cognitive tests

5 2011

6 Cognitive stimulation therapy Cognitive stimulation therapy351 is the psychological approach with the strongest evidence for improving cognition.

6 6 Cognitive stimulation therapy Cognitive stimulation therapy351 is the psychological approach with the strongest evidence for improving cognition. It stems from reality orientation and is usually group-based. It consists of group sessions led by a trained coordinator incorporating social activity, reminiscence, and simple cognitive exercises (panel 2). Results of meta-analyses352,353 found that cognitive stimulation therapy benefits general cognition (Hedges g effect size 0 51, 95% CI , equivalent to a mean difference of cognitive stimulation therapy vs control of 1 78 points; 95% CI on the MMSE; figure 9),352 which is similar to that of cholinesterase inhibitors; although, unlike in cholinesterase inhibitor trials, the control group in cognitive stimulation therapy trials353 has no placebo therapy. A Cochrane review353 found that cognitive stimulation therapy might improve self-reported quality of life (standardised mean difference [SMD] 0 38, 95% CI 0 11 to 0 65), but had no significant effect on activities of daily living (0 21, 0 05 to 0 47). Cognitive

7 Cognitive Stimulation Therapy (CST) A structured group treatment for people with mild to moderate dementia Theoretical concepts of reality orientation, validation, reminiscence, and cognitive stimulation World Alzheimer Report 2011, Cochrane Review 2012, NICE Guidelines

8 CST Program Maximum number per group 7-8 Sessions twice a week for 7 weeks Maintenance (optional) sessions once a week for 24 weeks Both community and residential care settings Delivered by health professionals

9 CST: Key Principles Mental stimulation Inclusion Opinions, rather than facts Involvement Use of reminiscence Choice Respect Build and strengthen relationships Person centered Maximize potential And most all have.fun

10 NZ Experience 1. Feasibility study 2. Formulate competencies 3. Training workshops Master Classes 150 to date Undergraduate SLT, Nursing, OT curriculum Masters Students Public engagement

11 CST Feasibility Study Te Pou Report Publication date: 21 January 2015 Cognitive stimulation therapy (CST) is a structured group therapy for people with mild to moderate dementia. This report looks at the acceptability of CST in the New Zealand context. The report evaluates two pilot CST groups held in community and residential care settings. Key findings CST is an acceptable psychological therapy for older people with a clinical diagnosis of mild to moderate dementia. It is able to be delivered relatively easily in both community and residential care settings. Benefits of CST include a positive effect on mood, improved memory, and improved quality of life.

12 ARC Narratives We started with 7 depressed residents with mild to moderate dementia and ended with 6 (one died who demanded to go to memory group the day before she died) and ended with 6 happy healthy friends who are no longer clinically depressed (Clinical Nurse Manager) NB: not one resident was charted medications for depression while participating in this group.

13 ARC Narrative Resident X cried much of the day and wandered aimlessly now strides with purpose and recalls events from the past to share with the group. He laughs at himself and has strong opinions to share. He expressed he was too stupid to belong to the group but his friends patted his shoulder and told him he was important to the group and valued. He has shown the most improvement. He knows he can t remember but his lack of memory no longer defines who he is.

14 Community CST Original CST group graduated to Maintenance CST still running - lead by one participant Narratives of PWD Thanks for giving me back my brain Thanks for getting me back to my old routines in the home I can be left at home now for a few hours on a Friday so my husband can go to the club

15 Adapting CST to Other Cultures Aguirre et al, 2014

Pepeha. Draw plan of marae. Toys made by group.

Barley sugars 4. Food Rotten corn, crayfish 5.

16 Themes Modifications 1. Physical games Stick games, poi, creative in team work i.e. taiha, Kupa Haka 3. Childhood Pictures of marae, mountains, rivers. Pepeha. Draw plan of marae. Toys made by group. Knuckle bones. Sweets blackballs. Barley sugars 4. Food Rotten corn, crayfish 5. Current affairs Community newsletter, Maori politics 6. Faces / scenes Pictures of maraes

17 CST Facilitators Research shows three main skills required to be an effective CST facilitator: 1. Knowledge of dementia (1-4) 2. Understand the Principles of CST (5-8) 3. Successfully implement a CST program in a (variety) of settings (9-11)

18 Competencies 1-6 Competencies Learning & teaching activities Assessment A competent CST facilitator should be able to 1. Describe the etiologies of mild to moderate dementia, including the pathophysiology of Alzheimer s disease 2. Understand the clinical features of mild to moderate dementia 3. Understand the neuroanatomy and impact of communication and language deficits for people with dementia 5. Describe the key principles and evidence base of CST and Maintenance CST (MCST) Pre-reading: Cummings & Cole Alzheimer Disease Pre-reading: UK Alzheimer s Society Factsheets on What is dementia? and What is Alzheimer s disease Formal Teaching Session Formal Teaching Session 4. Describe the role of the CST facilitator Formal teaching session 6. Apply the principles of person centred care to CST Pre-reading: Brooker D (2004) What is personcentred care in dementia? Peer observation, feedback & reflection

19 Competencies Conduct a CST session according to the structure 8. Facilitate group participation during a CST session 9. Set up and implement a CST program in various settings Role play Role Play Demonstration on DVD Formal teaching session Formal teaching session Peer observation, feedback & reflection Peer observation, feedback & reflection 6 month follow up by CST team 10. Involve families and friends during a CST program Group discussion 6 month follow up by CST team 11. Evaluate a CST program and provide feedback to other CST facilitators Formal teaching session - Experiential learning - Feedback - Routine outcome measures 6 month follow up by CST team

20 Self Assessment Pre- and Post Training (n=20) Strongly Disagree Disagree Neutral Agree Strongly agree Agree Agree Agree Agree Agree Agree Pre Post Pre Post Pre Post 4. Key principles and evidence base of CST 5. Role of a CST facilitator. 6. Apply the principles of person centred care to CST.

21 Self Assessment Pre- and Post Training (n=20) Strongly Disagree Disagree Neutral Agree Strongly agree Agree Agree Agree Agree Pre Post Pre Post 7. Conduct a CST session according to the structure 8.Facilitate group participation.

22 Post workshop follow up - Peer observation, feedback & reflection - 6 month follow up by CST team - NZ CST Website & online discussion & support -

23 Individual icst UK icst did not improve cognition or quality of life for people with dementia, or carers physical and mental health. Some evidence of improvement in terms of the caregiving relationship and carers health-related quality of life, Most people received fewer than the recommended number of icst sessions.

24 icst Pilot Study Alzheimer's Auckland in partnership with University of Auckland icst being delivered by Key workers Alzheimer accredited volunteers Waiting Control - Usual care Twice a week for 10wks (modified) for mins Baseline, 12wk and 18 wk follow ups with participants and carers (Blinded assessors) to be completed September 2017

25 Results Adherence to 20 sessions 85% 7 keyworkers in the keyworker arm (9 participants) 9 volunteers in the volunteer arm (10 participants)

26 Main themes from two focus groups of keyworkers and volunteers Establishing a trusting therapeutic relationship Just by virtue of being in her life twice a weekmy client did disclose she had depression and these conversations just wouldn t have happened. We wouldn t have gotten to know each other that well.

27 Benefits for clients Feeling valued, stimulation through activities and gaining confidence A lot of people with dementia are forgotten about or left aside. Being part of something makes them feel special Understanding the live experience Really helped me understand about how people with dementia are

28 Engaging caregivers I think we need to open the training to family members so that they can continue the sessions and then everyone will be speaking the same. If they know the tools about the way to talk to them give ideas and resources with a few ideas of how to keep them engaged.

29 Individual icst Feasibility Results Feasibility issues examined: Recruitment of participants (Montreal Cognitive Assessment score 15) Recruitment of volunteers Training of keyworkers and volunteers Adherence to treatment protocol (twice weekly for 10 weeks)? Use of outcome measures

International CST Picture Australia Brazil

Philippines Portugal Singapore South Africa

30 International CST Picture Australia Brazil Canada Chile China Denmark Germany Greece Hong Kong India Indonesia (Jakarta) Israel Ireland Italy Japan Nepal Nigeria Philippines Portugal Singapore South Africa South Korea Tanzania Turkey The Netherlands United States 30

31 New Activity CST App development (Italy) Dr Simona Gardini, University of Parma Television icst (UK) CST Research team MRI scanning (Hong Kong) CST and physical activity (USA) Bi Annual Conferences USA (St Louis University; 2019)

32 Thank you Any Questions

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