Dementia defines a set of syndromes characterised by cognitive decline including memory loss, executive functions, and language impairment, which affects different areas of daily functioning, such as social and occupational. Recently, the need for early intervention for people with dementia (PWD) has been highlighted, and Cognitive Stimulation Therapy (CST) has been particularly successful.
CST promotes the “engagement in a range of group activities and discussions aimed at general enhancement of cognitive and social functioning” (Clare and Woods, 2004, p. 387). It is cost-effective (Knapp et al., 2006), and the only psychosocial intervention recommended by the National Institute for Health and Clinical Excellence (NICE, 2018) to improve PWD’s cognition. Additionally, Maintenance CST (MCST) and individual CST (iCST) were developed to examine CST benefits over time and offer family caregivers a deliverable-at-home intervention, respectively.
In this field, qualitative research has been relatively neglected, although it is essential for understanding the intervention’s impact on people’s life (Craig et al., 2008). Gibbor et al. (2020) attempted to fill this gap by conducting a systematic review of qualitative studies of CST, MCST, and iCST, focusing on PWD’s, their carers’, and facilitators’ personal experiences. The authors are the first to investigate all CST formats, including international versions of the intervention. Specifically, they aimed to answer what do qualitative studies on CST reveal about its a) acceptability and feasibility, (b) key features, and (c) effects.
A review and analysis of qualitative research focusing on all CST formats was conducted. Included studies were published in English and involved formal interview procedures.
To search for relevant papers, the researchers searched five major healthcare databases and consulted two original developers of CST and iCST. They then assessed the quality of shortlisted studies by rating them out of 10, based on an instructional checklist criteria (CASP, 2018). Papers scoring two standard deviations below the mean were excluded from the analysis, since the quality of each included paper would ultimately affect the quality of the review.
To combine and interpret all qualitative findings, the authors performed the following steps:
- Read the full texts of included papers twice and coded them word-for-word to identify common themes within the ‘results’ sections;
- Reviewed each theme’s relevance to the research questions and accordingly revised the coding;
- Repeated steps 1-2 until a hierarchy of themes and sub-themes was generated for each review question;
- Evaluated themes and sub-themes based on their descriptions and hierarchical position;
- Re-read the paper to check for additional relevant data.
The analysis of 10 eligible articles generated three overarching themes and eighteen sub-themes.
1. Acceptability and feasibility
Fitting service needs varied as some places had few known treatment options, while others accepted CST. Carers engaged positively with CST, felt that it was worth travelling for, but were frustrated when they were not informed about the sessions’ content. Resources like manuals were found helpful, but time-limiting to conduct all iCST relevant activities. Training, experience, and appropriate communication skills were identified as crucial. Carers and facilitators associated lower patient motivation with increased difficulty getting PWD to groups and MCST.
2. Features of CST
Mental stimulation encouraged concentration, reflection, and supported learning. The adaptability and flexibility of CST enable a person-centered approach, allowing efficiency in managing people at different stages of dementia. Being with others offered the opportunity to be heard, gain new perspectives, help each other and share experiences. Practical activities kept the body active. Participants appreciated the supportive, friendly, relaxed environment of CST, but questioned the optimal level of difficulty of the session.
3. Key outcomes
A positive impact was observed on cognition. Confidence also improved due to a reduction in anxiety and improved self-esteem. PWD seemed to enjoy the sessions and were sad when they ended. Even after the session, participants reported an elevated and more relaxed mood, with a need for continued stimulation. Relationships also improved, because of better social communication and functioning with others. Finally, PWD and carers appreciated that CST made a difference.
PWD and stakeholders regard CST as acceptable, feasible, and beneficial. Different CST formats share many characteristics, which may provide for common processes underlying the benefits shown by quantitative and qualitative research. The authors have efficiently summarised qualitative studies, helping us to better understand these processes. Results also suggest potential guidelines for carers and stakeholders wanting to offer CST at home or within services and provide information for researchers intending to further advance CST and its efficacy.
Strengths and limitations
The authors provided a holistic understanding of CST, as this is the first review to their knowledge that includes solely qualitative studies of all CST forms. A range of stakeholders were involved, therefore different perspectives were adopted to enrich our understanding. Overall, the authors included good quality papers, and on average 7.5 out of 10 criteria were met.
However, the research had no geographic restriction. Although allowing comparison across cultures, the authors included studies mainly conducted in the UK (only three studies from different countries), possibly due to the language search limitation. Thus, the findings may not be as generalisable. Lastly, this study involved CST original authors. The developers of CST and iCST helped the research team to retrieve more relevant articles due to their in-depth knowledge. Nonetheless, all together they might be more inclined to select papers favouring CST, as we rarely see negative comments about the intervention in the included studies, so bias was hypothesised.
The paper shows that more high-quality qualitative research with a clearer methodology is necessary for this field. Future studies may consider devising more suitable outcome measures, particularly for assessing outcomes highlighted by the review.
Facilitators and barriers highlighted in this review can help to improve CST accessibility and delivery through mental health services beyond what is mentioned in the manual. For example, providing training for implementing iCST will not only help manage PWD unsuitable for groups, but will also psycho-educate carers.
Moreover, identifying common characteristics makes it easier to evaluate which components of CST might maximise its efficacy or acceptability. This is especially helpful for services that are unable to implement CST as a whole, owing to limited resources. Means beyond the intervention manual should also be considered, such as time for providers to prepare and deliver sessions.
Statement of interests
Thanks to the UCL Mental Health MSc students who wrote this blog from Bass Group: Margherita Zenoni (@Margher05558151), Aggelos Stamos (@stamos_angelos), Aparnna Sree Asok, Lui Kwan Cheng, and Wing Tung Chung.
UCL MSc in Mental Health Studies
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Gibbor, L., Yates, L., Volkmer, A., & Spector, A. (2020). Cognitive stimulation therapy (CST) for dementia: a systematic review of qualitative research. Aging & mental health, 1–11. Advance online publication.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex interventions: The new Medical Research Council guidance. BMJ, 337, a1655. doi:10.1136/bmj.a1655
Critical Appraisal Skills, & Programme. (2018). Critical appraisal skills programme. CASP Qualitative Checklist.
Clare, L., & Woods, R. T. (2004). Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer’s disease: A review. Neuropsychological Rehabilitation, 14(4), 385–401. doi:10. 1080/09602010443000074
Knapp, M., Thorgrimsen, L., Patel, A., Spector, A., Hallam, A., Woods, B., & Orrell, M. (2006). Cognitive stimulation therapy for people with dementia: Cost-effectiveness analysis. British Journal of Psychiatry, 188(6), 574–580. doi:10.1192/bjp.bp.105.010561
NICE. (2018). Dementia: Assessment, management and support for people living with dementia and their carers. Last accessed: 7 February 2021.