Cognitive stimulation is a structured approach that aims to engage people with dementia in enjoyable activities that generally stimulate areas of cognition such as thinking, language skills, concentration and memory. In this blog, retired clinical psychologist and dementia care researcher, Bob Woods, explains how it might help people living with dementia.
Take-home points
Have you noticed that hardly a month goes by without a potential new treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. for Alzheimer’s disease hitting the news headlines? Whilst it is great that there is hope that, one day, drugs capable of halting or even reversing the effects of this disorder will become available, even the most optimistic observer acknowledges that there is still some way to go. There are many more tests of benefits, costs and potential harms to evaluate; we must also remember that there are many different forms of dementia, each potentially requiring a different drug.
With dementias occurring so commonly, often in later life but sometimes earlier, most families now have some personal experience of how changes in areas such as memory, thinking and emotions can have a huge impact on the person affected and on those who seek to provide care and support. It seems evident that any approach that could be shown to make a difference in the lives of those affected by dementia in the here and now would be warmly welcomed.
Cognitive stimulation: fun, social and enjoyable activities to stimulate thinking and memory
Although seldom making the headlines, there is a growing body of research on the effects of therapies other than drugs for people with dementia and their carers. Several of these have been the subject of Cochrane ReviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research., which bring together the best available evidence addressing specific questions about treatments. One of these is ‘cognitive stimulation’. This is a structured approach that has been developed specifically to help people with dementia. It aims to engage the person with dementia in enjoyable activities that generally stimulate cognition, including thinking, concentration and memory. Typically, a small group of people with dementia meet twice a week, for 45 minutes, with activities varying from session to session. The activities might include a discussion of past and present events and topics of interest, word games, puzzles, music, and creative practical activities.
Those leading the groups do not need to have a formal professional qualification, but some training is helpful. Various manuals are available to assist with this. Cognitive stimulation has also been offered on an individual basis and family carers have also been trained to provide cognitive stimulation to their relative. In recent years, digital formats have been developed and during the pandemic online groups were developed, using platforms such as Zoom.
Although the terms are often mixed up, cognitive stimulation is quite different from ‘cognitive training’, which involves repetitive practice and mental exercises to maintain or enhance specific cognitive skills, and ‘cognitive rehabilitation’, where the person establishes goals they wish to achieve in day-to-day life. At its best, cognitive stimulation should be fun, social and enjoyable, with the stimulation of memory and thinking planned to be present but incidental, rather than an explicit focus.
The evidence for cognitive stimulation
Back in 2012, we completed a Cochrane Review of ‘Cognitive stimulation’ for people with dementia, finding it was associated with some positive outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. in relation to both cognition and quality of life. A decade on, there have been many new studies internationally, so we have now updated the review and its conclusions, based on 37 studies involving 2766 people with mild or moderate dementia and an average age of 79 years: ‘Cognitive stimulation to improve cognitive functioning in people with dementia’ (published January 2023).
Probable benefits
Our main conclusion was that cognitive stimulation probably results in a small benefit to cognition at the end of the course of sessions in comparison with usual care or unstructured activities. To give an indication of the extent of this benefit, we have estimated that it is roughly equivalent to a six-month delay in the expected decline in cognition in mild to moderate dementia.
There were also benefits in other areas of function – arguably as important as those in cognition. People with dementia improved on measures of communication and social interaction and showed slight benefits in day-to-day activities and in their own ratings of their mood. There is probably also a slight improvement in the quality of life of the people with dementia and in experiences that people with dementia and carers find upsetting and distressing.
No unwanted effects of cognitive stimulation were reported.
We have more and better research – but more uncertainty
The results of the updated review are comparable to those from 2012, with benefits now apparent in a wider range of outcomes. There is though a note of caution, that means we describe some of our findings as ’probable’, despite them being based on a much wider evidence base than previously. This does not arise from doubts about the quality of the individual studies included, which is improving over time, and which is reasonable for this type of real-world research. The uncertainty comes because with more studies we have found less consistency between studies in the results reported. Simply put, some studies are finding more positive outcomes than others.
Variation in cognitive stimulation programmes and context
In some ways, this is not surprising. In contrast to a drug trialClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., implementing a psychosocial interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. like cognitive stimulation is bound to be subject to variations in language, culture, health and social care systems, attitudes, and expectations. The studies were conducted in no less than 17 countries from five continents, and we noted a number of clear differences in the way cognitive stimulation was implemented across studies. These included:
- The specific programme of activities included. Although a specific structure and manual developed in the UK has been widely used, translated and culturally adapted there are a number of others also in use.
- The mode of delivery of cognitive stimulation; most studies had a group format, but eight offered individual cognitive stimulation and one used an app.
- The person or people delivering the cognitive stimulation. In different studies, these were trained professionals, care workers or family carers.
- The frequency of sessions, which varied from 1 per week to 5 per week.
- The duration of the programme, which varied from a minimum of 4 weeks to (in very few studies) as long as 1 or 2 years
- The type(s) of dementia with which people were diagnosed and the severity of the dementia. There was a fairly even split between studies where the people taking part were on average in the mild stages of dementia at the outset and those where they were in the moderate stages.
- The living situation of those taking part. Sixteen studies included at least a proportion of people with dementia living in care homes and hospitals. In the remainder, all the people with dementia lived in their own homes.
We were limited in how many of these sources of potential variation could be accounted for in our analyses, as for many aspects there were a relatively small number of studies. We did find evidence suggesting that offering group sessions twice weekly or more (rather than just once a week) led to greater cognitive benefits. Cognitive benefits were also greater in studies where average dementia severity at the outset was mild as opposed to studies where those taking part, on average, had moderate dementia.
Cognitive stimulation in practice
Cognitive stimulation has been widely recommended for some years by bodies such as NICE, the UK body that issues guidelines for health and social care practice, as well as by Alzheimer’s Disease International in their 2011 World Alzheimer’s Report. These recommendations are largely based on studies of cognitive stimulation groups. Although we did not find evidence to suggest the group approach is more effective than one-to-one stimulation, the evidence base for the individual approach is as yet far less well developed and includes studies where family carers deliver the intervention as well as studies where professionals undertake this role. Family carers may need additional support (with resources, training and encouragement) to take on this role.
Qualitative studies of cognitive stimulation groups often highlight the social aspects, and it is important to consider how individual and digital approaches may retain this core element and benefit those who are not able to or do not wish to access groups. It is likely that remote and digital approaches will now become more commonplace; we cannot assume these approaches will achieve the same outcomes, but they do offer exciting opportunities for development.
The updated review continues to support the recommendations for practice referred to previously. Of course, cognitive stimulation does not cure or reverse dementia. But for many people with mild or moderate dementia, it could make a difference, not just on cognitive tests but in social interaction, mood, well-being and day-to-day function.
Studies have shown that it can be a cost-effective intervention. The resources required to implement it are relatively modest; staff at all levels can deliver it with a small amount of training. It can be implemented in care homes, day centres and outpatient settings. Unlike certain of the drugs currently being evaluated, negative side effects have not been reported, and qualitative studies suggest that many people with dementia do indeed find the experience enjoyable and rewarding. Negative feedback only seems to arise when the level of activities is not geared appropriately to the person; they should be neither too easy nor too difficult, avoiding the twin pitfalls of the person with dementia feeling either patronised or overwhelmed. This is where staff delivering groups need training and support, to ensure their practice in this area, as in all aspects of dementia care, is person-centred, respectful, and supportive.
Finally, while it’s unlikely we’ll see tabloid headlines such as ‘Cognitive stimulation probably delays decline in dementia’, it is worth all of us in the field of dementia care reminding ourselves that we already have a number of approaches available to us that have the potential to make a difference to the lives of those living with dementia and their supporters. Our updated review reinforces the place of cognitive stimulation as just such an approach, which can be enjoyable as well as beneficial.
Further information and support
- If you’re interested in finding out more, the International Cognitive Stimulation Therapy Centre website provides information about availability of cognitive stimulation in different countries, details of manuals available and of training.
- In the UK, the majority of Memory Services report that they offer cognitive stimulation to at least some of their patients, so if you have been diagnosed with dementia you should enquire with your local service regarding availability.
- Age UK is among a number of third-sector and community organisations also offering cognitive stimulation sessions in a number of locations.
Reference: Woods B, Rai HK, Elliott E, Aguirre E, Orrell M, Spector A. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2023, Issue 1. Art. No.: CD005562. DOI: 10.1002/14651858.CD005562.pub3.
Bob Woods declares that, with others, he has produced various training materials in dementia care, including cognitive stimulation therapy manuals, in order to disseminate research findings to care workers, family caregivers and others. Royalties for the manuals are received by the International Cognitive Stimulation Therapy Centre, based at University College London.
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