CAROLINE BARTLE discusses how becoming competent in Cognitive Stimulation Therapy can help practitioners achieve significantly improved outcomes for those in dementia care.
Since the launch of the dementia strategy 2010 some really great work has been done within New Zealand to improve the quality of support that people receive. The scope of the work streams has been vast; ranging from developing dementia pathways, to creating good dementia design, thinking more about the physical environment, and building on psycho-social type interventions.
It is an exciting time as the New Zealand Government looks to reduce the economic impact of the disease by promoting timely diagnosis, improving pathways of care, ensuring timely access to drugs and ensuring that care and support within residential services is at its optimum level. This process will sort the good from the bad and the downright ugly. Services need to be efficient, targeted and above all cost-effective. There will always be a need within New Zealand to offer residential services, but there is clearly a focus on how home-based support services can be developed to minimise admissions to residential environments.
There are many treatments available which aim to improve cognition in early to middle stages of the condition. However, one treatment receiving international acclaim and research has shown favourable result not only in its effectiveness but also in its economic value in relation to comparable medical interventions. Cognitive Stimulation Therapy, or CST, was developed by
Dr Aimee Spector and colleagues in 2003. A systematic review was carried out of the evidence for psycho-social treatments that worked, and those that didn’t were discounted. The types of interventions that worked were utilised in the development of CST and therefore as an intervention it has its origin in a very broad framework.
Some of the interventions incorporated include reality orientation, music therapy, validation and reminiscence. However, whilst the scope of interventions is vast, what works is not just what is delivered but also how it is delivered with person-centred care being the central theme. Arguably the social environment creates a platform in which these interventions can take place positively and progressively and therefore how and what is delivered are interlinked, and dependent on each other.
The first CST trials took place in 2003 and involved a multi-centre, single-blind, randomised control trial (RCT). Mini Mental State Examinations (MMSE) and Quality of Life tools where used to measure the effectiveness of the intervention, and the results were favourable; showing cognitive improvements in some areas, notably language, as well as evidence of new learning. However, there were limited improvements in functional ability such as everyday skills. CST trial results also varied across centres, possibly as a result of differential facilitator skills and levels of person-centred care.
In 2003, another significant study took place (Livingstone and Katona 2006) that compared the use of CST to medications used to enhance cognitive function including Rivastigmine, Donepezil and Galantamine. It found that for larger improvements in quality of life (four or more points on ADAS-Cog) CST was as effective as Rivistigmine or low dose (5mg) Donepezil.
In 2006 there was a further study (Knapp et al, 2006) which looked at how costs compared between the two treatments: CST (non-medical intervention) and cognitive enhancer (medical intervention). What is so exciting here is that they found CST cheaper, or rather more cost effective than the medical comparison. Following this, in 2006 National Institute for Clinical Excellence in the UK NICE recommended that CST should be offered to all people in mild to moderate stages of the condition. CST and since developed ground internationally and in 2012 the World Alzheimer’s Report also recognised and publicly advocated its use.
However, since this time, the take up of it on a large scale has been slow. In the UK where it has been developed, mainstream services still do not offer this as a standard practice. The barriers to this are possibly that the evidence suggested that a fixed number of sessions should be completed, and sustainability of this is difficult. In addition the delivery of this takes a skilled approach, in a common sense sort of way, as it is essential to utilise the best of person-centred care within a group context. For example, the individual with dementia must have important psychological needs met before any learning can take place; without this the intervention can be less effective.
CST has a number of other ‘guiding principles’ that must be adhered to. These principles draw on the vast range of different, evidenced-based non-medical therapies noted above, but also includes what we know about memory, cognitive function, neuroplasticity and learning theory (explicit and implicit learning). The therapy surely should be congratulated for the breadth of its framework, drawing from very extensive research in a number of fields. As a practitioner, becoming trained and competent in CST ultimately leads to truly embracing the bio-psychosocial sphere of dementia care; understanding how also we can affect change on a physical level through the development of new neural pathways simply by the way we treat people, and the opportunities we give them.
Some might argue that this is an over-simplistic view; however it is testament to the power of the social model of care, and our understanding of the interplay between both medical and social models, and that this probably holds the key to the most effective treatments for dementia care available to us today.
CST is not completely new to New Zealand as all of the major stakeholders are exploring how to make this work; the University of Auckland is already starting to map the competencies and skills required to deliver this so that a training programme can be developed to start training up clinicians in this area. The Alzheimer’s society in Hamilton also has a clear agenda as to the role that CST could play in the delivery of its services. However more work needs to be done within New Zealand on how to make this viable economically, so that it can have sustainability.
The absence of CST is distinctly evident in the new Framework for Dementia Care published by the Ministry of Health in November last year, which is more than a little disappointing. Despite this there are other aspects of the framework with highlight new and emerging practice, however its focus on workforce development could be substantially extended, as this is clearly a driving force.
Since the creation of CST, work has developed and several off shoots of this have been developed which offer great potential in New Zealand.
The first, CST research, is currently being carried out based on individual CST (www.ucl.ac.uk/icst), delivered on a one-to-one basis. This offers great potential for home-based support services, as well as for independent individual family interventions, potentially leading to reduced admissions to residential care and enhanced quality of life. However, this research is not complete, and the publication of the results is not expected before the end of July. Individual CST (iCST) is fundamentally different to the original CST as it is done one-to-one, rather than in a group. It is likely to have limits, as well as benefits. Group support received in a peer setting clearly has a value, and there must also be a level of implicit learning through others. However, CST as we know it is delivered in a group setting, usually 6 – 8 with two facilitators over a period of fourteen sessions. Maintenance sessions were also developed by the team at UCLH in London, and this includes a following of sixteen ‘maintenance’ sessions (MCST, Orrell et al 2005).
The second is something developed by an incredible, inspirational woman: Jackie Tuppen. Jackie states that what she has developed is not CST but draws from its principles, and offers a real alternative to respite, or day services. Jackie calls her creation COGS (www.cogsclub.org.uk), a very apt name. She has developed independently a series of extended five-hour sessions, drawing on the themes of the CST sessions. Feedback commonly received from her sessions includes: “happy”, “improved my concentration”, “more relaxed”, “company with other people equal to myself”, “keeps my mind active”. Cynics may argue that this feedback is subjective, and that rigorous cognitive testing alongside is essential. However any service that achieves the outcomes of the people in receipt of care, on any level is worth investing in. Jackie states, “The concept filled a gap for people with mild to moderate dementia, that can maintain a person’s wellbeing over a longer period.”
Many are watching the development of her concept with great excitement, as this evolves the idea of respite to one that is functional, has aims, ambitions and utilises time and money with optimum results. It is an outcome-based service that has its reaches beyond what has become the acceptable goal of respite, as not necessarily focused on the individual with dementia.