INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2005; 20: 446–451.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1304

A pilot study examining the effectiveness ofmaintenance Cognitive Stimulation Therapy (MCST)for people with dementia

Martin Orrell1*, Aimee Spector1, Lene Thorgrimsen1 and Bob Woods2

1Department of Mental Health Sciences, University College London, London, UK2Dementia Services Development Centre, Department of Clinical Psychology, University of Wales, Bangor, UK

SUMMARY

Background A recent randomised controlled trial on Cognitive Stimulation Therapy (CST) identified the need to evaluateits more long-term benefits for people with dementia. This study evaluates the effectiveness of a weekly maintenance CSTprogramme for people with dementia in residential care.Method Thirty-five people with dementia were included, following on from a seven-week twice-weekly study of CST.The maintenance CST sessions ran in two residential homes using a once a week programme of CST over an additional16 weeks. Two control homes did not receive the maintenance intervention.Results Using repeated measures ANOVAS, there was a continuous, significant improvement in cognitive function(MMSE) for those receiving MCST (CSTþmaintenance CST sessions) as compared to CST alone or no treatment(p¼ 0.012). There were no effects on quality of life, behaviour or communication following maintenance sessions. Theinitial cognitive improvements following CST were only sustained at follow-up when followed by the programme of main-tenance CST sessions.Conclusions The cognitive benefits of CST can be maintained by weekly sessions for around 6 months. A large-scale,multi-centre maintenance CST trial is required to clarify potential longer-term benefits of maintenance CST for dementia.Copyright # 2005 John Wiley & Sons, Ltd.

key words— dementia; cognition; maintenance; cognitive stimulation; quality of life

INTRODUCTION

The findings of a Cochrane review and a systematicevaluation of the research on Reality Orientation ther-apy for dementia were used to develop and evaluatean evidence-based Cognitive Stimulation Therapy(CST) programme for people with dementia (Spectoret al., 1998; 2001, 2003). The CST groups were basedon the concepts of Reality Orientation (RO; Folsom,

1966) with a particular emphasis on more recent workdescribed as ‘Cognitive Stimulation’ (Breuil et al.,1994) which was identified through the systematicreviews as having the best results. The programmeconsisted of 14, 45-minute sessions which ran twiceweekly for groups of approximately five people.Topics included; using money, word games, the pre-sent day and famous faces, and multisensory stimula-tion was used when possible. The programmeincluded an ‘RO board’, displaying both personaland orientation information, including the groupname (chosen by participants). Two hundred andone people were recruited for this single-blind,multi-centre RCT from 23 residential homes andday centres in greater London. The treatment groupimproved significantly relative to no-treatment con-trols on the main outcome measures (cognition and

Received 13 October 2004Copyright # 2005 John Wiley & Sons, Ltd. Accepted 14 December 2004

*Correspondence to: M. Orrell, Department of Mental HealthSciences, University College London, Wolfson Building, 48 RidingHouse Street, London, W1W 7EY, UK. Tel: 020 7679 9452. Fax:020 7679 9426. E-mail: m.orrell@ucl.ac.uk

Contract/grant sponsors: Responsive Funding Programme of theDepartment of Health; Barking, Havering and Brentwood Com-munity NHS Trust.

quality of life). In terms of Numbers Needed toTreat the results compared favourably with trials ofcholinesterase inhibitors for dementia (Spector et al.,2003).

However, the long-term effects of CST were notevaluated by Spector et al. (2003) and the Cochranereview found no clear evidence of any long-termeffects of RO. Gerber et al. (1991) found that benefitsfor cognition and behaviour gained from RO were lostten weeks after stopping the programme. Wallis et al.(1983) found that one month after RO terminated,benefits in cognition were lost yet behavioural func-tioning continued to improve. It therefore appearsuncertain as to how long any benefits of RO, or similarinterventions, may remain after the programmefinishes. Further, it is uncertain how far maintenanceprogrammes of RO might continue to benefit theparticipants.

The studies included in the RO Cochrane reviewranged from using programmes of four to 21 weeks.However, there did not appear to be a relationshipbetween the duration of the intervention and the out-come, and the trial with the best results (Breuil et al.,1994) only had a five-week intervention. Zanetti et al.(1995) cited an expected yearly decrease in Mini-Mental-State-Examination score (MMSE, Folsteinet al., 1975) of 1.8–4.2 points in people with demen-tia. Therefore, it might be that pre-post comparisonsin the studies which had used longer interventions(20 and 21 weeks) would have shown weaker results(Ferrario et al., 1991; Woods, 1979).

A number of studies have looked at the effects of anextended RO programme. Zanetti et al. (1995), in acontrolled trial, evaluated the effects of more long-term RO. Their intervention ran in four cycles of 20session blocks with rest periods in between, lasting8.2 months in total. They found that the effect ofRO on cognitive performance (a small increase inMMSE score of 0.68 points) appeared to counteractthe decline, observed in the control group, of 2.58points. Metitieri et al. (2001) studied the more long-term effects of RO by assessing 74 people withdementia over a 30-month period, who completed atleast one ‘cycle’ of RO groups (20 sessions). Theycompared 46 people who completed from 2–10 cycles(8–40 weeks of training) with the 28 who only com-pleted one cycle. They found that people receivinglong-term treatment declined in cognitive functionsignificantly later, and remained at home longer thanthose receiving only one cycle of RO. Both studiesconcluded that more long-term RO was effective inslowing, at least temporarily, the dementia process.This exploratory pilot study investigates the effective-

ness of a weekly maintenance programme followingparticipation in the CST trial (Spector et al., 2003).

The aim was to investigate whether benefits in cog-nition and quality of life could be maintained throughparticipation in 16 further weekly sessions, in com-parison with a group of people who participated inthe initial CST programme but did not receive main-tenance CST.

METHOD

When the maintenance trial began, groups for theCST study were running in six residential homes,all part of the Quantum Care group. Managers wereapproached and invited to participate in the mainte-nance trial through either: (i) the group participatingin the 16-week maintenance programme and follow-up assessments or (ii) the group not receiving mainte-nance sessions but participating in follow-up assess-ments after 16 weeks (i.e. ‘control’ homes). Twohomes agreed to participate in the maintenance trialand two to be control homes. Thirty-five people withdementia according to DSM-IV criteria (APA, 1994)were recruited for this study [see Spector et al. (2003)for full details of inclusion/exclusion criteria]. Theyhad previously been randomly allocated into treatmentor control groups for the initial CST programme.

Procedure

Blind assessments were conducted at baseline and inthe week following the main CST trial (see Spectoret al., 2003). The 16, weekly maintenance sessionsfollowed on immediately from the original CST pro-gramme. Participants were re-assessed in the weekfollowing the maintenance programme. There werethree groups. The maintenance CST group (MCST)consisted of eight people participating in both theinitial and maintenance CST groups. These eightcomprised four from each of the two maintenanceCST homes (one person had dropped out from bothoriginal CST groups). The CST only group consistedof twelve people only participating in the initial CSTgroups (two groups of five from the ‘control homes’and one person in each home where maintenancegroups ran, but who could not participate in mainte-nance CST for health reasons). The baseline controlgroup consisted of 15 people who received no CST.

Programme

Like the main CST programme, maintenance sessionsfocused on ‘themes’, with a primary emphasis on

mcst for people with dementia 447

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 446–451.

cognitive stimulation, yet incorporating the process ofreminiscence therapy and multi-sensory stimulation.Group names and songs, an ‘RO board’ and introduc-tory exercises provided continuity between sessions.The content of sessions can be found in Appendix 1.

Measures

Cognition. Mini-Mental State Examination (MMSE),(Folstein et al., 1975). This is a brief, widely usedtest of cognitive function, with good reliability andvalidity.

Quality of life. Quality of Life—Alzheimer’s Dis-ease Scale (Qol-AD; Logsdon et al., 1999). This brief,self-report questionnaire has 13 items covering thedomains of physical health, energy, mood, livingsituation, memory, family, marriage, friends, chores,fun, money, self and life as a whole. It has good inter-nal consistency, validity and reliability (Logsdonet al., 1999; Thorgrimsen et al., 2003).

Communication. Holden Communication Scale(Holden and Woods, 1982). This scale, completedby staff, covers a range of social behaviour and com-munication variables including conversation, attempts

at communication, awareness, pleasure, humour andresponsiveness. Higher scores indicate more difficultyin communication.

Behaviour. The Clifton Assessment Procedures forthe Elderly—Behaviour Rating Scale (CAPE-BRS;Pattie and Gilleard, 1979). This covers general beha-viour, personal care and behaviour towards others,with higher scores indicating greater dependency. Ithas good reliability and validity, and was includedto assess the overall level of functional impairmentand dependency.

RESULTS

The clinical and demographic profiles of participantsat baseline in each group are presented in Table 1.The CST only group had more communicationdifficulties on average than the other two groups.The groups were relatively similar at baseline. Abreakdown by group of mean scores on each measureat the three assessment stages is given in Table 2.Results were analysed using repeated measures ANO-VAs, with ‘time’ as the within subjects factor and‘group’ as the between subjects factor. Table 2 showsthe results of these analyses. Changes in cognitive

Table 1. Demographics by group at baseline

Group No of Gender Mean Cognitive Quality of Communication Behaviourparticipants (female: male) age function (MMSE) Life (QoL-AD) (Holden) (CAPE-BRS)

MCST 8 7:1 84.3 13.6 (3.3) 34.1 (5.1) 7.5 (5.9) 10.0 (3.1)CST 12 12:0 82.8 12.6 (4.3) 34.5 (4.3) 12.8 (4.7) 12.7 (4.7)No CST 15 15:0 85.2 13.5 (3.1) 34.2 (5.0) 8.5 (5.3) 11.9 (4.8)

Table 2. Means (and standard deviations) for the three groups on each measure, at the three assessment phases including repeated measuresANOVAs

Group MMSE1 MMSE2 MMSE3 MMSE

MCST 13.63 (3.29) 14.88 (4.12) 15.50 (5.17) Wilk’s Lambda¼ 0.53, F(4, 40)¼ 3.72, p¼ 0.012*CST 12.58 (4.34) 13.67 (3.94) 10.63 (2.92)No CST 13.53 (3.11) 12.27 (4.08) 12.80 (4.42)

QOL1 QOL2 QOL3 QOL-ADMCST 34.13 (5.14) 35.75 (4.83) 35.67 (3.83) Wilk’s Lambda¼ 0.69, F(4, 38)¼ 1.92, p¼ 0.13CST 34.50 (4.30) 35.67 (4.66) 29.25 (5.12)No CST 34.20 (4.97) 34.73 (6.77) 34.33 (7.97)

BRS1 BRS2 BRS3 BRSMCST 10.00 (3.07) 14.57 (4.89) 11.71 (6.07) Wilk’s Lambda¼ 0.78, F(4, 32)¼ 1.06, p¼ 0.39CST 12.67 (4.66) 11.70 (4.06) 15.75 (3.20)No CST 11.87 (4.76) 12.43 (5.14) 14.13 (5.49)

Holden1 Holden2 Holden3 HoldenMCST 7.50 (5.88) 10.29 (6.13) 9.29 (6.63) Wilk’s Lambda¼ 0.67, F(4, 30)¼ 1.68, p¼ 0.18CST 12.83 (4.71) 13.60 (3.24) 20.75 (3.86)No CST 8.47 (5.25) 14.23 (6.57) 15.20 (6.55)

448 m. orrell ET AL.

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 446–451.

function over time, as measured by the MMSE, weresignificantly different between the groups ( p¼ 0.012).The programme ran over a period of almost sixmonths, with a mean improvement of 1.9 points onthe MMSE for those receiving continuous treatment,compared to a mean decline of 0.7 points for thosereceiving no treatment. Figure 1 shows how peoplein the MCST group improved following CST andagain following the maintenance programme. In con-trast, those in the CST only group improved followingCST yet deteriorated over the follow-up period. Thosein the control group (no CST) performed worse atboth follow-up assessments than at baseline. Therewere no differences between groups in quality oflife, communication or behavioural function overtime.

DISCUSSION

This study indicates that 16 weekly sessions, follow-ing the same principles of CST, can be successful inmaintaining and even accentuating the cognitive ben-efits of a more intensive seven-week CST programme.These findings, like those of Zanetti et al. (1995) sug-gest that such interventions over a longer period canbe highly beneficial. Benefits in quality of life, asfound following CST, were not maintained, suggest-ing that weekly sessions might not be sufficient toimpact on how QoL is experienced by people withdementia in residential care. The results of the initialCST trial showed no significant changes in behaviouror communication (although there were positivetrends in the latter) and so changes were not predictedfollowing the maintenance programme. Zanetti et al.(1995) suggested that behavioural outcome measuresare often not sensitive enough to detect the functional

impact of cognitive stimulation programmes andSpector et al. (2003) concluded that small changesin cognition were unlikely to have any impact onareas of functional dependence described in theCAPE-BRS, such as feeding and dressing.

For those in the CST only group, at the final assess-ment, the mean MMSE and QoL-AD scores droppedto levels lower than at baseline, suggesting that thebenefits gained in cognitive function and quality oflife were lost 16 weeks after CST ended. This cogni-tive deterioration mirrors that found four and tenweeks post intervention in other studies (Walliset al., 1983; Gerber et al., 1991), though neither mea-sured quality of life.

Limitations

The sample was small and hence may not have beenrepresentative of the total CST sample, for exampleonly 3% of the maintenance sample was male, com-pared to 21% of the total CST sample. The Holdenand CAPE-BRS were completed by staff who werenot blind to group allocation and it was often not pos-sible for the same staff member to complete theassessments each time. However, due to the explora-tory pilot nature of this study, such limitations wouldbe expected. Homes were recruited through voluntaryparticipation rather than randomisation. This mayhave resulted in bias, for example homes wheregroups were going well might have been more likelyto volunteer for the maintenance programme than thetwo homes that did not agree to take part. Addition-ally, two people were included as part of the CST onlygroup, as they were too unwell to participate in themaintenance CST sessions. This might have resultedin bias if their physical deterioration been associatedwith cognitive decline. Lastly, the small sample sizelacks power to detect potential differences betweenthe groups so there is the possibility of a type 2 statis-tical error, particularly for outcomes such as quality oflife which had been found to significantly improvewith CST (Spector et al., 2003).

Implications for research

A large, multi-centre maintenance CST trial, follow-ing a similar design to the CST study, would provide abroader evaluation of the maintenance programme,the longer-term effects of CST and how outcomeschange when maintenance CST is discontinued. Itmight be helpful to examine the effectiveness of anextended programme to match the duration of drugtrials which may last as long as 52 weeks, adding a

Figure 1. Change in cognitive function (MMSE score) over time

mcst for people with dementia 449

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 446–451.

more detailed measure of cognition such as theADAS-Cog (Rosen et al., 1984), and to evaluatemaintenance CST in combination with cholinesteraseinhibitors. Further, the question of whether QoL canbe maintained would be better assessed with a largersample.

It has been demonstrated that in the short-term atleast CST results in significant improvements in cog-nition comparable to those found following treatmentwith acetylcholinesterase inhibitors (Spector et al.,2003). We have run a number of one-day trainingcourses across the UK and other centres have startedto implement CST locally. Training of staff in resi-dential and day facilities could lead to appreciablebenefits to people with dementia. This study suggeststhat benefits in cognition can be maintained byweekly sessions of CST following a more intensiveprogramme. Such findings offer hope of potentiallydelaying cognitive deterioration in people withdementia.

ACKNOWLEDGEMENTS

This study was funded by grants from the ResponsiveFunding Programme of the Department of Health andBarking, Havering and Brentwood Community NHSTrust. We are extremely grateful for the input of resi-dents and staff at the four residential homes, all part ofthe Quantum Care group. We also thank Dr PascoFearon for his statistical advice.

REFERENCES

American Psychiatric Association. 1994. Diagnostic and StatisticalManual of Mental Disorders, 4th edn. APA: Washington, DC.

Breuil V, De Rotrou J, Forette F, et al. 1994. Cognitive stimulationof patients with dementia: preliminary results. Int J Geriatr Psy-chiatry 9: 211–217.

Ferrario E, Cappa G, Molaschi M, Rocco M, Fabris F. 1991. Realityorientation therapy in institutionalized elderly patients: prelimin-ary reports. Archives of Gerontology and Geriatrics 2: 139–142.

Folsom JC. 1966. Reality Orientation for the Elderly MentalPatient. Read at 122nd Annual Meeting of American PsychiatricAssociation, May 1966.

Folstein MF, Folstein SE, McHugh PR. 1975. ‘Mini-mental State’:a practical method for grading the cognitive state of patients forthe clinician. J Psychiatr Res 12: 189–198.

Gerber GJ, Prince PN, Snider HG, Atchinson K, Dubois L, KilgourJA. 1991. Group activity and cognitive improvement amongpatients with Alzheimer’s disease. Hosp Commun Psychiatry42(8): 843–846.

Holden UP, Woods RT. 1982. Holden Communication Scale. InReality Orientation: Psychological Approaches to the ‘Con-fused’ Elderly. Churchill Livingstone: Edinburgh, UK.

Logsdon R, Gibbons LE, McCurry SM, Teri L. 1999. Quality of lifein Alzheimer’s disease: patient and caregiver reports. J MentHealth Aging 5: 21–32.

Metitieri T, Zanetti O, Geroldi C, Frisoni GB, De Leo D, DelloBuono M. 2001. Reality Orientation Therapy to delay outcomesof progression in patients with dementia: a retrospective study.Clin Rehab 15: 471–478.

Pattie AH, Gilleard CJ. 1979. Clifton Assessment Procedures for theElderly (CAPE). Hodder and Stoughton: Sevenoaks.

Rosen WG, Mohs RC, Davis KL. 1984. A new rating scale for Alz-heimer’s disease. Am J Psychiatry 141: 1356–1364.

Spector A, Orrell M, Davies S, Woods B. 1998. Reality Orientationfor dementia: a review of the evidence for its effectiveness. InThe Cochrane Library, Issue 4, 1998. Update Software: Oxford.

Spector A, Orrell M, Davies S, Woods B. 2001. Can reality orienta-tion be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people withdementia. Neuropsychologic Rehab 11(3/4): 377–397.

Spector A, Thorgrimsen L, Woods B, et al. 2003. Efficacy of an evi-dence-based cognitive stimulation therapy programme for peo-ple with dementia: Randomised Controlled Trial. Br JPsychiatry 183: 248–254.

Thorgrimsen L, Selwood A, Spector A, et al. 2003. Whose qualityof life is it anyway? The validity and reliability of the Quality ofLife-Alzheimer’s Disease (QoL-AD) Scale. Alzheimers disAssoc Disord 17(4): 201–208.

Wallis GG, Baldwin M, Higgenbotham P. 1983. Reality OrientationTherapy: a controlled trial. Br J Medic Psychol 56: 271–277.

Zanetti O, Frisoni GB, De Leo D, Buono MD, Bianchetti A, Tra-bucci M. 1995. Reality Orientation Therapy in Alzheimer’s dis-ease: useful or not? A controlled study. Alzheimers Dis AssocDisord 9: 132–138.

APPENDIX 1—MAINTENANCE CST SESSIONS

(1) Childhood. Questions from the memory diarieswere used as prompts for discussion. (e.g.‘describe your childhood bedroom’). Use ofchildhood toys and games.

(2) Current affairs (A). Duplicate copies of discus-sion-provoking articles from newspapers wereused to generate opinion and debate.

(3) Current affairs (B). As above.(4) Using objects (A). This involved making a

chocolate cake.(5) Number game (bingo).(6) Quiz, involving two teams.

KEY POINTS

* Little is known about the long term effects ofCST on cognition in dementia.

* This study compares maintenance CST, withshort-term CST and a treatment as usual controlgroup.

* Over 23 weeks people receiving maintenanceCST continued to show improvements incognition whereas cognition declined in boththe CST only and the control groups.

450 m. orrell ET AL.

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 446–451.

(7) Music session. This involved the playing ofmusical instruments, singing along to old songsand a ‘song completion game’, where people aregiven the first few words of a song and are askedto sing the remainder.

(8) Physical games, such as hoopla, skittles, boulesand football. The group was encouraged tocalculate the scores.

(9) Categorising objects. New ‘odd one out’ sheetswere used, in which four words were presentedon a sheet and the group required to guess theodd one out. The topix game was used again(naming objects beginning with a particularletter in a certain category).

(10) Using objects (B). The reminiscence kit andmodern objects (such as a mobile phone) werepresented and discussed.

(11) Useful tips. A book called ‘what our grand-mothers knew’ was used to generate a discussionof useful tips, e.g. soothing burns, treating milk.

(12) Golden expressions cards (A). Cards askingdiscussion-provoking questions were passedaround the group, e.g. ‘what is your favouritecharity?’ ‘How are elderly people treated bysociety?’.

(13) Golden expressions cards (B). As above.(14) Opinions on different types of art, generated

through the presentation of art ranging fromclassic to modern.

(15) Famous faces (B). Pictures of people from thepast were used to make comparisons and togenerate discussion.

(16) Word completion (B), for example completionof proverbs and ‘famous couples’.

mcst for people with dementia 451

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 446–451.