Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials

Abstract

Cognitive stimulation is a psychological intervention widely used in dementia care, which offers a range of activities for people with dementia and provides general stimulation of cognitive abilities. This systematic review evaluates the effectiveness of cognitive stimulation in dementia. The review included studies from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, called ALOIS. This yielded ninety-four studies, of which fifteen were randomised controlled trials meeting the inclusion criteria. The analysis included 718 subjects (407 receiving cognitive stimulation and 311 in control groups). Results were subjected to a meta-analysis. A consistent significant benefit to cognitive function was identified following treatment and the benefits appeared to be over and above any medication effects. This remained evident at follow-up up to three months after the end of treatment. In secondary analyses, with smaller total sample sizes, significant benefits were also noted for quality of life and well-being, and on staff ratings of communication and social interaction. No differences in relation to mood, activities of daily living or challenging behaviour were noted. There is consistent evidence that cognitive stimulation interventions benefit cognitive function and aspects of well-being. Cognitive stimulation should be made more widely available in dementia care.

Introduction

Interventions with a cognitive focus have long been used in dementia care, and developed in parallel with approaches emphasising the stimulation of the senses (Woods and Britton, 1977). One of the first established non-pharmacological interventions for dementia that focused on improvement of cognitive abilities was Reality Orientation (RO) (Taulbee and Folsom, 1966). RO included, amongst other interventions, classroom sessions, normally held daily for 30 minutes where a small group of participants were presented with basic personal and current information and a variety of materials used, such as individual calendars, word-letter games, building blocks and large piece puzzles. A Reality Orientation board would be used in each session and would list the name of the unit and its location, the day, date, weather, current events, etc. The first controlled evaluation of RO classes was reported in the UK by Brook et al. (1975), reporting positive results for cognitive and social functioning in patients A number of controlled studies of RO followed, with outcome measures typically including assessments of orientation, other aspects of cognitive functioning and level of independent functioning (Holden and Woods, 1995). However, this approach raised some concerns in relation to its clinical significance for people with dementia and attracted some criticism when used in a mechanical, inflexible manner (Burton, 1982, Dietch et al., 1989, Powell-Proctor and Miller, 1982) with one set of guidelines on the management of dementia (APA, 1997) even cautioning against its use. However, a Cochrane review specifically examining RO (Spector et al., 2000) that included a total of 6 RCTs with 125 participants overall (67 in experimental and 58 in control groups) concluded that this therapy had cognitive and behavioural benefits for people with dementia. Following Breuil et al. (1994), the term ‘cognitive stimulation’ is now widely used to describe approaches, including RO, which have a general cognitive focus. This builds on the positive aspects of RO, whilst ensuring that it is implemented in a coherent, person-centred and sensitive manner (Spector et al., 2001, Woods, 2002). Whilst the terms ‘cognitive training’, ‘cognitive stimulation’ and ‘cognitive rehabilitation’ have been used almost interchangeably in the past, Clare and Woods (2004) established the following definitions.

(a) ‘Cognitive stimulation’ as engagement in a range of activities and discussions (usually in a group) aimed at general enhancement of cognitive and social functioning; (b) ‘cognitive training’ as guided practice on a set of standard tasks designed to reflect particular cognitive functions with a range of difficulty levels to suit the individual's level of ability; and (c) ‘cognitive rehabilitation’ as an individualised approach where personally relevant goals are identified, and the therapist works with the person and his/her family to devise strategies to address these. The emphasis is on improving performance in everyday life, rather than on cognitive tests, building on the person's strengths and developing ways of compensating for impairment.

With the Cochrane review of RO being superceded by these developments, it was timely to consider the evidence base for cognitive stimulation as defined by Clare and Woods and excluding cognitive training and cognitive rehabilitation interventions. Accordingly, the aim of this study was to evaluate the effectiveness of cognitive stimulation trials in dementia. The reported systematic review was carried out with the Cochrane Collaboration Cognitive Impairment and Dementia group, based in Oxford, United Kingdom (Woods et al., 2012).