Facilitating Cognitive Stimulation Therapy groups for people with dementia.

An interview with an Occupational Therapist

Hello, my name is Sarah Whyte and I’m an Occupational Therapist working in the dementia assessment wards at the Royal Edinburgh Hospital. In this blog, I’ll discuss the Cognitive Stimulation Therapy (CST) group programme we offer, and its value for the patients on the wards.

1. What is Cognitive Stimulation Therapy and more specifically, what are the groups?

For the past 10 years, the Occupational Therapy team in the dementia assessment wards in the Royal Edinburgh Hospital (REH) have been successfully running CST groups – “a programme of memory provoking, problem-solving and conversational fluency activities” – as an intervention to help address the behavioural & psychological symptoms of dementia. This was recommended in SIGN Guideline 86 – Management of patients with Dementia. Although this guideline was superseded in 2023, CST is currently recognised as an essential rehabilitation intervention to optimise the mental and cognitive functions of people living with dementia, featuring in the 2023 “World Health Organisation (WHO) Package of Interventions for Rehabilitation (PIR) for Dementia”.  (https://iris.who.int/server/api/core/bitstreams/6c0d3f5d-6d20-4424-af4b-4f6ff04b84e3/content.

The WHO PIR for Dementia describes CST as “aiming to improve cognition and psychosocial functioning in people with difficulties in cognitive functions (e.g. memory, thinking, attention and perception deficits). During CST sessions, participants … engage in exercises that are mentally challenging, to improve their ability to think and interact effectively with their environment and with other people”. We describe it to our members as “something fun, to get us thinking, while spending time together as a team”. We explain that for both our physical and mental wellbeing, it’s as important to exercise our brains as much as our other muscles.

We offer an evidence-based “programme of memory provoking, problem-solving and conversational fluency activities” by following the group structure outlined in the “Making a Difference” manual by Spector et al (2015) which was produced following their research (Spector et al, 2003). They created a group intervention of varied enjoyable activities for men & women with mild to moderate dementia, aimed at “enhancing cognitive function and quality of life”.

In conjunction with the ward multi-disciplinary teams, the Occupational Therapists identify 4-6 patients to attend the block of 14 sessions, which are run for an hour, twice a week over 7 weeks.  We select and prioritise potential members based on their clinical need, and to ensure a therapeutic experience for all, their ability to meet specific criteria:

• having a diagnosis of dementia or cognitive impairment

• communicating and interacting positively within a group setting

• consenting to attending each session

CST is run as a ‘closed’ group to foster a sense of orientation, familiarity, ownership and belonging – this means the same 4-6 people are invited to attend every session in the 14 session block. This is reinforced by the members collaborating to choose a group name and theme song, which is played to mark the start and end of each session. We hold the sessions in the ward activity room which is a lovely, quiet, accessible space, and each session is led by 2 Occupational Therapy staff members. We try as much as possible to keep the staff consistent. Likewise, each session follows the same structure:

• Welcome & introductions
• Orientation board
• Theme song & warm-up (e.g. balloon tennis)
• News article
• Themed activity
• Goodbyes & theme song
• Group feedback

These strategies hopefully help build a therapeutic environment for the members.

In general, the sessions involve using reminiscence as an aid to the here-and-now, providing triggers to help memory, and the different props used for each themed session can offer a multi-sensory experience. Each session has a different theme to keep interest and to exercise all areas of the brain.

Also, as per the guidance, it’s important to ensure we include the following principles in every session

1. Why are CST groups of value for people with dementia in a hospital setting?

As mentioned previously, CST is a recognised form of rehabilitation for dementia, which is important in itself: within the “World Health Organisation (WHO) Package of Interventions for Rehabilitation (PIR) for Dementia” document, the benefit of offering rehabilitation to the 52 million people worldwide living with dementia is highlighted: “With…supportive treatment and rehabilitation, the lives of people with dementia and their carers can be significantly improved. Interventions for rehabilitation in dementia…all help not only to maintain independence and well-being, but also to be engaged in a meaningful life as long as possible”.

Being in hospital impacts our ability to keep to our usual routines or have the chance to engage in the daily activities we used to do before admission, which can mean our brains aren’t getting the work-out that they normally would. Without some form of cognitive rehabilitation opportunities whilst in hospital, there is a real risk of further cognitive and functional decline which could impact a person’s ability to return home or transfer successfully to care-home life.

 The rehabilitative value of regular CST sessions lies within the offer of a new routine for patients, and the chance to ‘use their brains’ within a varied range of topics and activities. Actually, CST manages to meet 2 of the recognised ways to keep your brain healthy (https://www.alzheimersresearchuk.org/brain-health/brain-health-basics/. ) Just as keeping connected to the people around us important for our brain health, it is also thought that challenging your brain helps to build your ‘cognitive reserve’, which is the brain’s ability to cope and keep working properly, even in the face of damage from diseases like Alzheimer’s.

We also find the CST groups play a huge role in the Occupational Therapy process – they can be a really good way to assess people’s abilities, as well as being a form of therapeutic intervention. The variety within the sessions can also highlight a person’s activity and environmental preferences, which can be taken into consideration when planning therapeutic ward activities for them or community activities post-discharge.

Because of all the specific benefits that CST can offer, people are prioritised for attendance based on their clinical need with each session aiming to target those needs:

1. People who are going home, to maintain their cognitive function and provide experience of daily structure
2. People who would benefit from more cognitive stimulation than could be provided effectively in general ward activity, to promote recovery and improved mental health
3. People who require assessment of their daily living skills, to enable occupationally focused discharge planning.

We evaluate each CST group afterwards to check we’re getting it right – that the group aims have been met and that we are offering a fun, useful, and stimulating time for the group members. We complete the observation sheet from the manual and ask the patients to complete a simple visual feedback form along with capturing any verbal or written feedback they want to offer (Spector et al, 2015). This also helps us plan and adjust future session content to be more effective for them.

3. What value does Occupational Therapy facilitating bring to the group sessions?

With our core professional skills in group work, observation and activity analysis (Turner and Alsop, 2015), Occupational Therapists are well-placed to combine each session’s particular topic with the 18 core principles of CST to creatively plan then deliver stimulating, meaningful and purposeful sessions accessible to patients with wide-ranging cognitive abilities. We can use our knowledge of adapting and grading activity to make it accessible and meaningful for each patient in accordance with their abilities. We will consider the therapeutic value of the group and the contribution it may have made towards maintained cognition and function, through observed enjoyment and active engagement in the session.  

1. Can CST be continued after discharge, or done at home?

Yes! There are CST groups being run in the community for people who it is felt could benefit from more sessions. There is also a manual for ‘individual CST’ available for purchase which fully outlines sessions that carers can do with the person they care for (ward OTs can advise on these options more specifically).

I hope this has given you a little insight into a valuable intervention we do with the people we work with.  Thanks for reading!

Contributor. Sarah WhyteOccupational Therapist, Older Person’s Mental Health In-patient Dementia team, Royal Edinburgh Hospital

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