Virtual Cognitive Stimulation Therapy (vCST): A new normal?

INTERNATIONAL COGNITIVE STIMULATION THERAPY CENTRE Partnering InstituteHost Institute

Aimee SpectorProfessor of Old Age PsychologyUniversity College [email protected]

Virtual Cognitive Stimulation Therapy (vCST): A new normal?


What is CST?• 14 session, manualised programme for people with mild/moderate dementia.• Aims to improve cognitive function through themed

group activities. Implicitly stimulates skills including memory, executive function and language through tasks including categorisation, word association, current affairs.

• Learning theory and brain plasticity suggests that targeted mental stimulation, e.g. through building new semantic connections, can lead to development of new neuronal pathways.

• Social theories suggest that creating an optimal and supportive group environment can enhance skills and increase wellbeing.


NICE guidance on the management of dementia (2018) Psychosocial interventions to promote cognition, independence and wellbeing:• “Offer group Cognitive Stimulation therapy to

people living with mild to moderate dementia.”*• “Consider group Reminiscence Therapy, Cognitive

Rehabilitation, Occupational Therapy”.• “Do not offer acupuncture, Cognitive Training,

Interpersonal Therapy, Ginseng, Vitamin E supplements, herbal formulations or deep brain stimulation”.

*National Institute for Health and Care Excellence. (2018). Dementia: assessment, management and support for people living with dementia and their carers (NICE Guideline No. 97). Retrieved from https://www.nice.org.uk/guidance/ng97 **National Institute for Health and Care Excellence. (2018). Dementia: assessment, management and support for people living with dementia and their carers: Methods, evidence and recommendations (NICE Guideline No. 97). Retrieved from https://www.nice.org.uk/guidance/ng97/evidence/full-guideline-pdf-4852695709


The evidence-baseSystematic review* of 12 studies (8 RCTs) evaluating UK developed CST group protocol, many culturally adapted. Research from the UK, US, Hong Kong, Japan, Tanzania and Portugal.Findings:

• All 12 studies examined cognition - 9 found significant positive impact.• 9 studies examined QoL- 4 found significant positive impact.• 8 studies examined depression - 4 found significant positive impact.• 3 studies examined impact on caregivers - 2 found some benefits.

Demonstrates how CST can successfully be generalised across language and culture.*Lobbia, A., Carbone, E., Faggian, S., Gardini, S., Piras, F., Spector, A., & Borella, E. (2018). The Efficacy of Cognitive Stimulation Therapy (CST) for People With Mild-to-Moderate Dementia. European Psychologist.


The evidence-base

*Livingston, G., & Katona, C. (2000). How useful are cholinesterase inhibitors in the treatment of Alzheimer's disease? A number needed to treat analysis. International Journal of Geriatric Psychiatry, 15(3), 203-207.**Orrell M, Aguirre E, Spector A, Hoare Z, Woods RT, Streater A, Donovan H, Hoe J, Russell I, (2014) Maintenance cognitive stimulation therapy (CST) for dementia: single-blind, multicentre, pragmatic randomized controlled trial. British Journal of Psychiatry 2014 (204): 1-8.***D’Amico F, Rehill A, Knapp M, Aguirre E, Donovan H, Hoare Z, Hoe J, Russell I, Spector A, Streater A, Whitaker C, Woods RT, Orrell M (2015) Maintenance cognitive stimulation therapy: an economic evaluation within a randomised controlled trial. Journal of the American Medical Directors Association, 16 (1): 63-70.

• CST had similar impact on cognition (NNT) to Galantamine, Rivastigmine and Donepezil*.

• Some benefits maintained over time. Follow on trial** including 237 people with dementia found significant benefits to quality of life for up to 6 months when attending weekly group CST sessions (Maintenance/ MCST). Subgroup receiving both MCST and dementia medication improved the most.

• Work with the London School of Economics showed that CST and MCST aremore cost-effective than usual care***. This includes reduced use of health and social care when receiving CST.


The evidence-base• Less evidence for CST when delivered to people individually by family

caregivers*. • This trial (n=356) led to significant benefits to the person-caregiver

relationship and caregiver quality of life. However, benefits to cognition and quality of life found in group CST were not observed.

• Subsequent pilot study** of 14 session iCST programme delivered by psychologists (n=33) found significant improvements in cognition (Adas-Cog).

*Orrell, M., Yates, L., Leung, P., Kang, S., Hoare, Z., Whitaker, C., ... & Pearson, S. (2017). The impact of individual Cognitive Stimulation Therapy (iCST) on cognition, quality of life, caregiver health, and family relationships in dementia: A randomised controlled trial. PLoS Medicine, 14(3), e1002269.**Gibbor, L., Forde, L., Yates, L., Orfanos, S., Komodromos, C., Page, H., Harvey, K. & Spector, A. (2020). A feasibility randomised controlled trial of individual Cognitive Stimulation Therapy (iCST) delivered by professionals: impact on cognition, quality of life and positive psychology in people with dementia. Aging and Mental Health, 1-9.


Key conclusion: 22 systematic reviews incorporating 197 unique studies met inclusion criteria. There is good evidencethat multi-component exercise with sufficient intensity improves global physical and cognitive functions and ADL, and that group based Cognitive Stimulation improves cognitive functions, social interaction and quality of life.


Royal College of Psychiatry MSNAP (Memory servicesNational Accreditation Programme) standards: Psychosocial InterventionsType 1 (essential): CST, tailored psychosocial interventions for behavior that challenges (e.g. Functional Analysis).

Type 2 (expected): Maintenance CST, interventions which address emotional needs, advice and support on assistive technology and telecare, interventions for carers supporting emotional, psychological and social needs, structured activities for young PWD including volunteering, work and education.

Type 3 (aspirational): Individual CST, Cognitive Rehabilitation, group ReminiscenceTherapy, art / creative therapies.

*Survey of 186 UK memory services contacted, 57 responded. 50/57 offered CST - huge variation in provision, 51% twice weekly sessions, only 45% offered 14 sessions, most fewer.*Holden, E., Stoner, C. R., & Spector, A. (2020). Cognitive stimulation therapy for dementia: Provision in National Health Service settings in England, Scotland and Wales. Dementia, 1471301220954611.


Global use of CST “CST should routinely be given to people with early stage dementia”

International CST Centre at UCL:

https://www.ucl.ac.uk/international-cognitive-stimulation-therapy




https://www.ucl.ac.uk/global/news/2020/may/ucl-and-hku-working-deliver-dementia-therapy-virtually

Hong Kong Project Background• Planned to test CST through Zoom

before COVID-19 outbreak• To cater for people with dementia

who cannot join CST groups physically (e.g. mobility, logistical challenges)

• To connect those with similar cultural background, language, interest beyond geographical boundaries

• Currently testing through large RCT.

https://www.ucl.ac.uk/global/news/2020/may/ucl-and-hku-working-deliver-dementia-therapy-virtually


Observations from Hong Kong (Dr Gloria Wong)

• Manageable in some people with mild to moderate dementia

• Most without any IT experience (e.g. a 92yo lady new to Zoom)

• “I feel like a celebrity!”• Novel and empowering to master

new technology• Positive feedback from caregivers:

improved mood


Key recommendations included shorter sessions to reduce Zoom fatigue, role of co-facilitator to support technology, Caregiver pre-training.


UCL Project• Group CST, following standard 14 session manual (2 x week, 7 weeks) via Zoom.

• Stage 1 (Completed July 2020): Focus groups with a) professionals who delivered vCST (n=7), people with dementia (n=3), caregivers (n=4) and service managers (n=7), asking questions around implementation. Feedback inputted into final design of virtual CST programme and interim guidelines about virtual CST.

• https://www.ucl.ac.uk/pals/sites/pals/files/vcst_interim_guidelines_august2020.pdf

• Stage 2 (In progress): Pilot randomized controlled trial comparing CST (through Zoom) to treatment as usual (n=48). Will examine whether people can engage in new CST groups online, follow sessions, work the technology, benefit from the content, which people are more suited, etc.

https://www.ucl.ac.uk/pals/sites/pals/files/vcst_interim_guidelines_august2020.pdf


Early qualitative feedback from participants“I felt just globally comfortable with the people who were facilitating, and a growing relationship with the [participants]

.... And so as the weeks and the sessions wore on I felt increasingly safe, relaxed and not inhibited.”

“I absolutely loved honing in on news events. Because one of things that I’m finding really, really difficult with my concentration at the moment is following something. And because I am too scared to air my views with my family because I’m not the, I know I’m not the brain I used to be, you know... So that setting gave me that opportunity.”

“You know if I had have been having to travel 10 or 15miles somewhere and I was feeling under the weather, I might have ‘ummed and ahhhhed’ and not gone, but because it was online and I was warm and comfortable at home,even though I didn’t feel particularly wonderful, I could still attend. So you know in that respect it’s great.”

“Stimulating... Also, and I know this is not a scientific thing, I felt a breadth of humanity, warmth from the facilitators and from the other participants, and oh my goodness when you feel as isolated as I do right now, that warmth and compassion can’t be measured, it’s just immeasurable, it was first class.”


Early qualitative feedback“It was really good, because as we’d never ever met, erm in person before…..there were people that I warmed to

immediately.”

“... there’s a group of people who want to remain in communication with one another.”

Negative“well one thing that [the facilitator] said would happen in a face to face meeting was that at the end of each session there tends to be a cup of tea, and a chat, and a biscuit and [the participant] missed the biscuit didn’t you? (laughs) It’s that social aspect that’s not there, I think.” (carer)

“well there’s a disconnect isn’t there?... A slight time-lapse. So sometimes, and I’m aware of this, and I feel really bad, sometimes I feel as though I’m interrupting what someone’s saying…. So when you’re in a real-life situation you can read people and, you know, by their movements and their expressions, when they want to speak. And that’s quite difficult to do that online.”


Examples of vCST activities……….


Have any famous

landmarks changed /

disappeared over the years?

What famous landmarks have you

visited / was your favourite

to visit?

Which famous

landmark would you

like to visit?

Biggest celebrity scandal /

tragedy you remember?

What type of landscapes do you prefer to

visit i.e. woodland,

cities, beaches, farmland?

What is the most

beautiful / picturesque place you’ve

visited?

Who is your

favourite movie or TV star?

How have celebrities /

celebrity culture

changed over the years?

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Group song with seated exercisehttps://www.youtube.com/watch?v=OuASky-rIcM&feature=youtu.be

https://www.youtube.com/watch?v=OuASky-rIcM&feature=youtu.be


Concluding thoughts• CST offered to most people in the UK post diagnosis, but services have

stopped since COVID. Promising anecdotal evidence for vCST. • Could provide an important long-term alternative for people who

cannot access group CST due to transport, frailty, health problems, etc, but should not replace face-to face groups.

• Research will confirm feasibility and acceptability, including who is eligible and might benefit, IT considerations.

• Ongoing research in UK, Hong Kong, Brazil and India.• Stay updated: www.ucl.ac.uk/international-cognitive-stimulation-

therapy

http://www.ucl.ac.uk/international-cognitive-stimulation-therapy

Virtual Cognitive Stimulation Therapy (vCST): A new normal?

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