Cognitive Stimulation Therapy (CST) Intervention in the Community - PDF document

3/2/2015 Cognitive Stimulation Therapy (CST) Intervention in the Community Janice Lundy, BSW, MA, MHA Debbie Hayden, RN BSN, OTR-L Disclosures We have no relevant financial relationships to disclose CST Intervention in the Community • Background • What is Cognitive Stimulation Therapy • How was CST developed • Evidence-base • CST in practice • Our results • Why CST works…an OT perspective • Questions 1

3/2/2015 Background •Initial interest in CST •Research (financial reimbursement) •Establishing OT support •Funding •Medical Community Education and referral •Fall 2014 attended training and interview with Dr. Spector (UCL)…London What is Cognitive Stimulation Therapy? • An evidence based Psychosocial treatment for individuals with mild to moderate dementia • Focuses on the improvement and strengthening of cognitive functions • Maintenance of social and interaction skills • Potential to improve mood and quality of life Development of CST • CST developed by Dr. Aimee Spector under the direction of Dr. Martin Orrell and his team at UCL. 2

3/2/2015 How was the CST Program Developed? Systematic review of the literature on the main non- pharmacological therapies. • Reality Orientation • Reminiscence Therapy • Validation Therapy • Multisensory Stimulation Spector et al (2000); Spector et al (2001); Woods et al (2005) Evidence–Based CST Program For People With Dementia – Spector et al 2003, Br Jr Psychiatry • UK Randomized Control Trial (n=201) • 14 sessions program ran twice a week for 45mins • Sessions in residential homes & day centers • Study measured group intervention program against “usual activities” – which was described as usually nothing CST Study (Spector et al 2003) • Found that ADAS –cog scores, MMSE scores and QOL improved following CST • CST results showed CST improved cognition, to those reported with effects similar to the currently available anti-dementia drugs 3

3/2/2015 Additional Benefits of CST • Significant impact on language skills including: •Naming •Word finding •Comprehension (Spector et al. 2010) • No reported side-effects • Has been determined to be cost-effective (Knapp et al. 2005) CST: Expanded • Maintenance Cognitive Stimulation Therapy (MCST) • Single-blind RCT • Longer-term MCST (24 wks) • Led to continuous benefits in quality of life (Orrell, Aquirre, Spector et al (2014) • Individual Cognitive Stimulation Therapy (iCST) • Taught to caregivers by trained CST providers The UK Government NICE Guidelines on Dementia • The only government recognized non- pharmacological treatment for dementia • Government NICE guidelines recommend the use of group Cognitive Stimulation Therapy for people with mild to moderate dementia, irrespective of drug treatments received National Institute for Health and Clinical Excellence (2006) w w w .nice.org.uk 4

3/2/2015 World Alzheimer’s Report (2012) • The World Alzheimer’s Report (Alzheimer’s Disease International), stated that CST should routinely be given to people with early stage dementia. http://www.alz.co.uk/research/WorldAlzheimer’sReport2011.pdf Key Features of CST Program • 14 CST sessions, usually twice a week • 45 minutes to an hour • Ideally 5-8 participants in a group, run by two therapists/facilitators • Each session has a choice of activities, to cater for interests and abilities of group • Group members should ideally be at similar stages of dementia, so activities can be pitched accordingly • Attention should be paid to gender mix Who is appropriate for CST? Meet criteria for dementia, Can Can s/he SLUMS YES s/he greater hear well have a than 10? enough to “meaningful” YES participate Is her/his conversation? in a small vision good group YES enough to Is s/he discussion see most likely to pictures? remain in YES N a group for N 45 O O N minutes? N Y O N O O E THIS PERSON S MIGHT BE THIS PERSON SHOULD NOT BE INCLUDED IN THE GROUP INCLUDED IN THE GROUP 5

3/2/2015 Key Principles of CST 1. Mental stimulation 2. New ideas, thoughts and associations 3. Using orientation, both sensitively and implicitly 4. Opinions rather than facts 5. Using reminiscence as an aid to the here-and-now 6. Providing triggers to aid recall 7. Continuity and consistency between sessions 8. Implicit (rather than explicit) learning 9. Stimulating language 10. Stimulating executive functioning 11. Person-centeredness 12. Respect 13. Involvement 14. Inclusion 15. Choice 16. Fun 17. Maximizing potential 18. Building / strengthening relationships Session Structure • Introduction • Welcome every member individually • Group name • Soft ball toss ( warm up and orientation of members) • Reference to day, weather, season (always on board as cue). • Any discussion of important events in their lives since last session • Theme Group Song • Current Affairs (Local and national). • Main Activity • Suggested activities for home (may include in take home handout). • Closure (discuss time, day, and activity for next session-get opinions ) CST SCREENINGS 40 35 38 35 30 32 30 25 20 21 15 17 14 10 11 5 6 4 0 SLUMS Self ‐ DP CG DP Self ‐ QOL ‐ AD CG QOL ‐ AD Pre Post 6

3/2/2015 CST SLUMS VARIANCE 39.2 38.5 40 36.5 36.6 33 35 31.7 31.8 29.75 28 30 26.5 26 25.7 25 25 21.6 18.1 18 20 16.1 15 14 14.4 15 10.8 10.3 10 8.6 10 7.5 7.2 6.4 5.25 5 2.65 2.3 0 SLUMS SLUMS Self DP Self DP CG ‐ DP CG ‐ DP Self QOL ‐ Self QOL ‐ CG QOL ‐ CG QOL ‐ AD AD AD AD Pre ‐ test Post ‐ test Pre ‐ test Post ‐ test Pre ‐ test Post ‐ test Pre ‐ test Post ‐ test Pre ‐ test Post ‐ test SLUM <10 SLUMS 10 ‐ 19 SLUMS 20 ‐ 29 Gender: mean 40 38 35.5 34 35 33 33 32 31 30 25 25 22 20 20 17 17 15 11 10 10 8 7 6 5 4 5 2 0 Pre SLUMS Post SLUMS Pre ‐ Self DP Post Self DP Pre ‐ CG DP Post CG DP Pre Self Post self Pre CG Post CG QOL ‐ AD QOL ‐ AD QOL ‐ AD QOL ‐ AD Male n =6 Female n=13 CST Success • Cognition-SLUMS:75% • Depression-Cornell: 80% • Quality- QOL-AD: 90% • MCST: 70% 7

3/2/2015 CST PROVISION • CST:14 sessions, twice a week • Maintenance CST (MCST): weekly • Individual CST (iCST) An OT Perspective on Participant Goals For CST • Initially looked at ADL performance, however, saw limited progress in most clients. (Canadian article) • Areas of Progress Identified: 1. Increased “presence” or engagement in life 2. More aware and interactive in conversations activities in the home. 3. Increased interest in activities (playing cards) 4. Improved mood and behavior (less irritability and anxiety, more cooperative and happier). 5. Improved memory and recall requiring less prompting and cuing. Why Does CST Work : An OT Perspective • Short Term Memory- How many pieces of information you can hold onto for short period of time. Information comes in from auditory and visual systems primarily. • Long Term Memory- If value is placed on information in short term will move to long term. Intensity about information helps it “stick”. • Working Memory- Taking information from short and long term and assimilating or manipulating it. Basis for higher executive function. CST guides participants through prompting memories and thoughts to stimulate working memory for assimilation and manipulation of thoughts. “Turning the lights on”. 8

3/2/2015 Affect of Stress on Memory • HPA axis (slide ) • Hippocampus along with several other areas of the brain is responsible for telling hypothalamus to turn off the cortisol producing mechanism (feedback system) once levels reach a certain level • Hippocampus is structure in brain that helps connect new information with what we already know- basis of learning. Everything we learn, read, do and understand relies on hippocampus. Brains production on new neurons and laying down connections to others takes place in the hippocampus (neurogenesis). Retention of memories relies on neuronal activity. • Hippocampus-area susceptible to damage from cortisol levels. High levels of cortisol result in damage to hippocampus and lead to decreased feedback system and more cortisol production. Older persons often have lost 20-25% of cells in their hippocampus which causes even more cortisol production. “Degenerative Cascade”. (Brain Longevity, Dharma Singh Khalsa, M.D.) Benefit of CST: Low Stress Environment • Participants perceive as an enjoyable experience more likely to continue to participate • Provides for controlling anxiety and therefore the HPA axis cycle activation by avoiding placing participant in an uncomfortable or anxious position this in turn allows for memory recall and learning to take place • Sense of belonging, sense of achievement and getting physiological rib cage expansion with slow release all aide in serotonin release • Improves overall self-esteem QUESTI ONS ? 9