Individual Cognitive Stimulation Therapy (iCST)
By Dr Phuong Leung (PhD, FHEA, MSc and BSc)
There is a wide range of cognitive and psychosocial interventions focusing on maintaining or improving cognition and quality of life (QoL) for people with dementia and their carers (Bahar-Fuchs, Clare, Woods 2013; Woods et al., 2012). Evidence shows that cognitive stimulation therapy (CST) improved cognition and QoL for people with dementia (Woods et al., 2012). CST is becoming more widely available both in the United Kingdom (UK) and internationally. However, some people may not have access to CST groups because of transport, health and mobility problems, lack of available local CST groups or not so keen on participating in a group setting. Furthermore, receiving CST individually may provide opportunities for family carers to be involved. A recent review finds that carer involvement in psychosocial interventions may enhance mutual understanding, communication, relationship quality and well-being for both people with dementia and their carers (Moon and Adams, 2013).
In response to the government's emphasis on improving early interventions and home care for people with dementia, a home-based individual Cognition Stimulation Therapy (iCST) package delivered by family carers was developed by adapting group CST. This study aimed to evaluate the clinical effectiveness of carer-delivered iCST for people with dementia and their family carers. A single-blind, pragmatic randomised controlled trial (RCT) was conducted at eight study sites across the UK. The development and evaluation of this study followed the Medical Research Council (MRC) guidance for complex psychosocial interventions (Craig et al., 2008). The research team produced the iCST programme (including a manual, activity workbook, and materials such as maps and dominoes) in collaboration with people with dementia, carer, healthcare professionals and dementia experts.
A total of 356 pairs of people with dementia and carers participated in the study. Participants were randomly assigned to iCST receiving a total of 75 activity sessions (30 minute-session for 3 times a week) or treatment as usual control over 25 weeks. iCST sessions consisted of a variety of themes including current affairs, being creative, word games and quizzes which were designed to be mentally stimulating and enjoyable. Carers were trained to deliver iCST by using the manual with guidance and key principles (Yates et al., 2015). A total of 23 pairs of people with dementia and their family carers who completed the iCST intervention took part in semi-structured in-depth interviews exploring their experiences in iCST sessions (Leung, Orgeta, & Orrell, 2017).
The study finds that iCST did not improve cognition or QoL for people with dementia. However, people with dementia taking part in iCST had better relationship quality with their carers (Quality of the Carer Patient Relationship Scale). Carers delivering iCST reported a significant improvement in health-related QoL (European Quality of Life–5 Dimensions [EQ-5D]). Carers delivering more sessions had fewer depressive symptoms (Hospital Anxiety and Depression Scale [HADS]) (Orrell et al., 2017).
From a clinical perspective, reduction in depressive symptoms and improvements in QoL of the carer may result in a low-cost, non-drug intervention. This may prolong their ability to provide care for the person with dementia and contribute to the cost-effectiveness of dementia care (Yaffe et al., 2002). Enhancing the caregiving relationship through iCST may reduce carers’ role constrain (Yang, Liu, & Shyu, 2014) and the risk of requiring more support and resources from healthcare services (Orrell and Beddington 1995).
A qualitative study of Leung and colleagues (2017) shows that most people with dementia perceived mental stimulation as an activity that provided opportunities to keep ‘the brain going’, reﬂect, concentrate and stay alert. They also emphasised the importance of being mentally active as ‘if you do not use it you lose it’
"Yeah even though like things might not stay with me… but it's brilliant" (Person with dementia) and iCST "made my relative more alert" (Carer)
Taking part in the iCST intervention motivated people with dementia to keep their mind active and look for more information about mental stimulation.
“It (iCST) made me start thinking about doing what I used to do which was paintings over there, that I've done …I can get up and do things more easily” (Person with dementia).
Carers found iCST helped them to frame conversations and enhance the caregiving relationship.
“… Just opening topics of conversation, maybe listening to her, encouraging her to express herself and talk about things.” (Carer)
“…You can get a laugh out of it, the barriers come down… We enjoyed that time together!”. (Person with dementia)
Given iCST has a positive effect on the caregiving relationship and carer well-being, the programme might be a useful part of personally tailored home care packages, which may help maintain people with dementia in their homes for longer (Yaffe et al., 2002).
Bahar-Fuchs, A., Clare, L., & Woods, B. (2013). Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews, 6, CD003260.
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008). Developing and evaluating complex social interventions: the new Medical Research Council guidance. Bmj, 337, a1655. doi:10.1136/bmj.a1655
Leung, P., Orgeta, V., & Orrell, M. (2017). The experiences of people with dementia and their carers participating in individual cognitive stimulation therapy. Int J Geriatr Psychiatry DOI: 10.1002/gps.4648
Moon H, Adams KB. 2013. The effectiveness of dyadic interventions for people with dementia and their caregivers. Dementia (London) 12(6): 821–839.
Orrell M, Bebbington P. (1995) Life events and senile dementia. I. Admission, deterioration and social environment change. Psychol Med. 25(02):373±386.
Orrell, M., Yates, L., Leung, P., Kang, S., Hoare, Z., Whitaker, C.,Orgeta, V. (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), 22.
Woods, B., Aguirre, E., Spector, A. E., & Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews, 2, CD005562
Yaffe K, Fox P, Newcomer R, Sands L, Lindquist K, Dane K, (2002) Patient and caregiver characteristics and nursing home placement in patients with dementia. 287(16):2090±2097. PMID:11966383
Yang, C. T., Liu, H. Y., & Shyu, Y. I. L. (2014). Dyadic relational resources and role strain in family caregivers of persons living with dementia at home: A cross-sectional survey. International Journal of Nursing Studies, 51(4), 593-602.
Yates, L. A., Leung, P., Orgeta, V., Spector, A., & Orrell, M. (2015). The development of individual cognitive stimulation therapy (iCST) for dementia. Clin Interv Aging, 10, 95-104.