Cognitive Stimulation Slows Mental Decline in Dementia

Fran Lowry

February 17, 2012

February 17, 2012 — Evidence from multiple clinical trials shows that cognitive stimulation therapies have beneficial effects on memory and thinking in people with mild to moderate dementia, according to a systematic review published in the Cochrane Library.

The review also shows that the therapies, which involve discussion of past and present events and topics of interest, word games, puzzles, music, and practical activities such as baking or indoor gardening with trained staff, increased patients' feelings of well-being.

However, these therapies had no effect on people with severe dementia.

"I have been carrying out research on this type of approach for many years, but in recent years, better-quality, larger studies have been funded and reported, and we now have a substantial enough evidence base to draw some conclusions," Bob Woods, PhD, from Bangor University, United Kingdom, told Medscape Medical News.

Dr. Bob Woods

"I see these results as a message of hope, that staff working with people with dementia can make a difference to the person's quality of life and slow down cognitive decline. The same may apply to family caregivers too," Dr. Woods said.

Cognitive stimulation is not the same as cognitive training, which involves repeated cognitive exercises, he noted.

"Cognitive stimulation has a social element and is intended to offer a variety of enjoyable, stimulating activities," Dr. Woods explained.

Consistent Benefit

The review included 15 randomized controlled trials involving 718 people with mild to moderate dementia, mainly in the form of Alzheimer's disease or vascular dementia. Of these, 407 people received cognitive stimulation, which was typically given in small groups of 4 or 5 for about 45 minutes at least twice a week.

Their improvement was compared with that of 311 control participants, who received either standard treatment, which could include pharmacotherapy, day care, or visits from community mental health workers, alternative activities such as watching television and engaging in physical therapy, or no treatment.

The results of the review showed a clear, consistent benefit on cognitive function associated with cognitive stimulation (standardized mean difference [SMD], 0.41; 95% confidence interval [CI], 0.25 - 0.57).

Those who received cognitive stimulation scored significantly higher in cognitive function tests. The main tests that were used were the Mini-Mental State Examination (MMSE) and the Alzheimer's Disease Assessment Scale – Cognitive (ADAS-Cog).

The mean difference between those who received cognitive stimulation compared with those who received no cognitive stimulation on the MMSE was 1.74 (95% CI, 1.13 - 2.36; P < .00001).

"The mean benefit of 1.74 points on the MMSE can be said to roughly equate to the expected decline in dementia over a 6- to 9-month period," Dr. Woods said.

At follow-up 1 to 3 months after the end of the cognitive stimulation treatment, this benefit remained evident, Dr. Woods said.

Should Be Offered More Widely

Further analyses with smaller samples also showed benefits on self-reported quality of life and well-being (SMD, 0.44; 95% CI, 0.17 - 0.71).

There were no differences in mood (either self-reported or staff-rated), activities of daily living, general behavioral function or problem behavior, or family caregiver outcomes.

In 1 trial, family members were trained to deliver cognitive stimulation on a 1-to-1 basis. They reported no additional strain when doing this.

"Cognitive stimulation should be offered more widely, with staff and carers trained and supported to carry it out," Dr. Woods said.

"And doctors should tell patients and their families that if the person with dementia is in the mild to moderate stages, they may well enjoy, and perhaps benefit from, a cognitive stimulation approach, either in a small group or 1 to 1 with a family member or other supporter."

Lisa L. Boyle, MD, MPH, from the University of Rochester Medical Center in New York, commented on the findings for Medscape Medical News.

"As a provider in a memory care program, I encourage my patients to engage routinely in activities, as tolerated, that are socially and cognitively stimulating," she said.

"I think this paper is important because it highlights that there can be cognitive benefits from participating in cognitive stimulation programs for patients with mild to moderate dementia, as well as possible benefits to overall wellbeing and one's ability to communicate."

Dr. Boyle added that there is a need for more research to help clinicians better understand what is the most optimal approach and setting for cognitive stimulation, to better understand how long people should participate, and whether there are short-term and long-term benefits for patients and families that have a clinical and functional effect.

"Real-world barriers to implementing nonpharmacological approaches to caring for patients with dementia are key issues that patients, family members, and providers face every day," she said.

"There is limited availability of resources and ability to access programs such as social day programs that can provide cognitive stimulating activities and that also take into account patient and family preferences. We need to find solutions to these problems."

The study was supported by Bangor University, University College London, and the National Institute for Health Research, United Kingdom. Dr. Woods and Dr. Boyle have disclosed no relevant financial relationships.

Cochrane Database of Systematic Reviews. 2012;2:CD005562. Abstract

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