Cognitive stimulation to improve cognitive functioning in people with dementia
Cognitive stimulation to improve cognitive functioning in people with dementia
Review information
Authors
Bob Woods1, Elisa Aguirre 2, Aimee E Spector3, Martin Orrell4
1Dementia
Services Development Centre Wales, Bangor University, Bangor, UK
College London, London, UK
3Research Department of Clinical, Educational and Health Psychology, University College, London, London, UK
4Research Department of Mental Health Sciences, University College London, London, UK
2University
Citation example: Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stimulation to improve cognitive functioning in
people with dementia. Cochrane Database of Systematic Reviews 2005 , Issue 4 . Art. No.: CD005562. DOI:
10.1002/14651858.CD005562 .
Contact person
Bob Woods
Professor of Clinical Psychology of Older People
Dementia Services Development Centre Wales
Bangor University
45 College Road
Bangor
Gwynedd
LL57 2DG
UK
E-mail: b.woods@bangor.ac.uk
Dates
Assessed as Up-to-date:6 December 2011
Date of Search:
6 December 2011
Next Stage Expected: 15 January 2013
Protocol First Published: Issue 4 , 2005
Review First Published: Not specified
Last Citation Issue:
Issue 4 , 2005
What's new
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Abstract
Background
Cognitive stimulation is an intervention for people with dementia which offers a range of enjoyable activities providing general
stimulation for thinking, concentration and memory usually in a social setting, such as a small group. Its roots can be traced
back to Reality Orientation (RO), which was developed in the late 1950s as a response to confusion and disorientation in
older patients in hospital units in the USA. RO emphasised the engagement of nursing assistants in a hopeful, therapeutic
process but became associated with a rigid, confrontational approach to people with dementia, leading to its use becoming
less and less common.
Cognitive stimulation is often discussed in normal ageing as well as in dementia. This reflects a general view that lack of
cognitive activity hastens cognitive decline. With people with dementia, cognitive stimulation attempts to make use of the
positive aspects of RO whilst ensuring that the stimulation is implemented in a sensitive, respectful and person-centred
manner.
There is often little consistency in the application and availability of psychological therapies in dementia services, so a
systematic review of the available evidence regarding cognitive stimulation is important in order to identify its effectiveness
and to place practice recommendations on a sound evidence base.
Objectives
To evaluate the effectiveness and impact of cognitive stimulation interventions aimed at improving cognition for people with
dementia, including any negative effects.
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Cognitive stimulation to improve cognitive functioning in people with dementia
Search methods
The trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register,
called ALOIS (updated 6 December 2011). The search termsused were: cognitive stimulation, reality orientation, memory
therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation.
Supplementary searches were performed in a number of major healthcare databases and trial registers to ensure that the
search was up to date and comprehensive.
Selection criteria
All randomised controlled trials (RCTs) of cognitive stimulation for dementia which incorporated a measure of cognitive
change were included.
Data collection and analysis
Data were extracted independently by two review authors using a previously tested data extraction form. Study authors were
contacted for data not provided in the papers. Two review authors conducted independent assessments of the risk of bias in
included studies.
Main results
Fifteen RCTs were included in the review. Six of these had been included in the previous review of RO. The studies included
participants from a variety of settings, interventions that were of varying duration and intensity, and were from several
different countries. The quality of the studies was generally low by current standards but most had taken steps to ensure
assessors were blind to treatment allocation. Data were entered in the meta-analyses for 718 participants (407 receiving
cognitive stimulation, 311 in control groups). The primary analysis was on changes that were evident immediately at the end
of the treatment period. A few studies provided data allowing evaluation of whether any effects were subsequently
maintained. A clear, consistent benefit on cognitive function was associated with cognitive stimulation (standardised mean
difference (SMD) 0.41, 95% CI 0.25 to 0.57). This remained evident at follow-up one to three months after the end of
treatment. In secondary analyses with smaller total sample sizes, benefits were also noted on self-reported quality of life and
well-being (standardised mean difference: 0.38 [95% CI: 0.11, 0.65]); and on staff ratings of communication and social
interaction (SMD 0.44, 95% CI 0.17 to 0.71). No differences in relation to mood (self-report or staff-rated), activities of daily
living, general behavioural function or problem behaviour were noted. In the few studies reporting family caregiver outcomes,
no differences were noted. Importantly, there was no indication of increased strain on family caregivers in the one study
where they were trained to deliver the intervention.
Authors' conclusions
There was consistent evidence from multiple trials that cognitive stimulation programmes benefit cognition in people with mild
to moderate dementia over and above any medication effects. However, the trials were of variable quality with small sample
sizes and only limited details of the randomisation method were apparent in a number of the trials. Other outcomes need
more exploration but improvements in self-reported quality of life and well-being were promising. Further research should
look into the potential benefits of longer term cognitive stimulation programmes and their clinical significance.
Plain language summary
Can cognitive stimulation benefit people with dementia?
People with dementia and their caregivers are often advised that 'mental exercise' may be helpful in slowing down the
decline in memory and thinking experienced by many people with dementia. This review examined the evidence for one form
of mental exercise, described as cognitive stimulation. This involves a wide range of activities that aim to stimulate thinking
and memory generally, including discussion of past and present events and topics of interest, word games, puzzles, music
and practical activities such as baking or indoor gardening. Typically this is carried out by trained staff with a small group of
four or five people with dementia for around 45 minutes at least twice a week. Family caregivers have also been trained to
provide cognitive stimulation to their relative on a one-to-one basis.
This review included 15 trials with a total of 718 participants. The findings suggested that cognitive stimulation has a
beneficial effect on the memory and thinking test scores of people with dementia. Although based on a smaller number of
studies, there was evidence that the people with dementia who took part reported improved quality of life. They were
reported to communicate and interact better than previously. No evidence was found of improvements in the mood of
participants or their ability to care for themselves or function independently, and there was no reduction in behaviour found
difficult by staff or caregivers. Family caregivers, including those who were trained to deliver the intervention, did not report
increased levels of strain or burden.
The trials included people in the mild to moderate stages of dementia and the intervention does not appear to be appropriate
for people with severe dementia. More research is needed to find out how long the effects of cognitive stimulation last and for
how long it is beneficial to continue the stimulation. Involving family caregivers in the delivery of cognitive stimulation is an
interesting development and merits further evaluation.
Background
Interventions with a cognitive focus have long been used in dementia care. They have been developed in parallel with
approaches emphasising the stimulation of the senses (Woods 1977). Reality Orientation (RO) (Taulbee 1966) was
developed in the late 1950s as a response to confusion and disorientation in older patients in hospital units in the USA, and
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was the prototype of the cognitive stimulation approach. Classes were held for 30 minutes once or twice per day. Basic
personal and current information was presented to the patient and a variety of materials used, such as individual calendars,
word-letter games, building blocks and large-piece puzzles. A Reality Orientation board would be used in each session and
would list the name of the unit and its location, the day, date, weather, current events etc. The approach emphasised the
engagement of nursing assistants in a hopeful, therapeutic process.
The first controlled evaluation of RO was reported in the UK by Brook et al (Brook 1975). They found positive benefits on
ratings of intellectual and social functioning in patients attending RO group sessions for 30 minutes per day, five days per
week for four months compared with a control group who visited a special RO room daily but were not given any
encouragement to engage with the materials or each other. A spate of controlled studies followed (Holden 1995), with
outcome measures typically including assessments of orientation, other aspects of cognitive functioning and level of
independent functioning. A Cochrane review specifically examining Reality Orientation (Spector 2000a; Spector 2000b)
concluded that there was some evidence that RO had benefits for people with dementia on both cognition and behaviour.
However, outside of a few countries (notably Italy), RO has been little practised or researched since 1990 and has attracted
some criticism (Burton 1982; Dietch 1989; Powell-Proctor 1982), especially for being applied in a mechanical, inflexible,
insensitive and confrontational manner. Doubts were also raised about the clinical significance of any improvements; the
person with dementia might now know what day of the week it was but would this have any meaningful impact on the
person's life? Such was the concern regarding the insensitive use of RO and other cognitive approaches that one influential
set of guidelines on the management of dementia (APA 1997) cautioned against their use with the possibility of a negative
impact on the person's well-being that outweighed any small cognitive improvements.
In addition to the 'classroom' element of RO, from the early days '24 hour RO' was also advocated. This involves staff taking
every opportunity to provide current information to the person, outside of the formal setting of the RO group, as well as using
environmental features such as sign-posting and orientation boards to assist orientation. There have been some positive
evaluations of the effects of training and sign-posting on orientation around a care facility (for example Hanley 1981;
McGilton 2003) but the effects of 24 hour RO per se have been more difficult to evaluate. This is not least of all because of
the difficulty in monitoring its implementation, with informal interactions being much more difficult to document than a formal
group meeting. Williams 1987 reports using a modified form of 24 hour RO where staff were trained to respond appropriately
to residents' requests for information, and found that 90% of staff responses to residents' requests complied with the
treatment protocol. This study reported improvements in cognition, independent functioning and orientation, compared with a
control group on a separate ward, when this form of 24 hour RO was implemented.
Alongside the RO literature, in recent years there has been increasing discussion of 'cognitive stimulation'. In part this
reflects a general view that lack of cognitive activity hastens cognitive decline, in normal ageing as well as in dementia (Breuil
1994; Small 2002), and in part it is an attempt to make use of the positive aspects of RO whilst ensuring that it is
implemented in a properly sensitive and respectful manner (Spector 2001; Woods 2002). There has also been growing
interest in the application of various forms of cognitive training and in teaching individual people with dementia to use
memory aids and strategies to assist with their particular difficulties that have been identified with the person. A Cochrane
review of cognitive training and cognitive rehabilitation in early stage dementia has been completed (Clare 2003) and it is
important to ensure that clear definitions are used to avoid confusion between the various cognition-based approaches, as in
the past 'training', 'stimulation' and 'rehabilitation' have been used almost interchangeably.
Clare and Woods (Clare 2004) proposed the following definitions.
Cognitive stimulation is engagement in a range of activities and discussions (usually in a group) aimed at general
enhancement of cognitive and social functioning.
Cognitive training is guided practice on a set of standard tasks designed to reflect particular cognitive functions; a range of
difficulty levels may be available within the standard set of tasks to suit the individual's level of ability. It may be offered in
individual or group sessions, with pencil and paper or computerised exercises.
Cognitive rehabilitation is an individualised approach where personally relevant goals are identified and the therapist works
with the person and his or her family to devise strategies to address these. The emphasis is on improving performance in
everyday life rather than on cognitive tests, building on the person's strengths and developing ways of compensating for
impairments
Using these definitions, this review included studies on RO group sessions but not on 24 hour RO or direct training in spatial
orientation. The primary outcomes examined will be in relation to the person's cognitive functioning. It is considered that this
is the minimum expectation of a general approach with this focus. However, given the concerns discussed above of a
possible negative effect, measures of quality of life, mood and well-being are highly pertinent secondary outcome measures.
The effects on the person's general level of function in everyday life also need to be considered in evaluating the meaning of
any changes observed for the individual and his or her supporters. The impact on family caregivers and careworkers is also
important to consider as they are key partners in the process of care.
Objectives
To evaluate the effectiveness and impact of cognitive stimulation interventions aimed at improving cognition for people
with dementia, including any negative effects.
To indicate the nature and quality of the evidence available on this topic.
To assist in establishing the appropriateness of offering cognitive stimulation interventions to people with dementia and
identifying the factors associated with their efficacy.
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Methods
Criteria for considering studies for this review
Types of studies
This review focused on randomised controlled trials (RCTs) for which adequate information was provided or could be
obtained from the researchers. The studies included must have been published, written in English and presented in a peerreviewed journal article.
Types of participants
Participants with a diagnosis of dementia. The main diagnostic categories that were included were Alzheimer's disease,
vascular dementia or mixed Alzheimer's and vascular dementia. These diagnostic categories were considered together.
Older studies, included from the previous review of RO, used other terms for this population but were included where the
review authors were satisfied that the included population would now be described as having a dementia. Participants with
mild cognitive impairment, where the extent of cognitive impairment or its effects on day-to-day function were insufficient
to justify a dementia diagnosis, were not included.
Severity of dementia was indicated through group mean scores, range of scores, or individual scores on a standardised
scale such as the Mini-Mental State Examination (MMSE) (Folstein 1975) or Clinical Dementia Rating (CDR) (Hughes
1982). All levels of severity were included.
Qualifying participants received the intervention in a range of settings, including their own home, as outpatients and in
day-care and residential settings.
No specific restrictions regarding age were applied.
Data from family caregivers were included where this was available and where the relationship between the caregiver and
the person with dementia was specified, including whether they were co-resident.
The number of participants receiving concurrent treatment with acetylcholinesterase inhibitors was documented, where
possible.
Types of interventions
Studies were considered for this review if they described a cognitive stimulation intervention targeting cognitive and social
functioning. These interventions may also have been described as RO groups, sessions or classes.
The definition of cognitive stimulation as proposed by Clare 2004 was adopted. This meant that some studies which
described their intervention as 'cognitive stimulation' were excluded. Interventions needed to offer exposure to generalised
cognitive activities rather than training in a specific modality.
Interventions were typically conducted in a group to enhance social functioning, or could involve family caregivers.
Studies were included if a comparison was made to 'no treatment', 'standard treatment' or placebo. Standard treatment
was understood to be the treatment that was normally provided to patients with dementia in the study setting and could
include provision of medication, clinic consultations, contact with a community mental health team, day care, or support
from voluntary organisations. Placebo conditions could consist, for example, of an equivalent number of sessions in which
general support, but no structured intervention, was offered.
The minimum duration of intervention for inclusion of a study was one month. There were no restrictions on the number of
treatment sessions, although this was noted.
Types of outcome measures
Outcomes were considered in relation to the impact of the intervention on the person with dementia and on the primary
family caregiver. Studies could present data in both these categories.
Short term (immediately after the intervention) and medium term (follow-up one month to one year after the intervention
finished) outcomes were considered.
Outcomes for the person with dementia and the caregiver were considered where these were assessed using scores on
standardised tests, rating scales and questionnaires.
Rates of attrition and reasons for participants dropping out from the study were noted.
Outcomes for the person with dementia
Outcome measures for the person with dementia sought to identify whether changes were observed following the
intervention. The following variables were considered as outcome measures for the person with dementia.
Performance on at least one test of cognitive functioning (including tests of memory and orientation).
Self-reported, clinically-rated or carer-reported measures for mood of the person with dementia.
Self-reported or carer-reported quality of life or well-being measures for the person with dementia.
Observer or carer ratings of everyday functioning (activities of daily living) of the person with dementia.
Carer ratings of the participant's behaviour.
Clinician or carer ratings of neuropsychiatric symptoms or behaviour problems of the person with dementia.
Clinician or carer ratings of the social engagement of the person with dementia.
'Carer' in this context included care staff as well as family caregivers.
Outcomes for the family caregiver
The outcomes for the family caregiver that were considered included any of the following.
Self-reported well-being, depression and anxiety.
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Self-reported burden, strain and coping.
Satisfaction with the intervention.
Search methods for identification of studies
We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialized
Register, on 6 December 2011. The search terms used were: cognitive stimulation, reality orientation, memory therapy,
memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation.
ALOIS is maintained by the Trials Search Co-ordinator of the Cochrane Dementia and Cognitive Improvement Group and
contains studies in the areas of dementia prevention, dementia treatment and cognitive enhancement in healthy populations.
The studies are identified from: 1. monthly searches of a number of major healthcare databases: MEDLINE, EMBASE, CINAHL, PsycINFO and LILACS;
2. monthly searches of a number of trial registers: meta Register of Controlled Trials; Umin Japan Trial Register; WHO portal
(which covers ClinicalTrials.gov; ISRCTN; Chinese Clinical Trials Register; German Clinical Trials Register; Iranian
Registry of Clinical Trials and the Netherlands National Trials Register, plus others);
3. quarterly search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library);
4. six-monthly searches of a number of grey literature sources: ISI Web of Knowledge Conference Proceedings; Index to
Theses; Australasian Digital Theses.
To view a list of all sources searched for ALOIS see About ALOIS on the ALOIS website.
Details of the search strategies used for the retrieval of reports of trials from the healthcare databases, CENTRAL and
conference proceedings can be viewed in the ‘methods used in reviews’ section within the editorial information about the
Dementia and Cognitive Improvement Group (CDCIG).
Additional searches in each of the sources listed above, to cover the timeframe from the last searches performed for the
Specialized Register to December 2011, were run to ensure that the search for the review was as up to date as possible.
The search strategies used can be seen in Appendix 1.
A total of 804 references were retrieved from the December 2011 search. After de-duplication and a first assessment,
authors were left with 41 references to further assess for either inclusion, exclusion or discarding.
Data collection and analysis
Searches were conducted as detailed above to identify all relevant published studies. The date and time of each search,
together with details of the version of the database used, were recorded. Additional information was sought, as outlined
above, and hard copies of articles were obtained.
Quality assessment
RCTs were identified and the two review authors (BW and EA) worked independently to determine which studies met the
criteria for inclusion. Trials that did not meet the criteria were excluded, and reasons for exclusion were noted in the table
'Characteristics of excluded studies'. Review authors' selections of trials were compared and the final list of included studies
was reached by consensus.
The selected RCTs were described in tabular form, permitting an evaluation of their methodological quality. Studies were
assessed against a checklist of quality requirements using the Cochrane approach (see risk of bias tables).
Grade A, 'Low risk': adequate concealment (randomisation; concealed allocation).
Grade B, 'Unclear risk': "randomised", but methods uncertain.
Grade C, 'High risk': inadequate concealment of allocation or no randomisation, or both.
Only trials with a grade A or B ranking were included in the review. Again, the review authors worked independently to
ascertain which studies met the quality criteria, and consensus was reached through discussion. Attempts were made to
obtain additional information from the study authors when further data were needed.
Data extraction
Data from the RCTs selected for inclusion were extracted, recorded and entered into RevMan. The summary statistics
required for each trial and each outcome for continuous data were the mean change from baseline, the standard error of the
mean change, and the number of patients for each treatment group at each assessment point. Where changes from baseline
were not reported, the review authors extracted the mean, standard deviation and the number of patients for each treatment
group at each time point, if available. The review authors calculated the required summary statistics from the baseline and
post-treatment group means and standard deviations, assuming in this case a zero correlation between the measurements at
the baseline and follow-up time points. This method overestimates the standard deviation of the change from baseline but
this conservative approach was chosen as it is preferable in a meta-analysis. For binary data, the review authors sought the
numbers in each treatment group and the numbers experiencing the outcome of interest. The baseline assessment was
defined as the latest available assessment prior to randomisation, but no longer than two months prior.
For each outcome measure, data were sought on every patient randomised. To allow an intention-to-treat analysis, the data
were sought irrespective of compliance and whether or not the patient was subsequently deemed ineligible or otherwise
excluded from treatment or follow-up. If intention-to-treat data were not available in the publications, 'on-treatment' data or
the data of those who completed the trial were sought and were indicated as such. In studies where a cross-over design was
used, only data from the first treatment phase after randomisation were eligible for inclusion.
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As the outcomes measured in clinical trials of dementia and cognitive impairment often arise from ordinal rating scales,
where the rating scales had a reasonably large number of categories (more than 10) the data were treated as continuous
outcomes arising from a normal distribution.
Data analysis
The meta-analyses included the combination of data from trials that may not use the same rating scale to assess an
outcome. Therefore, the measure of the treatment difference for any outcome used was the weighted mean difference when
the pooled trials used the same rating scale or test and the standardised mean difference (the absolute mean difference
divided by the standard deviation) when they used different rating scales or tests. The duration of the trials may vary
considerably. If the review authors considered the range too great to combine all trials into one meta-analysis, they divided it
into smaller time periods and conducted a separate meta-analysis for each period. Some trials may have contributed data to
more than one time period if multiple assessments were made.
The meta-analyses presented overall estimates of the treatment difference from a fixed-effect model and a test for
heterogeneity was performed using a standard Chi2 statistic. Where there was evidence of heterogeneity of the treatment
effect between trials then a random-effects model was utilised (which results in broader confidence intervals than for those of
a fixed-effect model).
The review authors discussed and reached consensus on the interpretation of the statistical analyses, seeking specialist
statistical advice from CDCIG as required. The review authors discussed and reached consensus on the presentation of the
findings in the background to the review.
Results
Description of studies
From the initial set of references identified by the updated systematic searches (since our last review, Spector 2000a), 53
potentially relevant studies were identified. Of these, seven studies met the inclusion criteria (Baldelli 2002; Bottino 2005;
Chapman 2004; Onder 2005; Requena 2006; Spector 2001; Spector 2003) and were included in this review. Our previous
review (Spector 2000a) included eight studies in the meta-analysis, six of which were included in this replacement review (
Baines 1987; Baldelli 1993a; Breuil 1994; Ferrario 1991; Wallis 1983; Woods 1979). For the two studies excluded at this
stage, the data needed for the current analyses were not available (Gerber 1991; Hanley 1981). Full details of included
studies and reasons for exclusion of excluded studies are presented in the tables 'Characteristics of included studies' and
'Characteristics of excluded studies'. The pre-publication search in December 2011 identified 41 further studies for
consideration. Two further studies (Buschert 2011; Coen 2011) met the inclusion criteria and have been added to the review,
with three further studies awaiting classification (Buettner 2011; Fernandez-Calvo 2010; Niu 2010).
Overall, 718 participants, 407 in the treatment groups and 311 in the control groups, were included in the analyses of the 15
included studies. The included studies varied in many aspects: (1) participant characteristics; (2) number and duration of
cognitive stimulation sessions; (3) activities which defined cognitive stimulation; (4) the activity of the control group; and (5)
outcome measures. These factors will be considered in turn.
1) Participant characteristics
Diagnosis: eight of the nine new studies specified the diagnostic criteria used. Coen 2011 simply described their participants
as having mild to moderate dementia; Spector 2001 and Spector 2003 used DSM-IV criteria, but did not break the
participants down by dementia subtype; Baldelli 2002 included similar numbers of participants with “Degenerative senile
dementia of the Alzheimer’s type (SDAT)” (N = 46) and “vascular multi-infarct dementia” (N = 41), although all had
experienced at least one cerebrovascular accident resulting in motor deficits; Bottino 2005, Buschert 2011, Chapman 2004,
Onder 2005 and Requena 2006 all specified a diagnosis of probable Alzheimer's disease (AD) according to NINCDSADRDA criteria linked with either ICD-10 or DSM-IIIR criteria. In these studies, participants were on a stable dose of an
acetylcholinesterase inhibitor (ACHEI) (rivastigmine in the Bottino 2005 study; donepezil in the remaining studies apart from
Buschert 2011 where a variety of medications including memantine were being taken). Amongst the earlier studies, Breuil
1994 specified DSM-III criteria for dementia and Baldelli 1993a stated that their participants were diagnosed with
"Alzheimer’s (SDAT) ". The four studies from 1991 and earlier specified more general criteria using cognitive measures that
indicated that dementia diagnoses were justifiable (Baines 1987; Ferrario 1991; Wallis 1983; Woods 1979).
Ten of the 11 most recent studies provided mean baseline scores on the Mini-Mental State Examination (MMSE), and the
11th (Ferrario 1991) provided the MMSE score range for participants. Coen 2011, Spector 2001 and Spector 2003 were the
only studies with a mean MMSE score in the moderate range (10 to 20), perhaps reflecting the upper limit of 24 for
participants to be included in these studies. The mean scores (16.9, 13.1 and 14.4 respectively) were several points lower
than those in the eleven studies reporting mean scores (mean average 19.7), and outside the range of 18 to 25 specified by
Ferrario 1991. However, those studies where the mean score was in the mild range (> 20) may well have included
participants in the moderate or even the severe range, for example the lowest score in the Breuil 1994 study was reported to
be 9. In general, however, it can be said that the studies included in this review had targeted participants in the mild to
moderate range of cognitive impairment.
The average age of participants was over 70 years in all studies (except Wallis 1983 where it was 69.8 years); in 6 studies it
was over 80 years. The average mean age across the 15 studies was 78.8 years, with the range of ages that were reported
from 38 to 97 years. Over half the studies reported inclusion of participant(s) aged 90 years and above.
Participants were resident in care homes, nursing homes or hospitals, apart from six studies (Bottino 2005; Breuil 1994;
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Buschert 2011; Chapman 2004; Onder 2005; Requena 2006) where all the participants were outpatients living in the
community. The participants included in the Spector 2001 and Spector 2003 studies were recruited from both residential care
homes and day centres, with the former being in the majority.
2) Length, number and duration of sessions
The length of the intervention varied from four weeks (the minimum for inclusion in the review) to 24 months, with the stated
length of sessions varying from 30 minutes to 90 minutes. In general, the sessions of longer duration were associated with
the lowest frequency (once a week). The median session length across the studies was 45 minutes, and the median
frequency was three times a week, ranging from once to five times a week. The total possible exposure to the intervention
varied dramatically, from 10 to 12 hours (Baines 1987; Breuil 1994; Chapman 2004; Coen 2011; Spector 2001; Spector 2003
) to 375 hours in the two-year (Requena 2006) study. Across the 15 studies, the median exposure time was 30 hours.
Requena 2006 presented data from both the 12 month and 24 months time point in their study. As there was less attrition at
the 12 month time point, and this was more comparable (although still longer) in duration to the other studies, the 12 month
data were used in combination with other studies in the meta-analyses, with the 24 month data reported separately.
3) Activities during cognitive stimulation
The level of detail provided in the published papers regarding the activities undertaken varied greatly. All studies used small
group sessions, typically with groups of five to seven participants, with the exception of Onder 2005 where family caregivers
were taught to carry out cognitive stimulation with the person with dementia on an individual basis. These individual
sessions, led by family caregivers, included current information, topics of general interest, historical events and famous
people, attention, memory and visuo-spatial exercises and the use of clocks, calendars and notes.
Early studies described the use of an RO board and discussion of current orientating information through newspapers,
photographs, calendars and clocks etc., with materials selected to stimulate all five senses (for example Baines 1987; Wallis
1983; Woods 1979). Breuil 1994 introduced a number of more specific cognitive activities including drawing, associating
words, object naming and categorising. Spector 2006 provided a detailed session by session treatment manual for the
approach used in their studies. Activities in their sessions were designed with four themes: (1) the senses, (2) remembering
the past, (3) people and objects, and (4) everyday practical issues. Activities included naming objects and people,
association of words, remembering the past, discussion of hobbies, activities and current affairs, using money, knowing the
way around and orientation topics. This treatment manual was also used by Coen 2011. Chapman 2004 reported topics
including current events, discussion of hobbies and activities, education regarding Alzheimer’s disease, life story work, and
links with daily life with groups of six to seven participants. Bottino 2005 described temporal and spatial orientation,
discussion of interesting themes, reminiscence activities, naming people, planning of daily activities and use of calendars and
clocks and other external memory aids. Requena 2006 described, for groups of five people with dementia, visual images
being shown on a TV screen from a computer and that reflected seven themes: orientation, bodily awareness, family and
society, caring for oneself, reminiscing, household activities, animals, people and objects. These were accompanied by
questions for discussion.
None of the included trials adopted 24 hour RO in addition to group sessions, although Bottino 2005 described involving
family caregivers in encouraging the use of external memory aids at home, Buschert 2011 described the use of exercises
and tasks to be carried out at home between sessions and Onder 2005 encouraged family caregivers to informally engage in
reality-based communication with the person with dementia two or three times a day.
4) Control group(s) activities
In the earlier studies, alternative group activities were offered that were of a social (Woods 1979) or diversional (Wallis 1983)
nature. Baines 1987 offered an alternative treatment, reminiscence groups, but for the purposes of this review it was the notreatment group that was included in the analyses. 'Treatment as usual' or no treatment was the control condition in a
number of studies (Baldelli 1993a; Breuil 1994; Coen 2011; Ferrario 1991; Spector 2001; Spector 2003). In those studies
where participants were also taking ACHEIs, the control group were typically monitored in relation to the medication (
Chapman 2004; Bottino 2005; Onder 2005; Requena 2006). Requena 2006 reported that their control participants watched
TV whilst the cognitive stimulation groups were in session. Baldelli 2002 engaged both the control and cognitive stimulation
participants in a physical therapy programme. Buschert 2011 asked control participants to complete pencil and paper tasks
at home, encouraged by monthly group meetings.
5) Outcome measures
As a condition of inclusion, cognitive tests were used in all the studies. Eleven studies used the MMSE (Folstein 1975) and
eight of the more recent studies also used the Alzheimer's Disease Assessment Scale - Cognitive (ADAS-Cog) (Rosen 1984
). Unfortunately, only the 10 month follow-up data on these and other measures could be utilised from Chapman 2004 as it
has not proved possible to obtain their data at earlier time points in an extractable form. Four studies used a self-report
quality of life measure with participants with dementia (Buschert 2011; Chapman 2004; Coen 2011; Spector 2003), but again
the Chapman 2004 data was not in a useable form. Five studies used a self-report depression measure (four making use of
a version of the Geriatric Depression Scale: Yesavage 1983), and four studies used a depression or anxiety scale completed
from carer reports as well as from interviews with the participants (such as the Cornell Scale for Depression in Dementia:
Alexopoulos 1988). A variety of scales have been used to evaluate behaviour, with activities of daily living (ADL) scales used
in four studies, general behaviour ratings in seven studies and problem behaviour scales used in three studies. Family
caregiver outcome measures were used in three studies (Bottino 2005; Onder 2005; Spector 2001).
A full list of the outcome measures used in the included studies can be found in the table Characteristics of included studies'.
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Cognitive stimulation to improve cognitive functioning in people with dementia
Risk of bias in included studies
Details for each study are provided in the 'Characteristics of included studies' table.
Allocation (selection bias)
For a study to be included in this review, the review authors had to be satisfied that random allocation to treatment conditions
had been used. To ascertain this, in several cases it was necessary to seek further information from the study authors (for
example Baldelli 1993a; Baldelli 2002; Ferrario 1991; Requena 2006). Remote or computerised randomisation was only
used in four of the most recent studies (Bottino 2005; Chapman 2004; Buschert 2011). Earlier studies described drawing
names from a hat or a sealed container, where it was possible to obtain details of the randomisation procedure.
Blinding (performance bias and detection bias)
Performance bias
With psychological interventions, unlike drug trials, it is impossible to totally blind participants and staff to treatment.
Participants will often be aware that they are being treated preferentially and the staff involved may have different
expectations of treatment groups. There may also be 'contamination' between groups in terms of group sessions not being
held in separate rooms and staff bringing ideas from one group to another, so that control participants receive elements of
cognitive stimulation. The latter effect would be reduced with clear therapeutic protocols, the existence of which was not clear
in most study reports.
In relation to contamination, Wallis 1983 and Baines 1987 both stated that the staff were unaware of the allocation of
participants to groups, as they were removed from the ward setting for treatment, and several other studies described the
groups being run in a separate or specific room (for example Ferrario 1991; Spector 2001; Spector 2003; Woods 1979).
Detection bias
Most studies took steps to ensure that at least part of the assessment of outcomes was carried out by assessors blind to
treatment allocation. Only three studies (Baldelli 1993a; Baldelli 2002; Ferrario 1991) did not report blinding of assessors. Of
course, even independent assessors may be given clues from participants during the assessments, but this was not reported
as an issue in the studies reviewed here. Using independent assessors works well for evaluating changes in cognition or
self-reported mood, well-being and quality of life. Ratings of day-to-day behaviour and function are typically carried out by
care staff, who may be more difficult to keep blind to group allocation, unless the group sessions were carried out in a
separate location to which all participants were taken.
Incomplete outcome data (attrition bias)
Only two studies described following an intention-to-treat analysis plan (Chapman 2004; Spector 2003). In contrast, Breuil
1994 stated that "All those who for any reason did not attend all evaluation and training sessions were eliminated", with five
participants excluded on this basis (three from the cognitive stimulation group).
All studies reported data on attrition. Given the nature of the condition and the age of the participants, attrition in several
studies was remarkably small, with zero attrition recorded in six studies (Baines 1987; Baldelli 1993a; Baldelli 2002; Bottino
2005; Buschert 2011; Coen 2011), out of 180 participants. The largest attrition rate was reported by Wallis 1983 where there
was 39% attrition in the group of participants with dementia. In this study patients who attended less than 20% of the group
sessions were eliminated from the study. Requena 2006 reported 32% attrition but this was over a two year period. The two
largest studies had rates of 19% (Onder 2005) and 17% (Spector 2003) over periods of six months and two months
respectively.
Other potential sources of bias
The absence of detailed treatment protocols raised queries regarding the extent to which the cognitive stimulation was
delivered as intended (having noted that there may have been differences in emphases between studies in any case).
Several studies noted that staff received training or supervision, or both, in running the groups and, from an early study,
Woods 1979 stated in a personal communication that "A sample of sessions were tape-recorded and rated to ensure
compliance with the therapeutic protocol". More recently, Chapman 2004 described weekly meetings to ensure their
treatment programme was implemented as designed. Subgroups were led by a licensed speech-language pathologist and
three master's level speech-language pathology students; all underwent two hour training before the groups started and
weekly meetings were held to ensure that the programme was implemented as designed. Onder 2005 described how family
caregivers were trained by a multi-disciplinary team and given a manual and specific schedules for each session. No records
were made, however, of how often caregivers did deliver the sessions, or how closely the manual was followed.
Effects of interventions
For meta-analyses we used RevMan 5.1.
Cognition
(See Figure 1)
For the overall evaluation of the effects of cognitive stimulation on cognitive function, all 14 RCTs which included useable
data immediately post-treatment were included, including a total of 658 people with dementia of whom 377 received cognitive
stimulation and 281 received no treatment or a placebo treatment. As most studies included more than one measure of
cognitive function, this analysis was conducted on the most extensive assessment included. For seven studies this was the
ADAS-Cog, and for two each it was the MMSE and CAPE Information/Orientation scales. The overall effect size, the
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Cognitive stimulation to improve cognitive functioning in people with dementia
standardised mean difference (SMD) was 0.41 (95% CI 0.25 to 0.57). This was a statistically significant finding (Z = 5.04, P <
0.00001). For the seven studies, including 434 participants, using the ADAS-Cog as an outcome measure (Figure 2), the
mean difference between the cognitive stimulation and control groups was 2.27 points (95% CI 0.99 to 3.55), a statistically
significant difference (Z = 3.48, P < 0.0005). In total, 10 studies involving 600 participants used the MMSE (Figure 3). The
overall mean difference was 1.74 points (95% CI 1.13 to 2.36). Again, this was a statistically significant difference (Z = 5.57,
P < 0.00001). These analyses were strongly influenced by two of the more recent studies, Spector 2003 and Onder 2005,
which were relatively large and had smaller confidence intervals around their reported mean differences. Five of the older
studies involving 81 participants used other measures of information or orientation (Figure 4); here the SMD was no smaller
(SMD 0.45, 95% CI -0.01 to 0.90) and was just statistically significant despite the much smaller numbers involved (Z = 1.93,
P = 0.05).
The largest effect sizes were seen at the 12 month time point in the Requena 2006 study (SMD 0.70 on ADAS-Cog) and the
Baldelli 1993a study (SMD 0.99 on MMSE), both of which offered above average durations of exposure to cognitive
stimulation. However, Breuil 1994, which offered only 10 hours exposure, also had an above average effect size (0.63 on
global cognitive score) and other studies with longer exposure (for example Ferrario 1991) had below average effect sizes.
The 24 month data from Requena 2006 indicated that effect sizes appeared to be maintained through continued exposure
(ADAS-Cog SMD 0.66: MD 11.94 points, 95% CI -0.97 to 24.85; MMSE SMD 0.56: MD 5.99 points, 95% CI -1.58 to 13.56).
However, these effects require replication as the confidence intervals were broad and crossed zero.
Communication and social interaction
(See Figure 5)
Four studies, involving 223 participants, included staff ratings of the person's communication and social interaction (outside
of the cognitive stimulation group), three using the Holden Communication Scale. The overall effect size (SMD) was 0.44
(95% CI 0.17 to 0.71) with participants in the cognitive stimulation groups showing a significant improvement in this area (Z =
3.15, P = 0.002). Spector 2003 was the most influential study in this analysis, although the effect was not reported as
significant in the primary study report.
Well-being and quality of life
(See Figure 6)
Four studies, involving 219 participants, included relevant self-report measures. Baines 1987 used the Life Satisfaction Index
and Spector 2003, Buschert 2011 and Coen 2011 used the QoL-AD. The meta-analysis indicated that cognitive stimulation
was associated with a significant benefit to well-being and quality of life compared with no treatment (SMD 0.38, 95% CI 0.11
to 0.65) (Z = 2.76, P = 0.006). The Spector 2003 findings were again a major influence.
Mood
(See Figure 7; Figure 8)
Five studies, involving 201 participants, used a self-report measure of mood (the Geriatric Depression Scale or the MADRS).
Cognitive stimulation was not associated with a clear improvement in mood across these studies. The SMD was 0.22 (95%
CI -0.09 to 0.53) (Z = 1.42, P = 0.16).
Staff ratings of mood and anxiety similarly did not show any benefit from cognitive stimulation. Four studies, involving 239
participants, contributed to this analysis, two using the Cornell Scale for Depression in Dementia, a third using a subscale of
the MOSES scale and the fourth the Rating of Anxiety in dementia. The SMD was close to zero in this domain (SMD 0.05,
95% CI -0.21 to 0.31).
Behaviour
(See Figure 9; Figure 10; Figure 11)
Three separate meta-analyses were conducted in this domain. One focused on activities of daily living (ADL) and basic selfcare skills; a second focused on behaviours seen as a problem, such as irritability, being demanding and difficult. The third
included 'general' behaviour rating scales, which may include some of the previous two aspects, together with some higher
level daily living skills. Four studies, involving 160 participants, used ADL scales. There was no benefit identified with
cognitive stimulation (SMD 0.21, 95% CI -0.05 to 0.47) (Z = 1.56, P = 0.12). Three studies, including 166 participants, used
scales evaluating behaviour problems. Again there was no difference related to cognitive stimulation (SMD -0.14, 95% CI 0.44 to 0.17) (Z = 0.86, P = 0.39). General behaviour rating scales showed a similar picture, with no difference emerging.
Eight studies, including 416 participants, reported data on relevant scales (SMD 0.13, 95% CI -0.07 to 0.32) (Z = 1.30, P =
0.20).
Caregiver outcomes
(See Figure 12)
Three studies reported on outcomes for family caregivers. The largest of these (Onder 2005) taught family caregivers to
deliver the cognitive stimulation, so the effects on caregivers were especially pertinent for that study. The effect sizes for
anxiety, depression and caregiver burden were all close to zero (SMDs 0.11, 0.04, -0.03 respectively), with confidence
intervals crossing zero indicating no differences between the caregivers in the cognitive stimulation condition and those in the
control conditions.
Only one study (Baines 1987) reported outcomes for care staff, so no meta-analysis was possible. The results of this study
indicated a significant increase in staff knowledge about residents participating in the cognitive stimulation intervention
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compared with knowledge of residents in the control condition.
Follow-up
The analyses for assessments carried out after the intervention had been completed were reported in two groups: Baines
1987 and Wallis 1983 had a one month follow-up, and Baldelli 1993a a three month follow-up on certain measures. These
three studies represent a short term follow-up; whereas Chapman 2004 reported useable data only from a 10 month followup, a much longer period in the context of the progression of dementia.
For cognitive measures (Figure 13), the three older studies with short term follow-up reported data for 52 participants. The
significant advantage for cognitive stimulation on cognitive measures seen immediately post-treatment remained at this point
(SMD 0.57, 95% CI 0.01 to 1.14) (Z = 2.00, P = 0.05). For the 54 participants included by Chapman 2004, there was no
significant effect on either the MMSE (SMD 0.18) or the ADAS-Cog (SMD 0.12) at the 10 month follow-up.
For self-report well-being and quality of life measures (Figure 14), the only short term follow-up data came from Baines 1987,
with only 10 participants, and showed no differences. The longer term follow-up from Chapman 2004 showed a SMD of 0.34
for the QoL-AD measure but this difference was not significant. No measures of mood were included in the studies reporting
follow-up.
For general behaviour rating scales (Figure 15), two studies reported short term follow-up, with 29 participants. The SMD of
0.44 was not significant. Similarly at 10 months the scale used by Chapman 2004 showed a non-significant SMD of 0.43. A
similar picture appeared in relation to problem behaviour (Figure 16), where there was only one small study in the short term
follow-up group (Baines 1987) and the longer term follow-up reported by Chapman 2004 did not show a significant difference
on either the Neuropsychiatric Inventory (NPI) severity score (SMD 0.29) or the caregiver distress score related to the
problem behaviour (SMD 0.41).
Finally, there were no differences in measures of communication and interaction (Figure 17) at either short term (Baines
1987) or longer term follow-up (Chapman 2004).
Discussion
In total, 15 RCTs with a total of 718 participants (407 receiving cognitive stimulation, 311 in control groups) met the inclusion
criteria for the meta-analyses. The most striking finding reflects the effects of cognitive stimulation on performance in tests of
cognitive function. The results of the meta-analyses reported here indicate that cognitive stimulation programmes for
dementia have a significant positive effect on cognition, which is evident in the post-2000 studies included in this review as
well as in the older studies which were included in our previous review of Reality Orientation. This is perhaps the most
consistent finding in the literature on psychological interventions with people with dementia. The studies included here came
from a variety of countries and contexts, from France, the UK, Italy, Spain and Brazil; from hospital, care home, nursing
home, day centre and outpatient settings; and administered in groups by staff or volunteers, or individually by family
caregivers.
The extent to which these changes in cognitive function are clinically important has not been generally addressed. An
average benefit of 1.74 points on the MMSE or 2.27 points on the ADAS-Cog can be taken to indicate a slowing down of the
rate of decline, which has been estimated, in mild to moderate dementia, to be between 2 and 4 points on the MMSE per
annum (Mohs 2000). In relation to the number needed to treat (NNT) for one more participant in the treatment group than in
the control group to benefit by a certain amount, Spector 2003 and Onder 2005 provide some evidence. For an improvement
of 4 or more points on the ADAS-Cog, Spector 2003 calculated an NNT of 6, and Onder 2005 14, figures broadly comparable
to those seen in trials of the ACHEIs.
However, as has been pointed out repeatedly over the years (Woods 2006), changes in cognition are not sufficient to justify
an extensive programme of intervention, unless they are accompanied by other changes, in behaviour and well-being. Here
there are two positive findings. Firstly, results from four RCTs (with 223 participants) indicated that positive changes in
communication and social interaction were evident in staff ratings outside the context of the cognitive stimulation group
sessions. Secondly, results from four RCTs (219 participants) identified a benefit on quality of life and well-being associated
with cognitive stimulation.
In contrast, there was no indication that cognitive stimulation was associated with changes in mood, whether self-rated or
rated by staff, or in behaviour including activities of daily living and self-care and problem behaviour. It is notable that in
general there is much less evidence available regarding these domains compared with that available for changes in
cognition. No benefits to family caregivers were identified in terms of mood or caregiver burden. However, it is important to
note that in the study where the responsibility for delivering the cognitive stimulation fell on famiy caregivers (Onder 2005),
this additional task did not appear to add to their stress and strain. One study showed an improvement in care home staff
knowledge of residents following participation in cognitive stimulation.
There is little evidence available on the cost-effectiveness of cognitive stimulation (CST). Knapp 2006 reported costeffectiveness acceptability curves for cognition and quality of life from the Spector 2003 trial and conclude that, for both
outcomes, 'under reasonable assumptions, there is a high probability that CST is more cost-effective than treatment as
usual'.
These findings all relate to the assessment point immediately after the treatment period has been completed. Only four
relatively small studies reported data on whether any changes were maintained after a period of follow-up without further
intervention. Here, again, cognition stands out with three RCTs showing a positive effect evident at a follow-up of one to
three months after the intervention; this was not evident in the one RCT reporting a 10 month follow-up. Other follow-up data
were limited in their extent and scope but there were no indications of benefits in the areas of behaviour and well-being that
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Cognitive stimulation to improve cognitive functioning in people with dementia
were evaluated.
A key area of difference between studies relates to the duration and frequency of the cognitive stimulation offered, leading to
a wide variation in the 'dosage' of cognitive stimulation received, as indicated by the total number of hours of stimulation
offered. As pointed out previously, there does not appear to be a clear relationship between dosage and the effect size on
cognitive function in the various studies; the Spearman's correlation was 0.25 (N = 14, P = 0.392). It is difficult to ascertain
whether the frequency of sessions per week makes a difference as the study with the largest effect sizes (Requena 2006)
has five 45-minute sessions per week and has the longest duration. As the duration increases, the anticipated decline
associated with dementia should tend to reduce the effects of cognitive stimulation, and so a simple linear relationship is
unlikely to hold. One study (Requena 2006) continued cognitive stimulation for two years. The decision was made to include
one year data from this study in the primary meta-analyses reported here, to reduce the impact of attrition. However, the
effects on cognition and self-reported mood appeared to be sustained over a further one year period, although the effects
were not statistically significant in our analyses. There is a need for further research on maintenance cognitive stimulation,
looking at whether lower-intensity input maintains gains from an initial period of cognitive stimulation (Aguirre 2010).
In five of the included studies all of the participants were prescribed ACHEI medication. For the four of these RCTs providing
post-treatment data, the additional effect of cognitive stimulation over and above the medication was 3.18 points on the
ADAS-Cog, compared with the overall finding (from seven RCTs) of 2.27 points. This supports the proposition that cognitive
stimulation is effective irrespective of whether or not ACHEIs are prescribed, and any effects are in addition to those
associated with the medication. One study (Requena 2006) reported comparative results from a control group who received
neither cognitive stimulation nor an ACHEI, but this was not a randomly allocated condition so that the additive effects of
these two treatment approaches were not established compared with no treatment. Such a study would perhaps not now be
seen as ethical in a context where ACHEIs are seen as standard treatment for Alzheimer-type dementia.
In general, it appears that outcome measures rated by staff are less likely to indicate positive change than those that are
completed by the person with dementia directly with an assessor blinded to the treatment received. In a care home or
hospital context, it is well known that achieving consistent staff ratings in research studies such as these is a major
challenge. It can often be impossible to have the same staff member rate the person at each time point due to staff turn-over
and sickness. There can be a 'drift' in ratings over time, even with the same rater. The observation period and opportunities
for observation may vary over time. Maintaining staff blind to treatment allocation is more challenging than for an assessor
who only visits the facility to carry out the assessments. The one area of staff-rated behaviour showing change in this review
relates to communication and social interaction, an area that has not been highlighted in previous reviews of this type of
intervention. Given the social emphasis of cognitive stimulation groups, this is an area of behaviour that is most closely linked
to the content of the intervention. Indeed, Spector 2010 have demonstrated that in their study language function was an area
of specific cognitive improvement.
Inevitably where the control condition is 'no treatment', the question is raised as to whether any benefits associated with the
treatment arise from non-specific effects such as meeting as a group, socialising, increased attention and so on. A few early
studies did include an 'attention' control group (Woods 1979) or diversional occupational therapy (Wallis 1983) and one study
offered physical rehabilitation sessions to both groups (Baldelli 2002). In the Requena 2006 study where stimulation
materials were presented on a TV screen to the group, control participants watched TV elsewhere. Although we cannot
provide a definitive conclusion on this matter, our results did not indicate any effects of these different control conditions on
outcome. In a mediation analysis, Woods 2006 demonstrated that in the Spector 2003 RCT the improvements in quality of
life were mediated by improvements in cognition, suggesting that it is the cognitive focus of the cognitive stimulation therapy
programmes (rather than merely the social contact and attention) which lead to improved well-being. Further work is required
to explore the relationship between changes in cognition and the changes in well-being and quality of life and communication
that are emerging from the current review.
The quality of the included studies is variable, and generally low, with lack of clarity regarding randomisation procedures
being evident in around half the studies (including some of the more recent studies). CONSORT type diagrams depicting the
flow of participants through the trial are provided by four of the recent studies (Bottino 2005; Buschert 2011; Onder 2005;
Spector 2003) and, along with remote, independent randomisation, will be a minimum expectation in future trials. The
number of participants included has increased markedly from an average of 23 per study prior to 2000 to 64 in the nine more
recent studies. Larger sample sizes will necessitate multi-centre trials, for example Spector 2003 recruited from 23 centres.
This will have implications for analyses, with cluster effects within a centre, even though participants are individually
randomised. Spector 2003 accordingly included centre as a covariate in their analyses. Studies do not yet appear to have
taken account of clustering effects arising from a group intervention. This occurs where changes in group members are not
entirely independent. Group leaders often report that some groups seem to work much better than others for example.
Intention-to-treat analyses were only described by two (recent) studies, although in most cases details of attrition were
reported. The need for assessors to be blind to treatment allocation is widely recognised and attempted in most studies.
More attention may need to be given in future studies to demonstrating the extent to which the cognitive stimulation is
delivered as planned. Well-developed treatment manuals will help with assuring the replicability of the intervention. In
general, there is a clear improvement in overall quality of the included studies over time, for example in the more consistent
information given regarding the diagnosis of participants and the criteria used, as well as the use of consistent outcome
measures and larger sample size.
The studies included in the review utilised therapists with a variety of backgrounds, experience and training. They included
volunteers, family caregivers, speech and language therapists, occupational therapists, nurses, care workers and research
staff. There are no indications from this review of the amount or type of training required to deliver cognitive stimulation,
although there is broad agreement that whilst training is needed the therapist does not need a professional qualification.
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Given the concerns regarding RO being delivered in a mechanical, dehumanising fashion (Dietch 1989), training and
supervision in person-centred care would be seen as a prerequisite for delivery of cognitive stimulation. In this review, there
were no reported side effects or adverse effects of any of the cognitive stimulation interventions. Attrition was due to
expected reasons in studies of this nature: illness, death, transfer to another facility and occasional refusal to complete
follow-up assessments. With only one study utilising an individual approach, in contrast to offering group cognitive
stimulation, it is not possible to draw on any evidence on the strengths and benefits of these different treatment modalities.
The range of severity of dementia experienced by patients included in the studies reviewed here ranged from mild to
moderate. There was no indication that the two studies with the lowest mean MMSE scores of participants (Spector 2001;
Spector 2003) had any different effects than those with more mildly impaired participants. Most studies included a mixture of
participants with mild and moderate dementia. Onder 2005 indicated that there was no differential benefit to either group,
with no significant interaction between severity of dementia and treatment on change in either MMSE or ADAS-Cog scores.
More work may be needed to define if there are people with dementia, or subgroups, who are more or less likely to benefit
from a cognitive stimulation intervention. No analyses have been attempted here seeking to establish whether different
subtypes of the dementias show specific responses to cognitive stimulation. One study (Baldelli 2002) included only
participants who had had a cerebrovascular accident (CVA), although less than half the participants had a diagnosis of
vascular dementia. Most recent studies have included those who are receiving AChEI medication, with a probable
Alzheimer's diagnosis, whereas Spector 2003 included all types of dementia. Given that the average age of participants
across the review was almost 80 years (over 85 in the Spector 2003 study), it is highly likely that neurodegenerative and
vascular changes are co-occurring in the majority of participants, and so the distinction may be of limited pragmatic utility.
The findings of this review are broadly in line with other more wide-ranging reviews of non-pharmacological interventions in
dementia. Livingston 2005 gives a relatively strong recommendation for cognitive stimulation in relation to its effects on
neuropsychiatric symptoms, including mood, but notes some inconsistencies in the evidence on these outcomes. Sitzer 2006
included 17 studies in their meta-analysis of 'cognitive training' in Alzheimer’s disease, four of which met our definition of
'cognitive stimulation' and three of which are included in this review. Sitzer 2006 concludes that there is a medium effect size
(0.47) across all types of 'training' over the whole range of outcome measures, making 'cognitive training' a promising
intervention. However, it is noteworthy that general stimulation techniques were prominent in four of the five trials reporting
the most beneficial results, with the review describing these as 'restorative strategies'. Olazaran 2010 reviewed 179 RCTs
across 26 categories of non-pharmacological interventions. They concluded that there was 'Grade B' evidence (consistent
evidence from lower quality RCTs) for cognitive stimulation in relation to cognition, behaviour and psychological well-being.
They did not identify any 'Grade A' evidence (consistent evidence from high quality RCTs) for any interventions with people
with dementia, although some caregiver interventions did reach this level. The 2011 World Alzheimer's Report (Prince 2011)
concludes, from a wide-ranging systematic review, "We found strong evidence (multiple RCTs) that acetylcholinesterase
inhibitors (for cognitive function, functional impairment), and cognitive stimulation (for cognitive function) are effective
interventions in mild dementia" and makes the following recommendation in relation to interventions for early-stage
dementia: "Acetylcholinesterase inhibitors and cognitive stimulation may enhance cognitive function in people with mild
Alzheimer’s disease, and these interventions should therefore be routinely offered."
Finally, consideration should be given to the possibility of publication bias in this domain. By reviewing only the studies on
cognitive stimulation that have been published in peer-reviewed journals, it must be acknowledged that these could represent
a biased sample of the studies undertaken world-wide on this topic. In many fields of endeavour, trials that are not successful
(that is do not produce the expected positive findings) are less likely to be published. This may be especially the case with
smaller trials. The welcome trend to pre-registration of trials, and the publication of trial protocols, makes this less likely to
occur in the future in relation to larger, well-funded trials. The meta-analyses here have been influenced strongly by the
larger trials included (such as Spector 2003 and Onder 2005), and a funnel plot of the cognition outcome appears reasonably
symmetrical (Figure 18) suggesting that possible publication bias is not a strong factor for this outcome at least.
Authors' conclusions
Implications for practice
The evidence base for the effectiveness of cognitive stimulation therapy for dementia in relation to cognitive function has
been consistently demonstrated, with small changes reported in multiple trials on commonly used brief measures of cognitive
function; adverse effects have not been reported. There is now evidence from a small number of studies that cognitive
stimulation may also be associated with improvements in quality of life and communication. These benefits are over and
above any medication effects.
This review is consistent with the NICE-SCIE 2006 Guideline recommendation that all people with mild to moderate dementia
should have the opportunity to participate in cognitive stimulation groups, irrespective of whether or not they are receiving
acetylcholinesterase inhibiting medication (ACHEIs). This recommendation was recently reinforced by the World Alzheimer's
Report (Prince 2011).
Although more research is needed, results from one study suggest that continuing involvement in cognitive stimulation may
be beneficial.
Implications for research
There are a number of areas, relating to both theory and practice, where further research is required. Now that its effects are
becoming better established, the theoretical basis of cognitive stimulation would benefit from fuller investigation. This would
involve studying cognitive changes both in relationship to neural processes and pathways; and their linkage, if any, with
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outcomes such as mood, quality of life, day-to-day function and behaviour.
There is a clear need for more randomised controlled trials of cognitive stimulation exploring the long term benefits of this
intervention. The effects of severity of dementia and different modalities (for example group versus with caregiver) need to be
systematically evaluated. These RCTs may be of particular value if used in conjunction with more qualitative studies in order
to understand the relationships between the different outcome measures. The clinical meaningfulness of any benefits needs
to be examined, particularly in relation to the impact of any cognitive changes. Are there benefits in terms of increased
participation in activities of importance to the person, increased social inclusion or of individual goals being attained?
Only one cost-effectiveness study has been identified to date and this gap should be addressed, particularly in relation to
clinically meaningful benefits.
Finally, the implementation of cognitive stimulation in real-life settings needs to be addressed. The key issue here is whether
the results obtained by those who attend brief training in the methods or make use of one of the treatment manuals that have
been developed, or both, are comparable to those obtained in the context of research studies and RCTs.
Acknowledgements
Maintenance Cognitive Stimulation Programme (ISRCTN26286067) is part of the Support at Home - Interventions to
Enhance Life in Dementia (SHIELD) project (Application No RP-PG-0606-1083) which is funded by the NIHR Programme
Grants for Applied research funding scheme. The grant holders are Professors Orrell (UCL), Woods (Bangor), Challis
(Manchester), Moniz-Cook (Hull), Russell (Swansea), Knapp (LSE) and Dr Charlesworth (UCL). The views and opinions
expressed in this review are those of the authors and do not necessarily reflect those of the Department of Health/NIHR. The
authors wish to thank Joanne Knowles for acting as consumer reviewer for this review.
Contributions of authors
BW: correspondence; drafting review versions; search for trials; selection of trials; extraction of data; entry of data; data
analysis; interpretation of data analyses; updating review.
AS: selection of trials; extraction of data; interpretation of data analyses; updating review.
EA: search for trials; obtaining copies of trial reports; entry of data; data analysis; interpretation of data analyses.
MO: selection of trials; extraction of data; interpretation of data analyses; updating review.
Declarations of interest
The authors have produced various training materials in dementia care, including cognitive stimulation therapy manuals, in
order to disseminate research findings to care workers and others. Royalties for the manuals are received by the Dementia
Services Development Centre Wales. AS receives fees for providing training in cognitive stimulation approaches.
Differences between protocol and review
Published notes
This review replaces the review of Reality Orientation for dementia (Spector A, Orrell M, Davies S, Woods B. Reality
orientation for dementia. The Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD001119. DOI:
10.1002/14651858.CD001119).
Characteristics of studies
Characteristics of included studies
Baines 1987
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Methods
RCT
Cross-over design: (only results from first phase are included in this review)
Treatment 1: 4 weeks; 4 week 'wash-out' period'; Treatment 2: 4 weeks
Participants
N=15 (14F, 1M)
'Moderate to severe Impairment of cognitive functioning'
Mean age=81.5 (range 72-90)
Living in care home
Interventions
RO
Reminiscence
Treatment as usual
Outcomes
Cognitive: Information/Orientation & Mental Ability (CAPE)
Behaviour: Behavioural Rating Scale (CAPE)
Well being: Life Satisfaction Index;
Problem Behaviour Rating Scale
Communication : Holden Communication Scale
4 week follow-up data available
Staff completed 'Personal Information Questionnaire', evaluating staff knowledge of
residents
Notes
Treatment duration 30 minute sessions, 5 days a week for 4 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Support for judgement
No details of the randomisation method used reported in the paper.
Allocation concealment (selection
bias)
Unclear risk
No details of the randomisation method used reported in the paper.
Blinding (performance bias and
detection bias)
Low risk
RO groups held in separate areas;
Blinding of outcome assessment
(detection bias)
Low risk
Incomplete outcome data (attrition
bias)
Low risk
No attrition at follow-up assessment
Other bias
Unclear risk
Cognitive assessments made by an independent psychologist; other
ratings made by staff not involved in the therapy groups.
Baldelli 1993a
14 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N=23 (23F/0M)
Alzheimer’s (SDAT)
Mean MMSE 20.6 (sd 4.9)
Mean age 84.5 (range 75-94)
All resident in institution
Interventions
RO
Treatment at usual
Outcomes
Cognition: MMSE; Berg Orientation Scale
Mood: GDS-30
ADL: Stewart ADL scale
3 month follow-up data on cognitive measures
Notes
60 minutes, 3 times a week for 3 months
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Support for judgement
Stated by e-mail that their trials were randomised (with no detail of the
methods used)
Stated by e-mail that their trials were randomised (with no detail of the
methods used)
Allocation concealment (selection
bias)
Unclear risk
Blinding (performance bias and
detection bias)
Unclear risk
No evidence of blinding in the paper
Blinding of outcome assessment
(detection bias)
Unclear risk
No details of who assessors were
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Unclear risk
Zero attrition at 3 month post-treatment assessment; no attrition
reported at follow-up 3 months later
Baldelli 2002
15 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N= 87 (61F/26M)
'Degenerative senile dementia of the Alzheimer’s type (SDAT)' (N=46) and “vascular
multi-infarct dementia” (N=41)
Mean MMSE 20.7 (sd 3.0)
Mean age 80.0 (range 65-97)
Resident in sub-acute care nursing home
All had at least elementary schooling
'All had comorbid conditions consisting of vascular accidents with acute motor deficits
of recent onset'
Interventions
RO + physical therapy programme.
Physical therapy programme only
Outcomes
Cognition: MMSE
Mood: Geriatric Depression Scale (GDS 30)
ADL: Barthel
Notes
60 minutes, 5 days per week for one month
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Support for judgement
Stated by e-mail that their trials were randomised (with no detail of
the methods used)
Stated by e-mail that their trials were randomised (with no detail of
the methods used)
Allocation concealment (selection
bias)
Unclear risk
Blinding (performance bias and
detection bias)
Unclear risk
No evidence of blinding in the paper
Blinding of outcome assessment
(detection bias)
Unclear risk
No details of assessors given
Incomplete outcome data (attrition
bias)
Low risk
No attrition reported
Other bias
Unclear risk
Bottino 2005
16 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N=13 (9F / 4M)
'Mildly impaired probable Alzheimer’s diagnosis'
All participants taking rivastigmine 6-12mg/day for 2 months
Mean MMSE 22.31 (sd 3.61; range 16-28)
Age 73.7 (range 62-83)
Out-patients
Interventions
'cognitive rehabilitation' plus rivastigmine; carers attended a support group at same
time
Treatment as usual: rivastigmine plus 30 minute monthly consultation with doctor in
relation to medication
Outcomes
Participants:
Cognition: MMSE; ADAS-Cog,
ADL (rated by carer)
Carers' mood: Hamilton Anxiety and Montgomery-Asberg Depression Rating Scales
Notes
90 minutes, once a week, for 5 months
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Randomised blocks design, randomly allocated to either group by
telephone by an assessor blind to the patient group
Randomised blocks design, randomly allocated to either group by
telephone by an assessor blind to the patient group
Allocation concealment (selection
bias)
Low risk
Blinding (performance bias and
detection bias)
Blinding of outcome assessment
(detection bias)
Unclear risk
Low risk
Assessment made by assessors blinded to group allocation
Incomplete outcome data (attrition
bias)
Low risk
No attrition reported
Other bias
Unclear risk
Breuil 1994
17 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N= 61 (37F / 24M)
Diagnosis of dementia (DSM-III) (90% have Alzheimer's Disease)
Age 77.1 (range 61-93)
Mean MMSE 21.5 (range 9-29)
Out-patients
Interventions
Cognitive stimulation
Treatment as usual
Outcomes
Cognition: MMSE, CERAD
ADl: ECA scale rated by family members
Notes
60 minutes, 2 times a week, for 5 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Allocation concealment (selection
bias)
Unclear risk
Blinding (performance bias and
detection bias)
Blinding of outcome assessment
(detection bias)
Unclear risk
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Unclear risk
Support for judgement
No details of randomisation reported
No details of randomisation reported
Low risk
Cognitive assessments made by an assessor blind to group allocation;
ADL assessment open
Five patients excluded as did not attend all training and evaluation
sessions (3 from treatment group, 2 from controls)
Buschert 2011
18 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N=39
24 amnestic MCI; 15 mild Alzheimer's disease (only data on Alzheimer's patients
reported in this review) 8F/7M
Mean MMSE 24.9 (sd 1.6; range 22-27)
All on stable doses of AChEIs or memantine
Age 75.9 (sd 8.1)
Out-patients
Interventions
Outcomes
Multi-component cognitive group intervention - for AD group emphasis on cognitive
stimulation (for MCI group more emphasis on cognitive training); Control group had
pencil and paper exercises for self-study and monthly meetings
Cognition: MMSE; ADAS-Cog, Trail Making Test, RBANS story memory & recall
Quality of life: QoL-AD
Mood: Montgomery Asberg Depression Rating Scale
Notes
2 hours, once a week for 6 months (20 sessions)
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Allocation concealment (selection
bias)
Low risk
Blinding (performance bias and
detection bias)
Blinding of outcome assessment
(detection bias)
Unclear risk
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Support for judgement
Blocked randomisation procedure; participants pooled in pairs with
respect to age, gender, education and ApoE genotype, then randomly
assigned pairs to intervention or control using a computerised random
number generator.
Blocked randomisation procedure
Unclear risk Assessors blind to group allocation
No attrition
Unclear risk Chapman 2004
19 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N= 54 (29F / 25M)
probable AD, on stable dose of donepezil for at least 3 months
Mean MMSE 20.87 (sd 3.55, range 12-28)
Age 76.4 (range 54-91)
Living at home initially
Interventions
cognitive stimulation + donepezil
Donepezil only
Outcomes
Cognition: MMSE; ADAS-Cog;
ADL: Texas Functional Living Scale
Behavioural problems: NPI - Irritability and Apathy
Quality of Life: QoL-AD
Global functioning: CBIC
Verbalisation: Composite discourse score
Carer distress - derived from the NPI
10 month follow up data available
Notes
90 minutes, once a week, for 8 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Independent randomisation, using an SAS procedure
Allocation concealment (selection
bias)
Low risk
Remote telephone randomisation
Blinding (performance bias and
detection bias)
Unclear risk
Carer ratings not blind to allocation
Blinding of outcome assessment
(detection bias)
Low risk
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Low risk
All raters underwent extensive training; assessors blinded to group
allocation
Intention to treat analysis used. 24% attrition rate at end of study
Programme led by trained speech therapist, weekly meetings held in
order to ensure the programme is implemented as designed.
Coen 2011
20 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 27 (14F/13M)
Dementia - MMSE 10-23
MMSE: 16.9 (sd 5.0)
Age: 79.8 (sd 5.6)
Groups ran in 2 long term care facilities and a private nursing home
Interventions
Cognitive stimulation
No treatment
Outcomes
Cognition: MMSE; ADAS-Cog
Quality of life: QoL-AD
Communication: Holden Communication Scale
Mood: Geriatric Depression Scale (14 item); RAID (Rating of Anxiety in Dementia)
Behaviour: Behaviour Rating Scale (CAPE)
Clinical Dementia Rating (sum of boxes)
Notes
45 minutes, 2 times a week for 7 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Support for judgement
Stated that participants were randomly assigned. Author confirms
computerised randomisation and random number tables were used
Allocation concealment (selection
bias)
Unclear risk
Stated that participants were randomly assigned. Author confirms
computerised randomisation and random number tables were used
Blinding (performance bias and
detection bias)
Unclear risk
Staff running groups also involved in other activities, involving control
participants
Blinding of outcome assessment
(detection bias)
Unclear risk
Tests administered by staff blind to group membership. Not clear if staff
ratings were made by staff who wre blinded
Incomplete outcome data (attrition
bias)
Unclear risk
No attrition
Other bias
Unclear risk
Sessions run by occupational therapists and activity coordinator
Ferrario 1991
21 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N=19 (8F / 11M)
elderly patients with cognitive disturbances
MMSE range 18-25
Age 82.5 (sd 5.2)
Resident in institution
Interventions
RO
No treatment
Outcomes
Cognition: CAPE I/O
Self-care: MOSES
Behaviour problems: MOSES - irritable, withdrawn
Mood: MOSES
Notes
60 minutes, 5 times a week, for 21 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Allocation concealment (selection
bias)
Unclear risk
Blinding (performance bias and
detection bias)
Unclear risk
Blinding of outcome assessment
(detection bias)
Unclear risk
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Low risk
Support for judgement
Stated by e-mail that the trial was randomised (with no detail of the
methods used)
Stated by e-mail that the trial was randomised (with no detail of the
methods used)
No information given in relation to where groups were held, but RO
materials were in evidence on the ward - may have been accessed by
control participants?
MOSES completed by nursing staff - not clear if raters were blind
2 dropouts (/21). 1 in each group (pneumonia and stroke). (Information
provided by the author)
RO administered by volunteers trained by physicians and psychologist
Onder 2005
22 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 156 (113F/ 43M)
Probable Alzheimer's Disease, on Donepezil for at least 3 months
MMSE 20.1 (sd 3.1)
Age 75.8 (sd 7.1)
Living at home
Interventions
RO + Donepezil
Donepezil only
Outcomes
Cognition:MMSE; ADAS-Cog
ADL: Barthel; IADL
Behaviour problems: NPI
Family caregiver outcomes: Hamilton anxiety and depression scales; Caregiver Burden
Inventory; SF-36
Notes
30 minutes, 3 times a week, for 25 weeks; plus informal contacts 2 or 3 times a day
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Computerised block randomisation process
Computerised block randomisation process
Allocation concealment (selection
bias)
Low risk
Blinding (performance bias and
detection bias)
Blinding of outcome assessment
(detection bias)
Unclear risk
Low risk
Assessment made by blind assessors
Incomplete outcome data (attrition
bias)
Low risk
Attrition data reported: 9 from RO group, 10 from control group i.e.
19%
Other bias
Low risk
Family caregivers trained by a multi-disciplinary team
Requena 2006
23 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 86 (61F / 25M)
Alzheimer-type dementia (severe dementia excluded)
MMSE 21.3
Age 77 (sd 7.5)
Attending daycare centre
Interventions
1) Cognitive stimulation + Donepezil
2) Donepezil only
3) Cognitive stimulation only
4) No treatment
Outcomes
Cognition: MMSE, ADAS-Cog
Mood: GDS-30
12 month and 24 month data reported
Notes
45 minutes, 5 times a week for 24 months
'No treatment' group were not part of the randomisation process. Comparison of
interest to this review is cognitive stimulation + donepezil v donepezil alone
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Unclear risk
Allocation concealment (selection
bias)
Unclear risk
Blinding (performance bias and
detection bias)
Low risk
Blinding of outcome assessment
(detection bias)
Low risk
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Unclear risk
Support for judgement
Randomisation by registration order: 'subjects were randomly
distributed in groups at the time they arrived at the Centre'
Randomisation by registration order
Spanish paper stated that groups were led by an independent member
of the research team
Spanish paper states 'Evaluator was blind to treatment allocation'
Attrition reported: 6/20 in CS + donepezil group; 10/30 in donepezil
alone group i.e. 32% over 2 year period
Spector 2001
24 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 35
Diagnosis of dementia according to DSM-IV criteria
MMSE 13.1 (sd 4.4)
Age 85.7 (sd 6.7)
Living at home: 12; living in residential home: 23
Interventions
Cognitive stimulation
Treatment as usual
Outcomes
Cognition: MMSE; ADAS-Cog
Communication: Holden Communication Scale
Mood: Cornell Scale for Depression in Dementia; RAID
Behaviour: Behaviour Rating Scale (CAPE).
Family caregivers: Relatives Stress Scale; GHQ
Notes
45 minutes, 2 times a week, for 7 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Randomly allocated to either group by drawing names from a sealed
container
Allocation concealment (selection
bias)
Low risk
Randomly allocated to either group by drawing names from a sealed
container
Blinding (performance bias and
detection bias)
Unclear risk
Not clear whether staff and carer ratings were made blind to treatment
allocation
Blinding of outcome assessment
(detection bias)
Low risk
Cognitive assessments made by a blind assessor
Incomplete outcome data (attrition
bias)
Low risk
Attrition reported: 4 in CS group, 4 in control group i.e. 23%
Other bias
Low risk
Groups led by a member of the research team in a separate room for
the programme in each of the centres
Spector 2003
25 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 201 (158F / 43M)
Dementia (DSM-IV criteria) - MMSE 10-24
MMSE: 14.4 (sd 3.8)
Age: 85.3 (sd 7.0)
Groups ran in 18 residential homes; 5 day centres
Interventions
Cognitive stimulation
No treatment
Outcomes
Cognition: MMSE; ADAS-Cog
Quality of life: QoL-AD
Communication: Holden Communication Scale
Mood: Cornell Scale for Depression in Dementia
Behaviour: Behaviour Rating Scale (CAPE)
Notes
45 minutes, 2 times a week, for 7 weeks
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Randomly allocated to either group by drawing names from a sealed
container
Randomly allocated to either group by drawing names from a sealed
container - would have been preferable for randomisation to have been
carried out independently
Allocation concealment (selection
bias)
Low risk
Blinding (performance bias and
detection bias)
Low risk
Members of staff involved in groups did not carry out ratings, but ratings
by other staff may not have been blind
Blinding of outcome assessment
(detection bias)
Low risk
Cognitive assessments and quality of life interview conducted by a blind
assessor
Incomplete outcome data (attrition
bias)
Low risk
Other bias
Low risk
34/201 did not complete study (18 CS / 16 controls); 17% attrition
Groups led by a member of the research team in a specific room for the
programme in each of the centres, with a member of staff
Wallis 1983
26 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N = 60
31 'Demented / organic'; 29 'functional' not included in this review
Age 69.8 (range 38-95)
All residents in long-stay psychiatric hospital
Interventions
RO groups
Diversional Occupational Therapy - group and individual
Outcomes
Cognition: Royal College of Physicians mental test score
Behaviour: Crichton Behaviour Rating Scale
One month follow up data available
Notes
30 minutes, 5 times a week, for 3 months
Risk of bias table
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Drawing from a hat and consecutive allocation
Allocation concealment (selection
bias)
Low risk
Drawing from a hat and consecutive allocation
Blinding (performance bias and
detection bias)
Low risk
Setting of treatment separate to assessment settings
Blinding of outcome assessment
(detection bias)
Low risk
Assessors unaware of group allocation
Incomplete outcome data (attrition
bias)
Unclear risk
Other bias
Low risk
Eliminated those attending less than 20% of sessions; 12/31
participants in 'organic' group lost i.e. 39%
Occupational therapists trained to carry out RO
Woods 1979
Methods
RCT
Participants
N = 18
'disorientated', significant memory impairment
Age 76.6 (range 61-90)
All living in specialist residential homes for people with dementia
Interventions
RO groups
Social Therapy groups
No treatment (in a different home, so not included in this review)
Outcomes
Cognition: Wechsler Memory Scale; composite Information & Orientation test
Behaviour: modified Crichton Behaviour Rating Scale
Notes
30 minutes, 5 times a week, for 20 weeks
Risk of bias table
27 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Bias
Random sequence generation
(selection bias)
Authors'
judgement
Low risk
Support for judgement
Stated that drawing from a hat was used
Allocation concealment (selection
bias)
Unclear risk
Stated that drawing from a hat was used
Blinding (performance bias and
detection bias)
Low risk
'Social therapy' was perceived by staff as an active therapy
Blinding of outcome assessment
(detection bias)
Low risk
Groups held in separate areas and assessors bind to group allocation
Incomplete outcome data (attrition
bias)
Low risk
4/18 dropped out: i.e. 22.2% attrition
Other bias
Low risk
Checks were made in order to ensure compliance with therapeutic
protocol, including rating tape-recorded sessions
Footnotes
Characteristics of excluded studies
Arcoverde 2008
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation. Diagnoses
varied, not purely dementia.
Basak 2008
Reason for exclusion
Intervention described doesn't meet the inclusion criteria for cognitive stimulation;
better fit for cognitive training.
Brook 1975
Reason for exclusion
Does not include a measure of cognitive function.
Carlson 2008
Reason for exclusion
Intervention described doesn't meet the inclusion criteria for cognitive stimulation but
for cognitive training. Diagnoses varied, not purely dementia.
Cassinello 2008
Reason for exclusion
Doesn't report an RCT, reports results from Tarraga 2001.
Cheng 2006
Reason for exclusion
Intervention described doesn't meet the inclusion criteria for cognitive stimulation.
Constantinidou 2008
Reason for exclusion
Intervention described doesn't meet the inclusion criteria for cognitive stimulation
Corbeil 1999
Reason for exclusion
Although intervention is described as "cognitive stimulation", it focuses on specific
cognitive modalities. Primary reports outcomes for family caregivers, no measure of
cognitive function. Relates to Quayhagen, 1995.
Croisile 2006
28 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Reason for exclusion
Doesn't report results from an RCT.
Davis 2001
Reason for exclusion
Cognitive stimulation (delivered for 30 minutes a day, 6 days a week by family
caregivers) confounded with cognitive training-spaced retrieval and face name
associations.
Eckroth-Bucher 2009
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation. Diagnoses
varied, not purely dementia.
Eggermont 2009a
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Eggermont 2009b
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Evans 2009
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Faggian 2007
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Fanto 2002
Reason for exclusion
No mention of randomisation; available only as a conference abstract.
Farina 2006a
Reason for exclusion
Non randomised allocation; comparison is with an active treatment group.
Farina 2006b
Reason for exclusion
Non randomised allocation; comparison is with an active treatment group.
Forbes 2004a
Reason for exclusion
Commentary on Spector 2003.
Gerber 1991
Reason for exclusion
Eligible study, but no extractable data provided. Only data available is for a composite
cognitive and behavioural scale.
Goldstein 1982
Reason for exclusion
Around 25% of participants appear not to have dementia, other diagnoses include
schizophrenia, epilepsy and ruptured aneurysm.
Gonzalez-Abraldes 2010
29 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Green 2009
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Greenaway 2008
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Hanley 1981
Reason for exclusion
Eligible study, but no extractable data available
Hernandez, 2007
Reason for exclusion
Reports on Requena 2006 study results. Article in Spanish.
Hirsch 2004
Reason for exclusion
Reports on Spector 2003 results.
Holden 1978
Reason for exclusion
Diagnoses varied, not purely dementia. Not clear that participants were randomised to
the intervention and control groups.
Johnson 1981
Reason for exclusion
Allocation of patients to treatment was not random for various practical reasons.
Leach 2004
Reason for exclusion
Commentary on Spector 2003.
Matsuda 2007
Reason for exclusion
Non-randomised study.
Meza-Kubo 2009
Reason for exclusion
Not a randomised control trial.
Milev 2008
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation - relates to
'snoezelen'.
Moniz-Cook 2006
Reason for exclusion
Reference to other studies in cognitive stimulation (e.g. Spector 2003) but not a new
RCT.
Mudge 2008
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Newson 2006
30 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation. Diagnoses
varied, not dementia.
Olazaran 2004
Reason for exclusion
12/84 participants with a diagnoses of MCI; results not presented separately for those
with Alzheimer's disease.Interventions include additional elements as physical
exercise.
Orrell 2000b
Reason for exclusion
Describes study aims for Spector 2003.
Orrell 2005
Reason for exclusion
Allocation to intervention and control groups not random for maintenance study.
Quayhagen 1995
Reason for exclusion
Although intervention is described as cognitive stimulation, it appears to focus on
specific cognitive modalities, and so fits better with cognitive training definition.
Quayhagen 2000
Reason for exclusion
Although intervention is described as cognitive stimulation, it appears to focus on
specific cognitive modalities, and so fits better with cognitive training definition.
Raggi 2007
Reason for exclusion
Not RCT.
Reeve 1985
Reason for exclusion
No indication of random allocation to groups.
Riegler 1980
Reason for exclusion
Comparin of RO plus music versus RO. No control groups without RO.
Ruiz Sanchez de Leon 2007
Reason for exclusion
No RCT and intervention doesn't meet the criteria for inclusion under cognitive
stimulation.
Salmon 2006
Reason for exclusion
No RCT, reports on Spector 2003 trial results.
Schmitter-Edgecombe 2008
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Schreiber 1998
Reason for exclusion
Cognitive training, targeting specific cognitive modalities, rather than cognitive
stimulation. Allocation to groups alternate, not random.
Schreiber 1999
31 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Reason for exclusion
See Schreiber 1998.
Scott 2003
Reason for exclusion
Doesn't report on a study intervention. No RCT.
Smith 2009
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation.
Spector 2008
Reason for exclusion
Reports on Spector 2003 results.
Tadaka 2004
Reason for exclusion
The intervention combines elements of Reality Orientation (RO) and reminiscence. The
RO element appears to be only an orientation board, used to reinforce orientation for
time, place and person. The reminiscence element appears to be predominant, with a
variety of reminiscence based triggers, and so the study would be a better fit for a
review of reminiscence work with people with dementia.
Tarraga 2005a
Reason for exclusion
Published as Tarraga 2006.
Tarraga 2005b
Reason for exclusion
Published as Tarraga 2006.
Tarraga 2006
Reason for exclusion
Allocation to groups is not entirely random. For the comparison of interest, integrated
psychostimulation program versus medication only control, allocation is clearly nonrandom.
Tarraga 2007
Reason for exclusion
As in Tarraga 2006.
Thickpenny-Davis 2007
Reason for exclusion
Intervention doesn't meet the inclusion criteria for cognitive stimulation, participants
included with other diagnosis than dementia.
Tsai 2008
Reason for exclusion
Not RCT.
Wenisch 2005
Reason for exclusion
Participants included with a diagnosis of MCI and not dementia.
Wenisch 2007
Reason for exclusion
As in Wenisch 2005.
Wettstein 2004
32 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Reason for exclusion
Does not report an intervention study.
Williams 1987
Reason for exclusion
Not a RCT, compares two wards, not cognitive stimulation, involves environmental
modification and informal RO.
Woods 2006
Reason for exclusion
Report on Spector 2003 study results.
Zanetti 1995
Reason for exclusion
Allocation non-randomised.
Zanetti 2004
Reason for exclusion
As in Zanetti 1995.
Zepelin 1981
Reason for exclusion
Not a RCT, compares residents at one home with those in another.
Zientz 2007
Reason for exclusion
Does not report an intervention study.
Footnotes
Characteristics of studies awaiting classification
Buettner 2011
Methods
RCT
Participants
N=77 (15M/62F)
Community dwelling
Mild memory loss - probable early stage Alzheimer's
MMSE 25.3
Interventions
Classroom style 'Mentally Stimulating Activities' v Structured early-stage social support
programme
Outcomes
Cognition: MMSE, Trail Making B
Quality of life: Cornell-Brown QoL
Depression: PHQ-9
Apathy Evaluation Scale
Notes
Sessions 1 hour, twice weekly for 4 weeks
Fernandez-Calvo 2010
33 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Methods
RCT
Participants
N=45
Probable Alzheimer's
MMSE 18.97
Interventions
Outcomes
Individual multimodal cognitive stimulation versus group multimodal cognitive
stimulation versus no treatment control
Cognition: ADAS-Cog
NPI
Cornell Depression Scale
Notes
In Spanish
Niu 2010
Methods
RCT
Participants
N=32
mild to moderate Alzheimer's with marked neuropsychiatric symptoms
MMSE 17.1
Inpatients in military sanatorium
All on donepezil
Interventions
Individual sessions, task based including reality orientation, fluency, and memory tasks
Placebo control - communication exercise
Outcomes
Cognition: MMSE
NPI, apathy, depression
Notes
45 minutes, twice a week for 10 weeks
Footnotes
Characteristics of ongoing studies
Aguirre 2010
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Cognitive stimulation to improve cognitive functioning in people with dementia
Study name
MCST - maintenance cognitive stimulation
Methods
RCT
Participants
Target N=230
Diagnosis of dementia with DSM-IV criteria
Mild to moderate dementia
Interventions
Outcomes
All participants receive 7 weeks of twice weekly cognitive stimulation; then randomised
to recive 6 months of once weekly maintenance cognitive stimulation
Cognition: ADAS-Cog, MMSE
Quality of Life: QoL-AD, DEMQOL
Starting date
Contact information
e.aguirre@ucl.ac.uk
Notes
ISRCTN 26286067
Vidovich 2011
Study name
PACE-AD
Methods
RCT
Participants
Target N=128
probable Alzheimer's
Interventions
Outcomes
Cognitive activity groups for person with dementia and companion together v
companions alone
Cognition: ADAS-Cog
Companion quality of life, mood, and general health
Starting date
Contact information
vidovichm@meddent.uwa.edu.au
Notes
Trial registration: ACTRN 12610000653066
Footnotes
Summary of findings tables
Additional tables
References to studies
Included studies
Baines 1987
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Baldelli 1993a
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Cognitive stimulation to improve cognitive functioning in people with dementia
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Breuil 1994
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Ferrario 1991
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Cassinello 2008
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Eggermont 2009b
Eggermont LH, Swaab DF, Hol EM, Scherder EJ. Walking the line: a randomised trial on the effects of a short term walking
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Evans 2009
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Data and analyses
1 Cognitive stimulation versus no cognitive stimulation: post-treatment
Outcome or Subgroup
Studies
Participants Statistical Method
1.1 Cognition
14
658
1.1.1 ADAS-Cog
7
434
1.1.2 Wechsler Memory Scale
1
10
1.1.3 Global cognitive score
(includes MMSE & CERAD)
1
56
1.1.4 MMSE
2
110
1.1.5 CAPE-I/O
2
29
1.1.6 RCP Cognition
1
19
Effect Estimate
Std. Mean Difference(IV, Fixed, 95%
0.41[0.25, 0.57]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.37[0.17, 0.56]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.47[-0.80, 1.74]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.63[0.09, 1.17]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.64[0.17, 1.10]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.29[-0.48, 1.06]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.13[-0.78, 1.03]
CI)
1.2 MMSE
10
1.2.1 One to twelve months of CS 10
1.2.2 24 months of CS
1
600
29
Mean Difference(IV, Fixed, 95% CI) Subtotals only
Mean Difference(IV, Fixed, 95% CI) 1.74[1.13, 2.36]
Mean Difference(IV, Fixed, 95% CI) 5.99[-1.58, 13.56]
1.3 ADAS-Cog
7
1.3.1 One to twelve months of CS 7
1.3.2 24 months of CS
1
434
29
Mean Difference(IV, Fixed, 95% CI) Subtotals only
Mean Difference(IV, Fixed, 95% CI) 2.27[0.99, 3.55]
Mean Difference(IV, Fixed, 95% CI) 11.94[-0.97, 24.85]
1.4 Other cognitive measure:
Information/Orientation
5
81
1.4.1 CAPE I/O
2
29
1.4.2 RCP Cognition
1
19
1.4.3 Berg Orientation Scale
1
23
1.4.4 Information / Orientation
1
10
4
223
3
204
1
19
1.6 Well-being & Quality of Life
4
219
1.6.1 Life Satisfaction Index
1
10
1.6.2 QoL-AD
3
209
1.5 Comunication and social
interaction
1.5.1 Holden Communication
Scale
1.5.2 MOSES - Withdrawn
behaviour
Std. Mean Difference(IV, Fixed, 95%
0.45[-0.01, 0.90]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.29[-0.48, 1.06]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.13[-0.78, 1.03]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.87[0.00, 1.74]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.60[-0.68, 1.89]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.44[0.17, 0.71]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.47[0.18, 0.75]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.10[-0.86, 1.07]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.38[0.11, 0.65]
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.23[-1.48, 1.01]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.41[0.13, 0.69]
CI)
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Cognitive stimulation to improve cognitive functioning in people with dementia
1.7 Mood: Self-reported
5
1.7.1 Geriatric Depression Scale
(GDS-30) One to twelve months of 3
CS
1.7.2 Geriatric Depression Scale
(14 item) One to twelve months of
1
CS
1.7.3 Montgomery Asberg
Depression Rating Scale (MADRS) 1
One to twelve months of CS
1.8 Mood: Staff-reported
4
1.8.1 Cornell Scale for Depression
2
in Dementia
1.8.2 MOSES - Depressed /
1
anxious mood
1.8.3 Rating of Anxiety in
1
Dementia (RAID)
201
Std. Mean Difference(IV, Fixed, 95%
0.22[-0.09, 0.53]
CI)
160
Std. Mean Difference(IV, Fixed, 95%
0.34[-0.01, 0.70]
CI)
26
Std. Mean Difference(IV, Fixed, 95%
-0.39[-1.16, 0.39]
CI)
15
Std. Mean Difference(IV, Fixed, 95%
0.31[-0.72, 1.33]
CI)
239
194
19
26
1.9 ADL scales
4
260
1.10 Behaviour, general
8
416
1.10.1 CAPE - BRS
4
231
1.10.2 Crichton BRS (modified)
2
29
1.10.3 MOSES Self-care
1
19
1.10.4 Instrumental ADL
1
137
1.11 Behaviour, problem
3
166
1.11.1 Problem Behaviour Rating
1
Scale
10
1.11.2 MOSES - Irritable
1
19
1.11.3 NPI
1
137
1.12 Caregiver outcome
3
1.12.1 Hamilton anxiety
2
150
1.12.2 Depression
2
150
1.12.3 Carer stress/burden
2
147
1.12.4 General Health
Questionnaire (GHQ-12)
1
10
Std. Mean Difference(IV, Fixed, 95%
0.05[-0.21, 0.31]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.01[-0.28, 0.30]
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.01[-0.98, 0.96]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.38[-0.40, 1.16]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.21[-0.05, 0.47]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.13[-0.07, 0.32]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.12[-0.14, 0.38]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.33[-0.42, 1.07]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.00[-0.97, 0.97]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.12[-0.22, 0.46]
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.14[-0.44, 0.17]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.40[-0.86, 1.66]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.12[-0.85, 1.09]
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.20[-0.54, 0.13]
CI)
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
0.11[-0.21, 0.44]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.04[-0.28, 0.36]
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.03[-0.35, 0.29]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.94[-0.41, 2.29]
CI)
2 Cognitive stimulation versus no cognitive stimulation: follow-up
Outcome or Subgroup
Studies
Participants Statistical Method
2.1 Cognition
4
2.1.1 One to three months follow3
up Information/ Orientation
52
2.1.2 Ten months follow-up MMSE 1
54
2.1.3 Ten months follow-up ADAS1
Cog
54
Effect Estimate
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
0.57[0.01, 1.14]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.18[-0.35, 0.72]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.12[-0.41, 0.66]
CI)
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Cognitive stimulation to improve cognitive functioning in people with dementia
2.2 Well-being & Quality of Life
2
1
10
1
54
2.3 Behaviour, general
3
2.3.1 One month follow-up
2
29
2.3.2 Ten months follow-up Texas
1
Functional Living Scale
54
2.4 Behaviour, problem
2
1
10
1
54
1
54
2.2.1 One month follow-up Life
Satisfaction Index
2.2.2 Ten months follow-up QoLAD
2.4.1 One month follow-up
Problem Behaviour Rating Scale
2.4.2 Ten month follow-up NPI
severity
2.4.3 Ten-month follow up NPI
(Caregiver Distress)
2.5 Communication and social
2
interaction
2.5.1 One month follow-up Holden
1
Communication Scale
2.5.2 Ten month follow-up
1
'Relevance of discourse'
10
54
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
-0.03[-1.27, 1.21]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.34[-0.19, 0.88]
CI)
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
0.44[-0.30, 1.18]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.43[-0.11, 0.97]
CI)
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
0.39[-0.87, 1.65]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.29[-0.24, 0.83]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.41[-0.13, 0.95]
CI)
Std. Mean Difference(IV, Fixed, 95%
Subtotals only
CI)
Std. Mean Difference(IV, Fixed, 95%
0.20[-1.05, 1.44]
CI)
Std. Mean Difference(IV, Fixed, 95%
0.15[-0.39, 0.68]
CI)
Figures
Figure 1 (Analysis 1.1)
47 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: Cognition.
Figure 2 (Analysis 1.3)
48 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: ADAS-Cog.
Figure 3 (Analysis 1.2)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: MMSE.
Figure 4 (Analysis 1.4)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: Other cognitive measure:
Information/Orientation.
Figure 5 (Analysis 1.5)
49 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment, outcome: Comunication and
social interaction.
Figure 6 (Analysis 1.6)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: QoL-AD.
Figure 7 (Analysis 1.7)
50 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: Geriatric Depression Scale (GDS30)
Figure 8 (Analysis 1.8)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment, outcome: Mood: Staffreported.
Figure 9 (Analysis 1.9)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: ADL.
Figure 10 (Analysis 1.10)
51 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation, outcome: Behavior, Other.
Figure 11 (Analysis 1.11)
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment, outcome: Behaviour,
problem.
Figure 12 (Analysis 1.12)
52 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment, outcome: Caregiver outcome.
Figure 13 (Analysis 2.1)
Caption
Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up, outcome: Cognition.
Figure 14 (Analysis 2.2)
53 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up, outcome: Well-being & Quality of
Life.
Figure 15 (Analysis 2.3)
Caption
Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up, outcome: Behaviour, general.
Figure 16 (Analysis 2.4)
Caption
Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up, outcome: Behaviour, problem.
Figure 17 (Analysis 2.5)
54 / 69
Cognitive stimulation to improve cognitive functioning in people with dementia
Caption
Forest plot of comparison: 2 Cognitive stimulation vs No Cognitive Stimulation: follow-up, outcome: Communication and
social interaction.
Figure 18 (Analysis 1.1)
Caption
Funnel plot of comparison: 1 Cognitive Stimulation vs No Cognitive Stimulation: post-treatment, outcome: 1.1 Cognition.
Sources of support
Internal sources
Bangor University, UK
University College London, UK
External sources
NIHR, UK
EA was supported by the Support at Home - Interventions to Enhance Life in Dementia (SHIELD) project (Application No
RP-PG-0606-1083) which is funded by the NIHR Programme Grants for Applied Research funding scheme.
Feedback
Appendices
1 Search: December 2011
Source
Search strategy
55 / 69
Hits
retrieved
Cognitive stimulation to improve cognitive functioning in people with dementia
1. ALOIS (www.medicine.ox.ac.uk/alois) (all dates)
cognitive stimulation OR reality orientation OR
139
memory therapy OR memory groups OR memory
support OR memory stimulation OR global stimulation
OR cognitive psychostimulation
2. MEDLINE In-process and other non-indexed citations and 1. exp Dementia/
MEDLINE 1950-present (Ovid SP)
2. Delirium/
3. Wernicke Encephalopathy/
4. Delirium, Dementia, Amnestic, Cognitive Disorders/
5. dement*.mp.
6. alzheimer*.mp.
7. (lewy* adj2 bod*).mp.
8. deliri*.mp.
9. (chronic adj2 cerebrovascular).mp.
10. ("organic brain disease" or "organic brain
syndrome").mp.
11. ("normal pressure hydrocephalus" and
"shunt*").mp.
12. "benign senescent forgetfulness".mp.
13. (cerebr* adj2 deteriorat*).mp.
14. (cerebral* adj2 insufficient*).mp.
15. (pick* adj2 disease).mp.
16. (creutzfeldt or jcd or cjd).mp.
17. huntington*.mp.
18. binswanger*.mp.
19. korsako*.mp.
20. or/1-19
21. "cognitiv* stimul*".mp.
22. "reality orientation".mp.
23. (memory adj2 therapy).mp.
24. "memory group*".mp.
25. "memory support".mp.
26. (memory adj2 stimulat*).mp.
27. "global stimulation".mp.
28. ("cognitive psycho-stimulation" or "cognitive
psychostimulation").mp.
29. *Psychomotor Performance/
30. or/21-29
31. 20 and 30
32. (2010* OR 2011*).ed.
33. 31 and 32
34. randomized controlled trial.pt.
35. controlled clinical trial.pt.
36. randomized.ab.
37. placebo.ab.
38. drug therapy.fs.
39. randomly.ab.
40. trial.ab.
41. groups.ab.
56 / 69
40
Cognitive stimulation to improve cognitive functioning in people with dementia
42. or/34-41
43. (animals not (humans and animals)).sh.
44. 42 not 43
45. 33 and 44
3. EMBASE
1. exp dementia/
1980-2011 Dec 05 (Ovid SP)
2. Lewy body/
239
3. delirium/
4. Wernicke encephalopathy/
5. cognitive defect/
6. dement*.mp.
7. alzheimer*.mp.
8. (lewy* adj2 bod*).mp.
9. deliri*.mp.
10. (chronic adj2 cerebrovascular).mp.
11. ("organic brain disease" or "organic brain
syndrome").mp.
12. "supranuclear palsy".mp.
13. ("normal pressure hydrocephalus" and
"shunt*").mp.
14. "benign senescent forgetfulness".mp.
15. (cerebr* adj2 deteriorat*).mp.
16. (cerebral* adj2 insufficient*).mp.
17. (pick* adj2 disease).mp.
18. (creutzfeldt or jcd or cjd).mp.
19. huntington*.mp.
20. binswanger*.mp.
21. korsako*.mp.
22. CADASIL.mp.
23. or/1-22
24. "cognitiv* stimul*".mp.
25. "reality orientation".mp.
26. (memory adj2 therapy).mp.
27. "memory group*".mp.
28. "memory support".mp.
29. (memory adj2 stimulat*).mp.
30. "global stimulation".mp.
31. ("cognitive psycho-stimulation" or "cognitive
psychostimulation").mp.
32. *psychomotor performance/
33. or/24-32
34. 23 and 33
35. (2010* OR 2011*).em.
36. 34 and 35
4. PsycINFO
1. exp Dementia/
1806-November week 5 2011 (Ovid SP)
2. exp Delirium/
3. exp Huntingtons Disease/
4. exp Kluver Bucy Syndrome/
5. exp Wernickes Syndrome/
57 / 69
29
Cognitive stimulation to improve cognitive functioning in people with dementia
6. exp Cognitive Impairment/
7. dement*.mp.
8. alzheimer*.mp.
9. (lewy* adj2 bod*).mp.
10. deliri*.mp.
11. (chronic adj2 cerebrovascular).mp.
12. ("organic brain disease" or "organic brain
syndrome").mp.
13. "supranuclear palsy".mp.
14. ("normal pressure hydrocephalus" and
"shunt*").mp.
15. "benign senescent forgetfulness".mp.
16. (cerebr* adj2 deteriorat*).mp.
17. (cerebral* adj2 insufficient*).mp.
18. (pick* adj2 disease).mp.
19. (creutzfeldt or jcd or cjd).mp.
20. huntington*.mp.
21. binswanger*.mp.
22. korsako*.mp.
23. ("parkinson* disease dementia" or PDD or
"parkinson* dementia").mp.
24. or/1-23
25. "cognitiv* stimul*".mp.
26. "reality orientation".mp.
27. (memory adj2 therapy).mp.
28. "memory group*".mp.
29. "memory support".mp.
30. (memory adj2 stimulat*).mp.
31. "global stimulation".mp.
32. ("cognitive psycho-stimulation" or "cognitive
psychostimulation").mp.
33. "psychomotor performance".mp.
34. or/25-33
35. 24 and 34
36. random*.mp.
37. trial.mp.
38. placebo.mp.
39. group*.mp.
40. exp Clinical Trials/
41. or/36-40
42. 35 and 41
43. (2010* OR 2011*).up.
44. 42 and 43
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Cognitive stimulation to improve cognitive functioning in people with dementia
5. CINAHL (EBSCOhost)
S1 (MH "Dementia+") S2 (MH "Delirium") or (MH "Delirium, Dementia,
Amnestic, Cognitive Disorders") S3 (MH "Wernicke's Encephalopathy") S4 TX dement* S5 TX alzheimer* S6 TX lewy* N2 bod* S7 TX deliri* S8 TX chronic N2 cerebrovascular S9 TX "organic brain disease" or "organic brain
syndrome" S10 TX "normal pressure hydrocephalus" and
"shunt*" S11 TX "benign senescent forgetfulness" S12 TX cerebr* N2 deteriorat* S13 TX cerebral* N2 insufficient* S14 TX pick* N2 disease S15 TX creutzfeldt or jcd or cjd S16 TX huntington* S17 TX binswanger* S18 TX korsako* S19 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or
S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16
or S17 or S18 S20 TX "cognitiv* stimul*" S21 TX "reality orientation" S22 TX memory N2 therapy S23 TX "memory group*" S24 TX "memory support" S25 TX memory N2 stimulat* S26 TX "global stimulation" S27 TX "cognitive psycho-stimulation" OR "cognitive
psychostimulation" S28 (MM "Psychomotor Performance") S29 S20 or S21 or S22 or S23 or S24 or S25 or S26
or S27 or S28 S30 S19 and S29 S31 EM 2010
S32 EM 2011 S33 S31 or S32
S34 S30 and S33
S35 TX random* S36 (MH "Clinical Trials+") S37 AB group S38 TI study S39 S35 or S36 or S37 or S38 S40 S34 and S39 59 / 69
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Cognitive stimulation to improve cognitive functioning in people with dementia
6. Web of Science (1945-present) (WOK)
Topic=(dement* OR alzheimer* OR "lew* bod*" OR 135
deliri* OR creutzfeldt OR cjd OR jcd OR huntington*
OR binswanger* OR korsako*) AND Topic=("cognitiv*
stimul*" OR CST OR "reality orienation" OR "memory
therapy" OR "memory group*" OR "memory support"
OR "psychomotor performance" OR "global
stimulation" OR "cognitive performance") AND
Topic=(random* OR trial* OR RCT OR "cross-over"
OR cross-over) AND Year Published=(2010-2011)
Timespan=All Years. Databases=SCI-EXPANDED,
SSCI, A&HCI, CPCI-S, CPCI-SSH.
Lemmatization=On 7. LILACS (BIREME)
"cognitiv$ stimul$" OR "reality orienation" OR
16
"memory therapy" OR "memory group$" OR "memory
support" OR "psychomotor performance" OR "global
stimulation" OR "cognitive performance"
[Words] and dementia OR alzheimer$ OR demenc$
OR AD OR demência [Words]
8. CENTRAL (The Cochrane Library) (Issue 3 of 4, Oct
2011)
#1 dement*
#2 alzheimer*
#3 deliri*
#4 chronic adj2 cerebrovascular
#5 (lewy* bod*)
#6 "organic brain disease" or "organic brain
syndrome"
#7 (pick* disease)
#8 creutzfeldt or jcd or cjd
#9 huntington*
#10 binswanger*
#11 korsako*
#12 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7
OR #8 OR #9 OR #10 OR #11)
#13 "cognitiv* stimul*"
#14 "reality orientation"
#15 "memory therapy"
#16 "memory group*"
#17 "memory support"
#18 "memory stimulat*"
#19 "global stimulation"
#20 "cognitive psycho-stimulation"
#21 "cognitive psychostimulation"
#22 MeSH descriptor Psychomotor Performance
explode all trees
#23 (#13 OR #14 OR #15 OR #16 OR #17 OR #18
OR #19 OR #20 OR #21 OR #22)
#24 (#12 AND #23)
#25 (#24), from 2010 to 2011
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Cognitive stimulation to improve cognitive functioning in people with dementia
9. Clinicaltrials.gov (www.clinicaltrials.gov)
#1 Intervention: Cognitive stimulation AND
Interventional studies AND First rec: 01/01/201012/05/2011 = 30
51
#2 Intervention: reality orientation AND Interventional
studies AND First rec: 01/01/2010-12/05/2011 = 1
#3 Interventional Studies | dementia OR alzheimers
OR AD OR alzheimer's OR alzheimer OR lewy OR
FTLD OR FLD | memory therapy OR memory training
| received from 01/01/2010 to 12/05/2011=20
10. ICTRP Search Portal (http://apps.who.int/trialsearch)
[includes: Australian New Zealand Clinical Trials Registry;
ClinicalTrilas.gov; ISRCTN; Chinese Clinical Trial Registry;
Clinical Trials Registry – India; Clinical Research Information
Service – Republic of Korea; German Clinical Trials
Register; Iranian Registry of Clinical Trials; Japan Primary
Registries Network; Pan African Clinical Trial Registry; Sri
Lanka Clinical Trials Registry; The Netherlands National
Trial Register]
Advanced search: (dementia OR alzheimer OR
86
alzheimers OR alzheimers) AND (cognitive
stimulation OR reality orientation OR memory therapy
OR memory training OR cognitive training) AND
(2010-2011)
TOTAL before de-duplication
804
TOTAL after de-dupe and first-assess
41
Graphs
1 - Cognitive stimulation versus no cognitive stimulation: post-treatment
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Cognitive stimulation to improve cognitive functioning in people with dementia
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Cognitive stimulation to improve cognitive functioning in people with dementia
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Cognitive stimulation to improve cognitive functioning in people with dementia
2 - Cognitive stimulation versus no cognitive stimulation: follow-up
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