Ageing Research Reviews 12 (2013) 253–262

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Ageing Research Reviews

journal homepage: www.elsevier.com/locate/arr

Review

Cognitive stimulation for dementia: A systematic review of the evidence of

effectiveness from randomised controlled trials
Elisa Aguirre a,∗ , Robert T. Woods b,1 , Aimee Spector c,2 , Martin Orrell a,3
a
University College London, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, England, United Kingdom
b
DSDC Wales, Bangor University, 45 College Road, Bangor, Gwynedd LL57 2DG, Wales, United Kingdom
c
University College London, 1-19 Torrington Place, London WC1E 7HB, England, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Cognitive stimulation is a psychological intervention widely used in dementia care, which offers a range
Received 14 March 2012 of activities for people with dementia and provides general stimulation of cognitive abilities. This system-
Received in revised form 28 June 2012 atic review evaluates the effectiveness of cognitive stimulation in dementia. The review included studies
Accepted 5 July 2012
from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, called ALOIS.
Available online 7 August 2012
This yielded ninety-four studies, of which fifteen were randomised controlled trials meeting the inclu-
sion criteria. The analysis included 718 subjects (407 receiving cognitive stimulation and 311 in control
Keywords:
groups). Results were subjected to a meta-analysis. A consistent significant benefit to cognitive function
Dementia
Cognition
was identified following treatment and the benefits appeared to be over and above any medication effects.
Stimulation This remained evident at follow-up up to three months after the end of treatment. In secondary analyses,
Therapy with smaller total sample sizes, significant benefits were also noted for quality of life and well-being, and
Alzheimer’s on staff ratings of communication and social interaction. No differences in relation to mood, activities of
daily living or challenging behaviour were noted. There is consistent evidence that cognitive stimulation
interventions benefit cognitive function and aspects of well-being. Cognitive stimulation should be made
more widely available in dementia care.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction by Brook et al. (1975), reporting positive results for cognitive and
social functioning in patients A number of controlled studies of
Interventions with a cognitive focus have long been used in RO followed, with outcome measures typically including assess-
dementia care, and developed in parallel with approaches empha- ments of orientation, other aspects of cognitive functioning and
sising the stimulation of the senses (Woods and Britton, 1977). level of independent functioning (Holden and Woods, 1995). How-
One of the first established non-pharmacological interventions for ever, this approach raised some concerns in relation to its clinical
dementia that focused on improvement of cognitive abilities was significance for people with dementia and attracted some criti-
Reality Orientation (RO) (Taulbee and Folsom, 1966). RO included, cism when used in a mechanical, inflexible manner (Burton, 1982;
amongst other interventions, classroom sessions, normally held Dietch et al., 1989; Powell-Proctor and Miller, 1982) with one set
daily for 30 minutes where a small group of participants were pre- of guidelines on the management of dementia (APA, 1997) even
sented with basic personal and current information and a variety cautioning against its use. However, a Cochrane review specifically
of materials used, such as individual calendars, word-letter games, examining RO (Spector et al., 2000) that included a total of 6 RCTs
building blocks and large piece puzzles. A Reality Orientation board with 125 participants overall (67 in experimental and 58 in control
would be used in each session and would list the name of the unit groups) concluded that this therapy had cognitive and behavioural
and its location, the day, date, weather, current events, etc. The benefits for people with dementia. Following Breuil et al. (1994),
first controlled evaluation of RO classes was reported in the UK the term ‘cognitive stimulation’ is now widely used to describe
approaches, including RO, which have a general cognitive focus.
This builds on the positive aspects of RO, whilst ensuring that it
∗ Corresponding author. Tel.: +44 20 7679 9452; fax: +44 20 7679 9426. is implemented in a coherent, person-centred and sensitive man-
E-mail addresses: [email protected] (E. Aguirre), [email protected] ner (Spector et al., 2001; Woods, 2002). Whilst the terms ‘cognitive
(R.T. Woods), [email protected] (A. Spector), [email protected] (M. Orrell).
1
training’, ‘cognitive stimulation’ and ‘cognitive rehabilitation’ have
Tel.: +44 01 2483 82463.
2
Tel.: +44 20 7679 1844; fax: +44 20 7679 1844.
been used almost interchangeably in the past, Clare and Woods
3
Tel.: +44 20 7679 9452; fax: +44 20 7679 9426. (2004) established the following definitions.

1568-1637/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.arr.2012.07.001
254 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262

(a) ‘Cognitive stimulation’ as engagement in a range of activities variety of settings (own home, out-patient, day care, residential
and discussions (usually in a group) aimed at general enhance- setting).
ment of cognitive and social functioning; (b) ‘cognitive training’ as
guided practice on a set of standard tasks designed to reflect partic- 2.2.3. Interventions
ular cognitive functions with a range of difficulty levels to suit the Participants attended regular therapy sessions (involving a
individual’s level of ability; and (c) ‘cognitive rehabilitation’ as an group or family caregiver) for a minimum period of 4 weeks. The
individualised approach where personally relevant goals are iden- intervention needed to meet the definition of cognitive stimula-
tified, and the therapist works with the person and his/her family tion described above (Clare and Woods, 2004), targeting cognitive
to devise strategies to address these. The emphasis is on improving and social functioning. The approach might also be described as
performance in everyday life, rather than on cognitive tests, build- RO groups, sessions or classes. Some studies, which described their
ing on the person’s strengths and developing ways of compensating intervention as ‘cognitive stimulation’ did not meet our operational
for impairment. definition, typically as they involved repeated training on specific
With the Cochrane review of RO being superceded by these cognitive tasks. The intervention needed to be compared to ‘no
developments, it was timely to consider the evidence base for treatment’, ‘standard treatment’, or placebo.
cognitive stimulation as defined by Clare and Woods and exclud- Outcome measures were required to evaluate performance on
ing cognitive training and cognitive rehabilitation interventions. at least one cognitive measure for the participant and could also
Accordingly, the aim of this study was to evaluate the effectiveness include the assessment of any of the following variables: mood,
of cognitive stimulation trials in dementia. The reported systematic quality of life, well being, activities of daily living, communication,
review was carried out with the Cochrane Collaboration Cognitive behaviour, neuropsychiatric symptoms and social interaction.
Impairment and Dementia group, based in Oxford, United Kingdom
(Woods et al., 2012). 2.3. Data extraction

2. Methods Descriptive characteristics (such as quality of randomisation

and blinding) and study results were extracted, recorded and
2.1. Search method entered into RevMan 5.1 (Updated Software 2011). Additionally,
letters and e-mails were sent to some authors of controlled trials
A systematic search for randomised controlled trials (RCTs) eval- asking for essential and additional information (statistics, sources
uating the effectiveness of cognitive stimulation programmes for of bias, details of randomisation). The summary statistics required
dementia was conducted. A combination of the search terms cog- for each trial and each outcome for continuous data were the
nitive stimulation, reality orientation, memory therapy, memory mean change from baseline, the standard error of the mean change,
groups, memory support, memory stimulation, global stimulation and the number of patients for each treatment group at each
and cognitive psychostimulation were used to search ALOIS on 6 assessment. Where changes from baseline were not reported, the
December 2011. The studies were identified from the following reviewers extracted the mean, standard deviation and the number
databases: of patients for each treatment group at each time point if available.
The reviewers calculated the required summary statistics from the
baseline and assessment time treatment group means and standard
1. Healthcare databases: Medline, Embase, Cinahl, Psycinfo and
deviations, assuming in this case a zero correlation between the
Lilacs
measurements at baseline and assessment time. This conservative
2. Trial registers: meta Register of Controlled Trials; Umin Japan
approach to estimation of the variance of change scores was cho-
Trial Register; WHO portal (which covers ClinicalTrials.gov;
sen, as it is preferable in a meta-analysis. The baseline assessment
ISRCTN; Chinese Clinical Trials Register; German Clinical Trials
was defined as the latest available assessment prior to randomi-
Register; Iranian Registry of Clinical Trials and the Netherlands
sation, but no longer than two months prior. For each outcome
National Trials Register, plus others)
measure, data were sought on every patient randomised. To allow
3. The Cochrane Library’s Central Register of Controlled Trials (CEN-
an intention-to-treat analysis, the data were sought irrespective of
TRAL)
compliance, whether or not the patient was subsequently deemed
4. Number of grey literature sources: ISI Web of Knowledge Confer-
ineligible, or otherwise excluded from treatment or follow-up. Dis-
ence Proceedings; Index to Theses; Australasian Digital Theses
cussion between the two reviewers (EA, BW) and the other authors
was used to resolve any queries.
A total of 670 references were retrieved from the December
2011 search. After de-duplication and a first-assessment, authors
2.4. Analyses
were left with 94 references to further assess for inclusion, exclu-
sion or discarding.
RevMan 5.1 (Updated Software, 2011) was used. The meta-
analyses presented overall estimates of the treatment difference
2.2. Inclusion criteria from a fixed-effect model and a test for heterogeneity was per-
formed using a standard Chi square statistic. Where there was
2.2.1. Studies evidence of heterogeneity of the treatment effect between trials
RCTs examining the effect of cognitive stimulation for dementia then a random-effects model was utilised (which results in broader
were initially included if they had been published in English in a confidence intervals than for those of a fixed-effect model). Because
peer-reviewed journal. Authors were contacted for missing data, trials used different tests to measure the same outcomes, the mea-
such as details of randomisation, means, and standard deviations. sure of the treatment difference for any outcome that we used was
the weighted mean difference, when the pooled trials used the
2.2.2. Participants same rating scale or test, and the standardised mean difference
Participants who had a diagnosis of dementia (Alzheimer’s (the absolute mean difference divided by the standard deviation)
disease, vascular dementia mixed Alzheimer’s and vascular demen- when different rating scales or tests were used. A weighted esti-
tia, other types of dementia), including all levels of cognitive mate of the typical treatment effect across trials was calculated.
impairment. The participants could receive the intervention in a The reviewers achieved consensus on the interpretation of the
 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262 255

statistical analyses, seeking specialist statistical advice from the chance of contamination (Ferrario et al., 1991; Spector et al., 2001,
Dementia and Cognitive Improvement Group (CDCIG) as required. 2003; Woods, 1979). Information regarding where groups were
held was not provided in the other studies (Bottino et al., 2005;
3. Results Chapman et al., 2004; Onder et al., 2005). In relation to detec-
tion bias, most studies took steps to ensure that at least part of
3.1. Selection of trials the assessment of outcomes was carried out by assessors blind to
treatment allocation. Baldelli et al. (1993, 2002) and Ferrario et al.
Ninety-four studies from the initial set of references were iden- (1991) did not describe the process of blinding of assessors.
tified since the RO review through the literature search (Spector
et al., 2000). A reviewer and co-reviewer independently assessed 3.2.3. Attrition
eligibility. Out of the 94 references, 9 studies met the inclusion Given the nature of the condition, and the age of the participants,
criteria (Baldelli et al., 2002; Bottino et al., 2005; Buschert et al., attrition in several studies was remarkably small, with zero attri-
2011; Chapman et al., 2004; Coen et al., 2011; Onder et al., 2005; tion recorded in six studies (Baines et al., 1987; Baldelli et al., 1993,
Requena et al., 2006; Spector et al., 2001, 2003) and were included 2002; Bottino et al., 2005; Buschert et al., 2011; Coen et al., 2011),
in the analysis. Three recent studies were left awaiting classifi- out of 180 participants. The largest attrition rate was reported by
cation, with further details being required (Buettner et al., 2011; Wallis et al. (1983), where there was 39% attrition in the group
Fernandez-Calvo et al., 2010; Niu et al., 2010). The previous review of participants with dementia. In this study, patients who attended
(Spector et al., 2000) included 8 studies in the meta-analysis and less than 20% of the group sessions were eliminated from the study.
six of these met the criteria for inclusion in this new review (Baines Requena et al. (2006) reported 32% attrition over a two-year period.
et al., 1987; Baldelli et al., 1993; Breuil et al., 1994; Ferrario et al., The two largest studies had rates of 19% (Onder et al., 2005) and
1991; Wallis et al., 1983; Woods, 1979). Two studies from the pre- 17% (Spector et al., 2003), over periods of 6 months and 2 months
vious review were excluded this time, as the data needed for the respectively.
meta analysis were not available (Gerber et al., 1991; Hanley et al.,
1981). Therefore, a total of fifteen studies were included in the 3.2.4. Other sources of bias
analysis (Table 1). All the studies included in this review included There was an absence of detailed treatment protocols, so the
participants with a diagnosis of dementia and in general, targeted extent to which the intervention was delivered as intended in each
participants in the mild to moderate range of cognitive impairment. study could be questioned. Some recent studies described that
The mean age across the 15 studies was 78.8 years (from 38 to staff received training and/or supervision in running the groups.
97 years). Over half the studies reported inclusion of participant(s) Chapman et al. (2004) described weekly meetings to ensure their
aged 90 years and above. Apart from six studies (Bottino et al., 2005; treatment programme was implemented as designed and Onder
Breuil et al., 1994; Buschert et al., 2011; Chapman et al., 2004; Onder et al. (2005) also described how family caregivers were trained by
et al., 2005; Requena et al., 2006) where all the participants were a multi-disciplinary team and given a manual and specific sched-
outpatients living in the community, the rest of the studies included ules for each session. No records were made, however, of how often
participants that were residents in care homes, nursing homes or caregivers did deliver the sessions, or how closely the manual was
hospitals. Spector et al. (2001, 2003) studies included participants followed. The only available data on treatment adherence came
from both residential and community settings. from Woods (1979), who stated in a personal communication, “A
sample of sessions were tape-recorded and rated to ensure com-
3.2. Quality of studies pliance with the therapeutic protocol”.

The quality of each study was assessed and details are shown in 3.3. Meta-analysis
Table 1.
Data from the included studies was entered into “Metaview”
3.2.1. Randomisation (the Cochrane term for meta-analysis). Data were identified,
All studies included randomly allocated participants to either included and pooled from the 15 included RCTs, including a total
treatment or control groups. Earlier studies described the ran- of 718 participants (407 in experimental groups, 311 in control
domisation process to be ‘drawing names from a hat’ or ‘using a groups). In order to evaluate the effect of cognitive stimulation on
sealed container process of randomisation’ whereas latest stud- cognitive function, data from 14 RCTs were included in the anal-
ies described a remote or computerised randomisation procedure ysis as one study (Chapman et al., 2004) did not include the data
(Table 1). needed at post treatment, leaving a total of 657 participants for
analysis (377 received treatment and 281 received no treatment or
3.2.2. Blindness placebo). Where more than one cognitive measure had been used,
Performance bias was difficult to evaluate. With psychological the more detailed test was used (e.g. ADAS-Cog was selected for
interventions, unlike drug trials, it is impossible to totally blind inclusion in this analysis over the MMSE where both were available
patients and staff to treatment. Patients are often aware that they from a study).
are being treated preferentially, staff involved may have different In comparison with the control groups at the post-treatment
expectations of treatment groups, and independent assessors may assessment, cognitive stimulation was associated with significant
be given clues from patients during the assessments. Ratings of day- improvements across the range of cognitive measures used. The
to-day behaviour and function are typically carried out by care staff overall results in the cognitive section were significantly in favour
who may be more difficult to keep blind to group allocation, unless of treatment (Fig. 1). The overall effect size (SMD) was 0.41 (95%
the group sessions are carried out in a separate location, to which all CI: 0.25, 0.57). The results were strongly weighted by Onder et al.
participants are taken. There may also be ‘contamination’ between (2005) (n = 137) and Spector et al. (2003) (N = 201) the largest stud-
groups, in terms of groups not being held in separate rooms and ies. Largest effect sizes were seen at the 12-month point in the
staff bringing ideas from one group to another. In relation to con- Requena et al. (2006) study (SMD 0.70 on ADAS-Cog) and the
tamination, Baines et al. (1987) and Wallis et al. (1983) said that Baldelli et al. (1993) study (SMD 0.99 on MMSE), both of which
staff were removed from the ward setting for treatment and other offered above average duration of exposure to cognitive stimula-
studies said that groups were held in separate areas, reducing the tion.
256 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262

Table 1
Description of included studies and bias.

Study ID Intervention Content of therapy Alternative Randomisation Attrition bias Blindness

activity (dropouts)

Baines et al. (1987) 30 min RO board, multisensory Reminiscence No details 0/15 dropouts Assessment by
5 times a week stimulation therapy/no independent psychologist
4 weeks treatment and staff not involved in
therapy.
No details of assessors

Baldelli et al. (1993) 60 min Formal RO No treatment No details 0/23 No details of assessors
3 times a week (TAU)
3 months
Baldelli et al. (2002) 60 min Physical therapy Physical No details 0/87 No details of assessors
5 times a week augmented by RO sessions therapy
1 month programme
Bottino et al. (2005) 90 min Temporal and spatial ACHEIs only Randomised 0/13 Assessment by a blind and
1 time a week orientation, discussion of blocks design independent assessor
5 months interesting themes,
reminiscence activities,
naming people, daily
activities, planning use of
calendars and clocks
Breuil et al. (1994) 60 min Drawing, associated words, No treatment No details 5/61 dropouts Assessment by a
2 times a week object naming, psychologist unaware of
5 weeks categorizing objects group allocation

Buschert et al. (2011) 120 min Multi-component cognitive Pencil and Blocked No attrition Cognitive assessments
1 time a week group intervention – for paper exercises randomisation N = 35 made by an assessor blind
6 months AD group emphasis on for self-study procedure to group allocation
cognitive stimulation (for and monthly
MCI group more emphasis meetings
on cognitive training)
Chapman et al. (2004) 90 min Current events; discussion ACHEIs only SAS procedure 6/54 Assessment by a
1 time a week of hobbies and activities; psychologist unaware of
8 weeks education regarding group allocation
Alzheimer’s disease; life
story work; links with daily
life encouraged
Coen et al. (2011) 45 min Cognitive stimulation No treatment Computerised No attrition Tests administered by staff
2 times a week randomisation N = 27 blind to group
for 7 weeks and random membership. Not clear if
number tables staff ratings were made by
were used staff who were blinded

Ferrario et al. (1991) 60 min Classroom RO No treatment No details 2/21 dropouts No details of assessors
5 times a week
21 weeks
Onder et al. (2005) 30 min Current information, topics ACHIES only Computerised 19/156 Assessment by a
3 times a week of general interest, block psychologist unaware of
25 weeks historical events and randomisation group allocation
famous people, attention, procedure
memory and visuo-spatial
Requena et al. (2006) 45 min Orientation, body ACHIES only Registration 10/50 Assessment by a
5 times a week awareness, family and No treatment order psychologist unaware of
24 months society, caring for oneself, procedure group allocation
reminiscing, household tips,
animals, people and objects
Spector et al. (2001) 45 min Orientation, categorizing No treatment Drawing names 8/35 Assessment by a researcher
2/3 times a objects, sounds, number, from a sealed blind to group allocation
week physical and word games, container
7 weeks current events
Spector et al. (2003) 45 min Orientation, categorizing No treatment Drawing names 34/201 Assessment by a researcher
2 times a week objects, sounds, number, from a sealed blind to group allocation
7 weeks physical and word games, container
(14 sessions) current events
Wallis et al. (1983) 30 min Repetition of orientation Diversional Drawing from a 22/60 dropouts Assessment by a senior
5 times a week information (e.g., time, occupational hat, nurse or occupational
3 months place, weather), charts, therapy (group consecutive therapist unaware of group
pictures, touching objects and individual allocation allocation
and material activities
Woods (1979) 30 min Daily personal diary, group “Social Drawing from a 4/18 dropouts Mixture: some
5 times a week activities (dominoes, therapy” hat assessments blind, some
20 weeks spelling, bingo) naming (various group others not
objects, reading RO board activities
E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262 257

Fig. 1. Meta analysis cognitive outcome.

Fig. 2. Meta analysis communication and social interaction.

258 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262

Fig. 3. Meta analysis behaviour seen as a problem outcome.

Four studies included staff ratings of the person’s communica- significant results were found in the other outcome measures at
tion and social interaction (n = 223). The overall effect size (SMD) either short term or long term follow up analysis (Fig. 9).
was 0.44 (95% CI 0.17 to 0.71) with participants in the cognitive
stimulation groups showing a significant improvement in this area
(Fig. 2). 4. Discussion
No differences were apparent in relation to either activities of
daily living (ADL) or behaviour (Figs. 3–5). Five studies, involving These results including 15 studies have shown consistently that
201 participants, used a self-report measure of mood (the Geriatric cognitive stimulation benefits cognition for people with demen-
Depression Scale or the MADRS) (Fig. 6) but cognitive stimulation tia but that it also benefits self rated well being and quality of life
was not associated with significant improvement in mood; SMD which is arguably of greater importance than any change in cog-
0.22 (95% CI: −0.09, 0.53), Z = 1.42, P = 0.16 and for proxy reports nition (Woods et al., 2006). Included studies came from a variety
of mood and anxiety the was close to zero; 0.05 (95% CI: −0.21, of settings and countries and trials varied greatly in factors such as
0.31) (Fig. 7). Four studies included self-reported well being and length of intervention, methodological quality and outcome meas-
quality of life measures (N = 219) (Fig. 8). Analysis showed a signifi- ures. There was some variation in the alternative activities offered
cant improvement on this outcome following treatment compared to control groups, with some trials giving them no treatment, others
to control groups. The SMD was 0.38 (95% CI: 0.11, 0.65); Z = 2.76, providing some alternative ‘social’ therapy, and others providing a
P = 0.006. control group with identical dementia drug treatment to those in
the cognitive stimulation group. In those studies where participants
were also taking ACHEIs, the control group were typically moni-
3.3.1. Medication effect in comparison to cognitive stimulation tored in relation to the medication (Chapman et al., 2004; Bottino
effect et al., 2005; Onder et al., 2005; Requena et al., 2006; Buschert
In five of the included studies (Chapman et al., 2004; Bottino et al., 2011). The results showed no effect in relation to the type
et al., 2005; Onder et al., 2005; Requena et al., 2006; Buschert et al., of control group on outcome, indicating that the actual qualities of
2011) all of the participants were prescribed ACHEI medication. cognitive stimulation programmes are the ones that matter, rather
For the four of these RCTs providing post-treatment data, the addi- than merely social contact and attention. Staff may however have
tional effect of cognitive stimulation over and above the medication had more positive attitudes to, and greater expectations for the
was 3.18 points on the ADASCog, compared with the overall find- cognitive stimulation therapy group, which may have affected par-
ing (from seven RCTs) of 2.27 points. This supports the proposition ticipants’ performance.
that cognitive stimulation is effective irrespective of whether or All included trials were randomised studies and had assessors
not ACHEIs are prescribed, and any effects are in addition to those blind to treatment group but RCTs may be especially valuable if
associated with the medication. used in conjunction with qualitative studies (e.g. Spector et al.,
2011) or quasi-experimental studies in which different treatments
are carried out in different centres. These may offer a greater insight
3.3.2. Follow-up into the most effective features of cognitive stimulation, the most
The short-term follow up analysis after stopping the cognitive effective ways in which it may be applied, and the types of people
stimulation sessions included 52 participants from Baines et al. most suited to this type of intervention. As with all psychological
(1987) and Wallis et al. (1983) studies with a one month follow-up, interventions, the success of a cognitive stimulation programme
and from Baldelli et al. (1993) with a three month follow-up. may be dependent on it being used at the appropriate time, by
These studies found significant benefits for cognitive stimulation sensitive and experienced facilitators or therapists with interested
on cognitive measures at follow up (SMD 0.57 (95% CI: 0.01, participants. Apart from the Onder et al. (2005) study where the
1.14), Z = 2.00, P = 0.05). Long-term follow up data included 54 therapy was run at home by a trained family caregiver, all the other
participants from the Chapman et al. (2004) study that reported interventions were run in a group setting by therapists, with a vari-
on a ten month follow-up but found no significant effects on either ety of backgrounds, experience and training. However, this review
the MMSE (SMD 0.18) or the ADAS-Cog (SMD 0.12). No other found no indications in relation to the required amount or type of
E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262 259

Fig. 4. Meta analysis behaviour ADL outcome.

Fig. 5. Meta analysis general behaviour outcome.

Fig. 6. Meta analysis self report mood outcome.

260 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262

Fig. 7. Meta analysis proxy report mood outcome.

Fig. 8. Meta analysis self report quality of life and well being outcome.

Fig. 9. Meta analysis follow up cognition outcome.

 E. Aguirre et al. / Ageing Research Reviews 12 (2013) 253–262 261

training necessary to run cognitive stimulation in an effective way. Acknowledgements

The Onder et al. (2005) study provides novel results for individual
cognitive stimulation and this appears to be a promising area for This review is published as a Cochrane Review in the Cochrane
further research (Orrell et al., 2012). Database of Systematic Reviews 2012, Issue 2. Cochrane Reviews
This review reports findings immediately after treatment and are regularly updated as new evidence emerges and in response to
only four small studies reported on follow up data. The results did comments and criticisms, and the Cochrane Database of System-
not show a clear relationship between either amount/frequency or atic Reviews should be consulted for the most recent version of the
length of intervention. Largest size effects were seen in both long Review. Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stim-
and short trials (Requena et al., 2006; Breuil et al., 1994) and long ulation to improve cognitive functioning in people with dementia.
exposure trials (Ferrario et al., 1991) showed below average effect Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.:
sizes. It remains unclear if the frequency of sessions per week makes CD005562. http://dx.doi.org/10.1002/14651858.CD005562.pub2.
a difference as the study with the largest effect sizes (Requena et al., Maintenance Cognitive Stimulation Programme
2006) had five 45-minute sessions per week and has the longest (ISRCTN26286067) is part of the Support at Home – Interventions
duration. As the duration increases, the anticipated decline associ- to Enhance Life in Dementia (SHIELD) project (Application No. RP-
ated with dementia should tend to reduce the effects of cognitive PG-0606-1083) awarded to Prof Orrell (UCL/NELFT), based in North
stimulation, and so a simple linear relationship is not likely to last. East London Foundation Trust, and funded by the NIHR Programme
Long-term benefits of the intervention remained unclear primarily Grants for Applied Research funding scheme. Other grantholders
because of the lack of follow up data and definitive evidence for the include Woods (Bangor), Challis (Manchester), Moniz-Cook (Hull),
long-term effects is needed. Short-term follow up data from three Russell (Swansea), Knapp (LSE) and Dr Charlesworth (UCL). This
studies suggested that a benefit from cognitive stimulation might report/article presents independent research commissioned by the
be maintained for at least three months but for cognitive stimula- National Institute for Health Research (NIHR) under its Programme
tion to have more lasting effects, there should be a detailed schedule Grants for Applied Research scheme (RP-PG-060-1083). The views
of reinforcement and follow-up, with an ongoing program. expressed in this publication are those of the author(s) and not
Recent reviews of psychosocial interventions for dementia are necessarily those of the NHS, the NIHR or the Department of
in line with the findings of this review and give strong recom- Health.
mendations for the use of cognitive stimulation for dementia (e.g.
Livingston et al., 2005; Olazaran et al., 2010). Moreover, the 2011 Appendix A. Supplementary data
World Alzheimer’s Report (Prince et al., 2011) concludes that
“acetylcholinesterase inhibitors (ACHEI) and cognitive stimulation Supplementary data associated with this article can be found, in
may enhance cognitive function in people with mild Alzheimer’s the online version, at http://dx.doi.org/10.1016/j.arr.2012.07.001.
disease, and these interventions should therefore be routinely
offered.” In relation to ACHEI medication and in line with Prince References
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Conflict of interest cognitive-communication stimulation for Alzheimer’s disease patients treated
with donepezil. Journal of Speech, Language, and Hearing Research 47 (5),
1149–1163.
The authors have produced various training materials in demen-
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tia care, including two cognitive stimulation therapy manuals, in with early-stage Alzheimer’s disease: a review. Neuropsychological Rehabilita-
order to disseminate research findings to care workers and others. tion 14, 385–401.
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C., McDonald, M., Delaney, D., Merriman, N., Edgeworth, J., 2011. Efficacy of a
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