the efficacy of cognitive stimulation therapy (cst) for people...

Original Articles and Reviews

The Efficacy of Cognitive StimulationTherapy (CST) for People WithMild-to-Moderate DementiaA Review

Alessandra Lobbia,1 Elena Carbone,1 Silvia Faggian,2 Simona Gardini,3 Federica Piras,4

Aimee Spector,5 and Erika Borella1

1Department of General Psychology, University of Padova, Italy2Centro Servizi Anni Sereni, Scorzè (VE), Italy3Department of Medicine, University of Parma, Italy4Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Santa Lucia Foundation, Rome, Italy5Research Department of Clinical, Educational and Health Psychology, University College London (UCL), London, UK

Abstract: Cognitive Stimulation Therapy (CST) is an internationally used, evidence-based psychosocial intervention for people with mild-to-moderate dementia. The present review thus aimed specifically to examine the reliability of the findings and the strength of the evidenceobtained in studies on the CST protocol concerning any benefit in terms of cognitive functioning, perceived quality of life, psychological,behavioral, and everyday life functioning of people with dementia, and their family caregivers’ health status, quality of life, and burden of care.A systematic literature search on studies specifically adopting the CST protocol in patients with mild-to-moderate DSM-IV dementia –eventually involving their family members – was performed. A total of 238 papers were screened and 12 finally included in the qualitativeanalysis after inclusion/exclusion criteria were applied. The Jadad Scale and the Stroke Prevention and Educational Awareness Diffusion(SPREAD) method were used to appraise the studies’ methodological quality. Moderate levels of evidence emerged for general cognitivefunctioning, language comprehension and production, and quality of life. The levels of evidence were weaker for short-term memory,orientation, praxis, depression, social and emotional loneliness, behavior, and communication in people with dementia, and for theircaregivers’ health status and anxiety symptoms. Albeit with the limited quality of reviewed evidence, and the need for more studies on CST, thepresent review highlights the value of this program as part of dementia care services to sustain the cognitive functioning and quality of life ofpeople with dementia.

Keywords: dementia, Cognitive Stimulation Therapy, cognitive functioning, quality of life

Dementia is the most prevalent cognitive degenerative dis-ease in the aging population and considered one of thegreatest global public health challenges (WHO, 2012).Dementia can have various etiological factors, but Alzhei-mer’s disease is considered the primary cause, accountingfor around 60% of all cases (Thies & Bleiler, 2011). Giventhat the costs of care for dementia will be $1 trillion by2018, and $2 trillion by 2030 (Alzheimer’s Disease Interna-tional, 2015), it is imperative for the neuroscientificapproach to dementia care to implement evidence-based,effective interventions to manage the cognitive and behav-ioral symptoms of dementia, and improve the quality of lifefor people with dementia and their carers.

Treatment options for dementia include pharmacologicaltherapies and psychosocial interventions (or non-pharma-cological treatments). Pharmacological therapies have

produced questionable results to date (e.g., Galimberti &Scarpini, 2012), so interest in psychosocial approaches todementia has increased considerably in recent years. Vari-ous programs (e.g., cognitive, multi-strategy, behavioral,and environmental interventions) have been suggested forpeople with dementia, and those based on cognitive stimu-lation seem the most effective (e.g., Cooper et al., 2012).

Cognitive stimulation programs, generally implementedin groups, aim to improve the cognitive and social function-ing of individuals with dementia, and consequently theirquality of life, by providing a stimulating environment thatprompts individual engagement in a range of activities anddiscussions (Woods, Aguirre, Spector, & Orrell, 2012). Asystematic review (Woods et al., 2012) of studies on pro-grams based on reality orientation and cognitive stimula-tion confirmed the benefits of the latter in various areas.

�2018 Hogrefe Publishing European Psychologist (2018)https://doi.org/10.1027/1016-9040/a000342

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In particular, while mood, behavioral functioning, or every-day life functioning did not change, the general cognitivefunctioning of people with dementia as well as their qualityof life and well-being clearly improved, based on staffratings of participants’ communication skills and socialinteraction abilities (Woods et al., 2012). A recent synthesisof 22 systematic reviews, covering 197 studies on a hugevariety of psychosocial interventions, also highlighted thatgroup cognitive stimulation improved cognitive functioning,social interaction, and quality of life for people with demen-tia (McDermott et al., 2018). However, these findings werebased on different stimulation programs and protocols, andthe procedures varied in terms of content, frequency, dura-tion, format, delivery mode, and number of sessions.

An exception among the cognitive intervention protocolsis the “Cognitive Stimulation Therapy” program (CST,Spector et al., 2003; Spector, Thorgrimsen, Woods, &Orrell, 2006), an evidence-based intervention (NICE,2006) being validated by a multicentered randomized con-trolled trial (RCT) at 23 residential homes and day centers(Spector et al., 2003). Its published and readily availablestandardized protocol has enabled the CST to become theonly program widely used in various countries and acrossdifferent cultures (in Italy, China, etc.) for the cognitivestimulation of people with mild-to-moderate dementia(Aguirre, Spector, & Orrell, 2014).

The CST protocol consists of 14 twice-weekly themedand structured group sessions lasting about 45 min each.The activities are based on the features of psychosocialinterventions proving effective in previous studies andreviews. The CST incorporates elements of reality orienta-tion (RO; Taulbee & Folsom, 1966), such as the use ofwhiteboards for temporal orientation, but overcomes someof the limits of this approach (see Woods et al., 2012). Italso includes aspects of reminiscence therapy, multisensorystimulation, and implicit learning principles. Innovatively,the CST protocol adopts the principles of the person-cen-tered care approach as its frame of reference, focusing onthe “personhood” of people with dementia (see Kitwood,1997). During CST, people are involved in activities thatplace the emphasis on their emotional, relational, and socialskills (Woods et al., 2012), and a respectful and sensitiveapproach to the individual is essential for the success of thisintervention.

The aim of combining a cognition-based approach withpsychosocial and relational features is to stimulate cogni-tion, and particularly language and executive functioning,spatial and temporal orientation, reminiscence, and theretrieval of personal information, but also to determine abroader impact on dementia-related symptoms (e.g., behav-ioral disorders, depression, impaired communication) andthus on the overall quality of life and well-being of peoplewith dementia.

Since CST is becoming increasingly popular, the aim ofthe present review was specifically to examine the reliabilityof the findings and the strength of the evidence obtained instudies on the CST protocol in terms of cognitive function-ing, perceived quality of life, psychological, behavioral, andeveryday life functioning for people with dementia; per-ceived health status, quality of life, and burden of care forfamily caregivers after their relatives attended the rehabili-tative protocol were also taken into consideration.

To this main aim we considered the soundness of theincluded papers’ experimental design (randomization,blinding, details of number of participants, and dropouts)based on standardized rating criteria, that is, the JadadScale (Jadad et al., 1996) and the Stroke Prevention andEducational Awareness Diffusion (SPREAD) method (Iniz-itari & Carlucci, 2006).

Method

Criteria for Inclusion of Studies in ThisReview

The review focused on CST studies conducted with a quan-titative design, for which adequate information was pro-vided or could be obtained from the authors of the study.The literature search was limited to studies published inEnglish in peer-reviewed journals from 2001 – that is, afterthe pilot study by Spector, Orrell, Davies, and Woods(2001) – to 2017 that (i) adopted the original CST program,or adapted the materials of the original protocol to differentcultural backgrounds; (ii) involved participants diagnosedwith mild-to-moderate dementia according to the Diagnos-tic and Statistical Manual of Mental Disorders (DSM) –Fourth or Fifth edition – criteria, and further classified ascases of Alzheimer’s disease, vascular dementia, mixed Alz-heimer’s and vascular dementia, or other types of demen-tia, who attended the intervention in various settings (e.g.,at home, in day care, in nursing homes); (iii) possiblyinvolved family caregivers too, either directly or by collect-ing data on the person–caregiver relationship.

The outcome measures (CST outcomes) were analyzedseparately for people with dementia and their family care-givers. For the former, since CST is supposed to act on cog-nitive functioning and also more generally, on quality of lifethe outcome measures were classified as primary and sec-ondary, depending on the aspect considered: those assess-ing improvements in general cognitive functioning andspecific cognitive domains (memory, executive functioning,language, attention, as detailed below) were primaryoutcome measures; those pertaining to quality of life,behavioral and psychological functioning, everyday life

European Psychologist (2018) �2018 Hogrefe Publishing

2 A. Lobbia et al., Efficacy of Cognitive Stimulation Therapy

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functioning, and communication skills were secondary out-come measures (see below). For the family caregivers, anychange in measures of health status, quality of life, and bur-den of care were considered as outcomes (see below).

Search Strategy

The following databases were searched systematically: Webof Science, PubMed, Psychology and Behavioral Science,PsycINFO (Ovid), SCOPUS, SocINDEX with Full Text(EBSCO). Literature search was limited to studies publishedin English in peer-reviewed journals from 2001 to 2017.Terms describing the target sample (i.e., Alzheimer’s dis-ease, dementia, people with dementia) were combined (us-ing the Boolean term “AND” to get more hits) with termsdefining the type of treatment (i.e., non-pharmacologicaltherapy, Cognitive Stimulation Therapy, CST, psychosocialintervention) and sought in the full-text field. Titles andabstracts were checked to ascertain whether each studymet our inclusion criteria. Reference lists, especially of pre-vious reviews on non-pharmacological interventions fordementia, were also reviewed to identify additional publica-tions. The literature search was run from November 2015 toMarch 2017 to include all studies adopting the CST pro-gram and meeting the inclusion criteria.

Evaluation Process

Three judges independently rated the quality of theselected studies, describing them in tabular form, and con-sidering the following different key aspects: design and pro-cedure; characteristics of the sample, and activities of thecontrol group; inclusion/exclusion criteria; outcome mea-sures considered; and outcomes of the intervention.

The overall methodological quality of each study wasexamined using the Jadad Scale (Jadad et al., 1996), whichallows researchers to monitor the likelihood of bias inresearch reports by awarding up to 5 points, based onwhether the study was randomized and/or blinded, andwhether details were provided regarding the randomizationand double blinding methods, and dropouts. A study was“high-quality” if it scored from 3 to 5, “medium-quality”if it scored 2, and “low-quality” if it scored 0 or 1.

The level of evidence derived from each study was clas-sified using the SPREAD method (Inizitari & Carlucci,2006) as follows:(a) 1++ for high-quality individual RCTs with small confi-

dence intervals (CIs) and highly significant results;(b) 1+ for good-quality individual RCTs with small CIs and

highly significant results;(c) 2++ for high-quality cohort studies with small CIs and/

or highly significant results;

(d) 2+ for good-quality cohort studies with small CIs and/or highly significant results.

A study with large CIs and/or scarcely significant resultswas classified with a minus (�) sign. The related strengthof evidence (grade of recommendation) was rated asfollows:(a) grade B for studies with levels of evidence 1++ or 1+;(b) grade C for studies with levels of evidence 2++ or 2+;(c) grade D for studies with level of evidence 2+, or stud-

ies classified with a minus (�) sign, regardless of thelevel of evidence.

The final ratings were reached by consensus between thethree judges.

Results

A total of 238 records were initially identified, but afterreviewing the titles and abstracts, 197 were excludedbecause they were duplicates, not in English, or unrelatedto the topic of our review. Of the 41 records included inthe analysis of the full texts, the review considered 14 stud-ies published from July 2001 to March 2017, comprising 10RCTs and four pretest–posttest studies (see Figure 1 fordetails). Three of the 10 RCTs (Spector, Orrell, & Woods,2010; Spector et al., 2003; Woods, Thorgrimsen, Spector,Royan, & Orrell, 2006) examined different aspects of theefficacy of CST in the same sample as Spector et al.(2003) and were consequently considered as a single study.Thus, 12 studies were examined, 8 RCTs and 4 pretest–posttest studies. Table 1 summarizes the design, sampleand setting, outcomes measures, results, and quality ratingsof these studies.

Description of the Studies Reviewed

Experimental DesignApart from Aguirre et al. (2013) and Spector et al. (2001),the other six RCTs were single-blind studies, and three ofthem were multicenter studies (see Table 1). Of the fourpretest–posttest studies, only Paddick et al. (2017) includeda control group (see Table 1).

SampleThe participants with dementia were enrolled at residentialcare homes, nursing homes, day centers, hospitals, ordementia care services, except for three studies that alsoincluded at least some people with dementia who were liv-ing at home (Cove et al., 2014; Paddick et al., 2017; Spectoret al., 2001).

�2018 Hogrefe Publishing European Psychologist (2018)

A. Lobbia et al., Efficacy of Cognitive Stimulation Therapy 3

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The inclusion/exclusion criteria adopted generallyreflected those of Spector et al. (2003, 2006). The inclusioncriteria were thus (a) a diagnosis of dementia of any sub-type according to the fourth edition of the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV); (b) ascore of 10 or more on the Mini-Mental State Examination(Folstein, Folstein, & McHugh, 1975), or a score between 10

and 25 on the Montreal Cognitive Assessment (Nasreddineet al., 2005), indicating a mild-to-moderate cognitiveimpairment. The exclusion criteria were (c) inability tounderstand and communicate adequately; (d) sensory abil-ities inadequate to participate in group activities and makeuse of most of the material in the program; (e) neurodevel-opmental disorders, premorbid intellectual disabilities,

Records identified through database searching(n = 234)

Scre

enin

gIn

clud

edE

ligib

ility

Iden

tifi

cati

on Additional records identified through reference list

(n = 4)

Records screened(n = 238)

Records removed because they were duplicates, not published in English, or unrelated to the topic

(n = 197)

Full-text articles assessed for eligibility

(n = 41)

Full-text articles excluded:- not CST protocol by Spector et al. (2001, 2003) (n = 5)- maintenance or individual CST program (n = 14)- qualitative studies or other types of study (n = 8)

Studies for the quantitative synthesis

(n = 14)*

Studies included in quantitative synthesis

(n = 12)

Figure 1. Flowchart showing the number of studies identified, included, and excluded. *Three studies out of the 14 included (Spector et al., 2003,2010; Woods et al., 2006) examined different aspects of the efficacy of the CST analyzing the sample of Spector et al. (2003), and wereconsequently considered as a single study. Thus, 12 studies were examined in all.



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Table1.

Des

cription

ofthe12

stud

ieson

theCSTprotoc

olby

Spe

ctor

etal.(200

6).Fo

rea

chstud

y,theJa

dadSca

lean

dtheSPREADqu

alityrating

saregivenin

thelast

column

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

Ran

domized

controlle

dtrials

1.Spe

ctor

etal.

(200

1)

RCT

Pilo

tstud

yCSTtrea

tmen

tgrou

pversus

controlgrou

p

35PWD

CSTgrou

p:n=

21Con

trol

grou

p^:n=

14Dropo

ut:n=

8Carers:

n=

10Mea

nag

e:85

.7years

(SD

=6.7).

Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Living

situation:

atho

me

(12);in

reside

ntialho

me

(23).

Setting

:3reside

ntialho

mes

;1da

yca

rece

nter.

Improvem

ents

in:ge

neralco

gnition(ADAS-C

og;MMSE);

depres

sive

andan

xietysymptom

s(Corne

llSca

le;RAID).

Severityof

demen

tia(CDR)increa

sedforco

ntrols.

Margina

lde

clinein

Beh

avior(CAPE-B

RS)an

dco

mmu-

nica

tion

(Holde

nSca

le)in

both

theCSTan

dco

ntrol

grou

ps-.

FC Improvem

entin

carers’ge

neralps

ycho

logica

ldistress

(GHQ-12).

Careg

ivers’

stress

(RS)increa

sedslightly

intheCST

grou

pan

dmoresu

bstantially

forco

ntrols.

JADAD

High(3/5)

SPREAD

Levelof

eviden

ce:1�

Grade

ofreco

mmen

dation

:D

Pos

:de

scribe

das

rand

omized

,de

scriptionof

the

metho

dof

rand

omizationinclud

ed,de

scriptionof

drop

-ou

tsinclud

ed.

Neg

*:Smallsa

mplesize

,as

sess

orsno

tblinde

d.

2.Spe

ctor

etal.

(200

3)

RCT

Multice

nter

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

201PWD

CSTgrou

p:n=

115

Con

trol

grou

p^:n=

86Dropo

ut:n=

34Mea

nag

e:85

.3years

(SD

=7.0).

Female:

158

Male:

43Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:18

reside

ntialho

mes

;5da

yca

rece

nters.

Improvem

ents

in:ge

neralco

gnition(M

MSE;ADAS-C

og),

qualityof

life(QoL

-AD),co

mmun

ication(Holde

nSca

le–

tren

dtowardsign

ifican

ce).

Nosig.

improvem

ents

infunc

tion

alab

ility

(CAPE–BRS),

anxiety(RAID),or

depres

sion

(Corne

llSca

le).

JADAD

Med

ium

(2/5)

SPREAD

Levelof

eviden

ce:1+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,go

odde

scriptionof

the

metho

dof

rand

omization,

blindas

sess

or,intention-to-

trea

tan

alysis

used

,nu

mbe

rne

eded

totrea

tca

lculated

.Neg

*:no

desc

riptionof

withd

rawalsan

ddrop

outs.

3.Woo

dset

al.

(200

6)

See

Spe

ctor

etal.(200

3)See

Spe

ctor

etal.(200

3)Sig.co

rrelations

betw

eenim

provem

entin

qualityof

life

(QoL

-AD)an

d:im

provem

entin

gene

ralc

ognition

(MMSE;

ADAS-C

og);redu

ctionof

depres

sion

symptom

s(Corne

llSca

le);im

provem

entin

commun

icationab

ilities

(Holde

nSca

le)-im

proved

-(on

lyforthesa

mpleas

awho

le).

Sig.improvem

ents

inqu

alityof

life(QoL

-AD)m

ediatedby

improvem

entin

gene

ralco

gnition(M

MSE,ADAS-C

og).

See

Spe

ctor

etal.(200

3)Pos

:de

scribe

das

rand

omized

,go

odde

scriptionof

the

metho

dof

rand

omization,

blindas

sess

or.

Neg

*:no

desc

riptionof

withd

rawalsan

ddrop

outs.

4.Spe

ctor

etal.

(201

0)

See

Spe

ctor

etal.(200

3)See

Spe

ctor

etal.(200

3)Im

provem

ents

in:thetotalADAS-C

ogsc

ore;

the

comman

dsan

dsp

oken

lang

uage

subs

calesof

the

ADAS-C

og.

See

Spe

ctor

etal.(200

3)Pos

:de

scribe

das

rand

omized

,go

odde

scriptionof

metho

dof

rand

omization,

blindas

sess

or.

Neg

*:no

desc

riptionof

withd

rawalsan

ddrop

outs.

(Con

tinu

edon

next

page

)



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Table1.

(Con

tinu

ed)

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

5.Coe

net

al.

(201

1)RCT

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

27PWD

CSTgrou

p:n=

14Con

trol

grou

p^:n=

13Dropo

ut:no

tsp

ecified.

Mea

nag

eof

CSTgrou

p:78

.4years(SD

=5.0).

Mea

nag

eof

controlgrou

p:81

.3years(SD

=6.2).

Female:

14Male:

13Dem

entiase

verity:mild

tomod

erate.

Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:2long

-term

care

facilities;

1privatenu

rsingho

me.

Improvem

ents

in:ge

neralco

gnition(M

MSE).

Qua

litativerating

s:av

erag

esc

ores

onco

mmun

ication,

enjoym

ent,an

dmoo

dof

participan

tsim

proved

betw

een

thefirstan

dlast

sess

ions

.CSTpa

rticipan

tsde

mon

-stratedgo

odinteractionan

den

thus

iasm

.

JADAD

Low

(1/5)

SPREAD

Levelof

eviden

ce:1�

Grade

ofreco

mmen

dation

:D

Pos

:de

scribe

das

rand

omized

,blin

das

sess

or,includ

edob

servationa

lmea

sures.

Neg

*:no

details

provided

ofrand

omizationmetho

d,no

desc

riptionof

withd

rawalsan

ddrop

outs,sm

allsa

mple

size

.

6.Agu

irre

etal.

(201

3)

RCT

CSTtrea

tmen

tgrou

pversus

controlgrou

p

272PWD

Dropo

ut:n=

36Mea

nag

e:82

.6years

(SD

=8.1).

Female:

177

Male:

95Con

trol

grou

p^:Spe

ctor

stud

yco

ntrolgrou

p(see

Spe

ctor

etal.,20

03)–bu

ton

lyforthreemea

sures.

Dem

entiadiag

nosissu

b-type

:Alzhe

imer’s

dise

ase

(n=

93);va

scular

demen

tia

(n=

68);othe

r(Lew

ybo

dyde

men

tia,

mixed

type

demen

tia,

Korsa

kov’sdis-

ease

)(n

=23

);un

spec

ified

demen

tia(n

=88

).Setting

:9reside

ntialho

mes

;9co

mmun

itymen

talh

ealth.

Improvem

entin:ge

neralco

gnition(M

MSE;ADAS-C

og).

Nosig.

improvem

entin:qu

alityof

life(QoL

-AD).

(Ben

efitsof

CSTwereinde

pend

entof

theus

eof

AChE

Is).

JADAD

Med

ium

(2/5)

SPREAD

Levelof

eviden

ce:1+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,de

scriptionof

with-

draw

alsan

ddrop

outs

includ

ed.

Neg

*:no

details

provided

onrand

omizationmetho

dfor

CSTgrou

pswithinea

chce

nter,as

sess

orsno

tblinde

d.

(Con

tinu

edon

next

page

)



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AM

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nive

rsità

deg

li St

udi d

i Pad

ova

IP A

ddre

ss:1

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40

Table1.

(Con

tinu

ed)

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

7.Ya

man

aka

etal.

(201

3)

RCT

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

56PWD

CSTgrou

p:n=

26Con

trol

grou

p^:n=

30Dropo

ut:n=

9Mea

nag

e:83

.91years

(SD

=5.98

).Fe

male:

44Male:

12Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:3reside

ntialho

mes

;1nu

rsingho

mein

theTo

kyo

metropo

litan

area

.

Improvem

ents

in:g

eneral

cogn

ition(COGNISTA

T;MMSE);

moo

d(Fac

eSca

le)(bothse

lf-rep

ortedrating

san

dprox

yrating

s);qu

alityof

life(EQ-5D)ratedby

prox

ies.

Nosig.

improvem

ents

in:qu

alityof

life(QoL

-AD;EQ-5D)

ratedby

participan

tsthem

selves

.Tren

dtowardan

improvem

entin:q

ualityof

life(QoL

-AD)

ratedby

prox

ies.

JADAD

High(3/5)

SPREAD

Levelof

eviden

ce:1+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,de

scriptionof

metho

dof

rand

omizationinclud

ed,g

oodde

scriptionof

withd

rawals

anddrop

outs,blindas

sess

or,intention-to-treat

mod

elus

ed.

Neg

*:therap

istan

dca

reworke

rswho

ratedtheQOLan

dmoo

dof

PWDwereno

tblinde

d,statistica

lpo

wer

not

exam

ined

.

8.Coveet

al.

(201

4)RCT

Single-blind

CSTplus

carertraining

ver-

susCSTon

lyversus

control

grou

p

68PWD

CSTplus

carertraining

grou

p:n=

21CSTon

lygrou

p:n=

24Waiting

listco

ntrolgrou

p:n=

23Dropo

ut:n=

18Carers:

n=

21Mea

nag

eof

CSTplus

carer

training

grou

p:75

.4years(SD

=5.56

).Mea

nag

eof

CSTgrou

p:76

.8years(SD

=6.62

).Mea

nag

eof

controlgrou

p:77

.8years(SD

=7.47

).Fe

male:

32Male:

36Dem

entiadiag

nosissu

b-type

:Alzhe

imer’s

demen

tia

–ea

rlyon

set

(n=

1),late

onse

t(n

=36

),atyp

ical/m

ixed

(n=

9);va

scular

demen

tia

(n=

4);su

bcortica

lva

scular

demen

tia(n

=5);de

men

tia

inParkins

on’s

dise

ase

(n=

5);un

spec

ifiedde

men

-tia(n

=7).

Living

situation:

63privateac

commod

ations

;1sh

elteredho

using;

4su

pportedliving.

Nosig.

improvem

ents

in:ge

neralco

gnition(M

MSE;

ADAS-C

og);qu

alityof

life(QoL

-AD);Qua

lityof

Careg

iver

andPatient

Relations

hip(QCPR).

JADAD

High(3/5)

SPREAD

Levelof

eviden

ce:1�

Grade

ofreco

mmen

dation

:D

Pos

:de

scribe

das

rand

omized

,des

cription

ofmetho

dof

rand

omizationinclud

ed,g

oodde

scriptionof

withd

rawals

anddrop

outs,blindas

sess

or,three-grou

pde

sign

.Neg

*:no

mon

itoringof

trea

tmen

tfide

lity,relativelysm

all

samplesize

.

(Con

tinu

edon

next

page

)



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rsità

deg

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udi d

i Pad

ova

IP A

ddre

ss:1

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26.2

40

Table1.

(Con

tinu

ed)

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

9.Apó

stolo

etal.

(201

4)

RCT

Multice

nter

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

56PWD

CSTgrou

p:n=

27Con

trol

grou

p^:n=

29Dropo

ut:n=

8Mea

nag

e:81

.65years

(SD

=5.64

).Fe

male:

33Male:

15Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:Portugu

esenu

rsingho

mes

(NHs).

Improvem

ents

in:ge

neralco

gnition(M

oCA).

Nosig.

decrea

sein

thede

pres

sive

symptom

s(GDS-15).

JADAD

High(3/5)

SPREAD

Levelof

eviden

ce:1+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,des

cription

ofmetho

dof

rand

omizationinclud

ed,g

oodde

scriptionof

withd

rawals

anddrop

outs,blindas

sess

or.

Neg

*:no

intention-to-treat

analysis.

10.Cap

otos

toet

al.

(201

7)

RCT

Multice

nter

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

39PWD

CSTgrou

p:n=

20Con

trol

grou

p^:n=

19Dropo

ut:n=

5Mea

nag

eof

CSTgrou

p:88

.25years(SD

=5.15

).Mea

nag

eof

controlgrou

p:86

.52years(SD

=5.55

).Fe

male:

27Male:

12Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:2reside

ntialho

mes

.

Improvem

ents

in:ge

neralco

gnition(ADAS-C

og);moo

d(Corne

llSca

le,Soc

ialan

dEmotiona

lLo

nelin

essSca

le–

withade

crea

sein

repo

rted

lone

lines

s);qu

alityof

life

(QoL

-AD).

CSTgrou

pmaintaine

dtheMMSEsc

oreat

posttest,w

hile

controlgrou

pdisp

layedde

terioration.

Nosig.

improvem

ents

in:s

hort-term

mem

ory(Bac

kward

DigitSpa

n),be

havior

(NPI),

everyd

ayfunc

tion

ing(DAD).

JADAD

Med

ium

(2/5)

SPREAD

Levelof

eviden

ce:1+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,de

scriptionof

with-

draw

alsan

ddrop

outs

includ

ed,blindas

sess

or,ac

tive

controlgrou

pus

ed.

Neg

*:no

desc

riptionof

themetho

dof

rand

omization,

smallsa

mplesize

.

(Con

tinu

edon

next

page

)



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roto

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onte

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rika

Bor

ella

<er

ika.

bore

lla@

unip

d.it>

- T

uesd

ay, N

ovem

ber

20, 2

018

5:21

:52

AM

- U

nive

rsità

deg

li St

udi d

i Pad

ova

IP A

ddre

ss:1

47.1

62.1

26.2

40

Table1.

(Con

tinu

ed)

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

Pre–po

ststud

ies

11.Hallet

al.

(201

3)Pretest–po

sttest

design

CSTtrea

tmen

tgrou

p41

PWD

Dropo

ut:n=

7(noco

ntrolgrou

p)Mea

nag

e:80

.3years

(SD

=8.8).

Female:

20Male:

14Dem

entiadiag

nosissu

b-type

:no

tsp

ecified(n

=12

);Alzhe

imer’s

dise

ase(n

=8);

Vasc

ular

demen

tia(n

=7);

Mixed

demen

tia(n

=5);

fron

totempo

ralde

men

tia

(n=

1);

Dem

entiawithLe

wybo

dies

(n=

1).

Setting

:2Nationa

lHea

lthService

(NHS)mem

oryclinics;

3NHSda

yho

spitals;

3loca

lau

thorityda

yce

nters.

Improvem

ents

inorientation(W

MS-IIIInform

ationan

dOrien

tation

test);mem

ory(im

med

iate

andde

layedthe-

matic

reca

llva

riab

leof

theWMS-IIILo

gica

lMem

orytest;

delayedreca

llva

riab

leof

theWMS-IIIVisu

alRep

rodu

c-tion

test);lang

uage

compreh

ension

(Tok

enTe

st);

Nosig.

improvem

ents

inge

neralco

gnition(M

MSE);

mem

ory(im

med

iate

reca

llor

reco

gnitionva

riab

lesof

the

WMS-IIIVisu

alRep

rodu

ctiontest);attention(TMT-A);

lang

uage

expres

sion

(BNT-2;

verbal

flue

ncy–D-K

EFS

);exec

utivefunc

tion

s(D-K

EFS

verbal

flue

ncysw

itch

ing

task

;TM

T-B);prax

is(“co

py”co

mpo

nent

oftheWMS-III

Visu

alRep

rodu

ctiontest);working

mem

ory(W

AIS-III

DigitSpa

nsu

btes

t–tren

dstowardsig.).

JADAD

Low

(1/5)

SPREAD

Levelof

eviden

ce:2�

Grade

ofreco

mmen

dation

:D

Pos

:de

scriptionof

withd

rawalsan

ddrop

outs

includ

ed.

Neg

*:Noplan

nedco

ntrolgrou

p,no

rand

omization,

noco

ntrolfortheus

eof

antide

men

tiamed

ication.

12.Pad

dick

etal.

(201

7)

Stepp

edwed

gede

sign

/pretes

t–po

sttest

design

Singleblind

CSTtrea

tmen

tgrou

pversus

controlgrou

p

34PWD

CSTgrou

p:n=

16Waiting

listco

ntrolgrou

p:n=

18Dropo

uts=

none

Carers:

unsp

ecified

Mea

nag

e:80

.00years

(IQR=

76.5–85

.3).

Female:

29Male:

5Dem

entiadiag

nosis

subtyp

e:Alzhe

imer’sdise

ase(n

=16

);Va

scular

demen

tia( n

=10

);Parkins

on’s

dise

ase

demen

tia(n

=2);

Pos

sibleLe

wybo

dies

demen

tia(n

=2);

Mixed

(n=

4).

Setting

:Com

mun

itybu

ildings

in6

ruralvilla

gesof

theHai

dis-

trictof

Kiliman

jaro

region

inno

rthe

rnTa

nzan

ia.

Improvem

ents

inge

neralco

gnition(ADAS-C

og);sp

ecific

cogn

itivedo

mains

oflang

uage

,mem

ory,

prax

is(ADAS-

Cog

subs

cales);qu

alityof

life(but

only

intheph

ysical

health

domainof

theWHOQOL-BREF);be

havioral

symptom

s(onlyNPIse

verity

ofde

pres

sive

symptom

s,nigh

ttim

edisturba

nce,

chan

gesin

appe

tite

asratedby

prim

aryca

rers);an

xietysymptom

sforprim

aryca

rers

(HAD)

Nosig.

improvem

ents

inps

ycho

logica

l,so

cial,an

den

vironm

entalas

pectsof

qualityof

life(W

HOQOL-BREF

subs

cales);an

xietyan

dde

pres

sion

(HAD)forPWD,an

dqu

alityof

life(W

HOQOL-BREF),ca

regiverbu

rden

(Zarit

Burde

nInventory)

andde

pres

sion

(HAD)forprim

ary

carers.

JADAD

High(3/5)

SPREAD

Levelof

eviden

ce:2+

Grade

ofreco

mmen

dation

:B

Pos

:de

scribe

das

rand

omized

,de

scriptionof

metho

dof

rand

omizationinclud

ed,de

scriptionof

withd

rawalsan

ddrop

outs

includ

ed,blindas

sess

ors,

numbe

rne

eded

totrea

tca

lculated

.Neg

*:ge

nerally

low

levels

ofed

ucation.

(Con

tinu

edon

next

page

)



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roto

col}

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onte

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rika

Bor

ella

<er

ika.

bore

lla@

unip

d.it>

- T

uesd

ay, N

ovem

ber

20, 2

018

5:21

:52

AM

- U

nive

rsità

deg

li St

udi d

i Pad

ova

IP A

ddre

ss:1

47.1

62.1

26.2

40

Table1.

(Con

tinu

ed)

Autho

rsExp

erim

entalde

sign

Sam

ple

Outco

mes

ofinterven

tion

fortheCSTgrou

pQua

lityrating

andco

mmen

ts

13.Stewart

etal.

(201

7)

Pretest–po

sttest

design

CSTtrea

tmen

tgrou

p40

PWD

Dropo

ut=

2(noco

ntrolgrou

p)Mea

nag

e:78

.08years

(SD=

11.10).

Female:

24Male:

16Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:co

mmun

ityan

dlong

-term

care

commun

ity.

Improvem

ents

inge

neralco

gnition(SLU

MS);de

pres

sion

(Corne

llsc

ale)

Nosig.

improvem

ents

inqu

alityof

life(QoL

-AD).

JADAD

Low

(1/5)

SPREAD

Levelof

eviden

ce:2�

Grade

ofreco

mmen

dation

:D

Pos

:de

scriptionof

withd

rawalsan

ddrop

outs

includ

edNeg

*:Noplan

nedco

ntrolgrou

p,no

rand

omization,no

controlfortheus

eof

antide

men

tiamed

ication.

14.Won

get

al.,

2017

Pretest–po

sttest

design

Pilo

tstud

y30

PWD

Dropo

ut=

4(noco

ntrolgrou

p)Traine

dCST-HKfacilitators:

n=

12Fa

mily

caregivers:n=

13Mea

nag

e:81

.5years

(SD=

5.9).

Female:

22Male:

8Dem

entiadiag

nosissu

b-type

:no

tsp

ecified.

Setting

:Hos

pitalde

men

tiaca

rese

rvices

inHon

gKon

g.

Improvem

ents

inqu

alityof

life(QoL

-AD–bu

ton

lyin

the

family

relation

ship)

Nosig.

improvem

ents

inge

neralco

gnition(ADAS-C

og),

qualityof

life(total

QoL

-AD).

JADAD

Low

(1/5)

SPREAD

Levelof

eviden

ce:2�

Grade

ofreco

mmen

dation

:D

Pos

:de

scriptionof

withd

rawalsan

ddrop

outs

includ

ed,

numbe

rne

eded

totrea

tca

lculated

.Neg

*:Noplan

nedco

ntrolg

roup

,norand

omization,

small

samplesize

.

Notes

.^Care-as

-usu

alco

ntrolg

roup

.*Th

emax

imum

score(5)req

uiresdo

uble

blinding

andap

prop

riateof

doub

leblinding

metho

d,bu

ton

lysing

leblinding

ispo

ssible

inps

ycho

logica

lres

earch,

sostud

iesin

this

review

couldon

lybe

awarde

damax

imum

scoreof

3.AChE

Is=

Ace

tylcho

lines

terase

inhibitors;ADAS-C

og=

Alzhe

imer’s

Disea

seAss

essm

entSca

le-C

ognition

;ADL=

Activitiesof

daily

living;

BNT-2=

Bos

tonNam

ingtest-2;CAPE-B

RS

=CliftonAss

essm

ent

Proce

duresFo

rtheElderly-B

ehav

iorRatingSca

le;C

DR=Clin

ical

Dem

entiaRatingSca

le(Hug

hes,

Berg,

Dan

zige

r,Cob

en,&

Martin,

1982

);COGNISTA

T=Neu

robe

havioral

Cog

nitive

StatusExa

mination;

Corne

llSca

le=Corne

lsca

leof

Dep

ress

ionin

Dem

entia;

CST=Cog

nitive

StimulationTh

erap

y;CST-HK=Cog

nitive

StimulationTh

erap

yHon

gKon

g;DAD=Disab

ility

Ass

essm

entforDem

entia;

D-K

EFS

=Delis–Kap

lan

Execu

tive

func

tion

system

;EQ-5D

=he

alth-related

qualityof

life;

FC=

Family

caregivers;GDS-15=

Geriatric

Dep

ress

ionSca

le-15;

GHQ-12=

Gen

eral

Hea

lthQue

stionn

aire-12;

HAD=

Hos

pitalAnx

iety

and

Dep

ress

ion

Sca

le;Holde

nSca

le=

Holde

nCom

mun

ication

Sca

le;IQR

=interqua

rtile

rang

e;JA

DAD

=Ja

dad

Sca

le;MMSE

=Mini-Men

talState

Exa

mination;

MoC

A=

Mon

trea

lCog

nitive

Ass

essm

ent;

Neg

=ne

gative

points;N

PI=

Neu

rops

ychiatricInventory;

Pos

=po

sitive

points;P

WD=Peo

plewithde

men

tia;

QCPR=Qua

lityof

Careg

iver

andPatient

Relations

hip;

QoL

-AD=Qua

lityof

Life-A

lzhe

imer’sDisea

se;

RAID

=RatingAnx

iety

inDem

entia;

RCT=Ran

domized

controlle

dtrial;RS=Relatives

’Stres

s;SD=Stand

ardDeviation

;Sig.=

sign

ifican

t;SLU

MS=Saint

LouisUniversityMen

talS

tatusExa

m;S

PREAD=Strok

ePreventionan

dEdu

cation

alAwaren

essDiffusion

scale;

TMT=

TrailMak

ingTe

st;WMS-III=

Wec

hslerMem

orySca

le3rded

.;WHOQOL-BREF=

Brief

WHOQua

lityof

Life.



${p

roto

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onte

nt.h

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om/d

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df/1

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- E

rika

Bor

ella

<er

ika.

bore

lla@

unip

d.it>

- T

uesd

ay, N

ovem

ber

20, 2

018

5:21

:52

AM

- U

nive

rsità

deg

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and/or current physical illness/disability that might affectparticipation.1 Four of the 12 studies also considered care-givers, but only Cove et al. (2014) specified the criteriafor their eligibility (see Table 1).

The average age of participants was over 70 years in allstudies, over 80 in five, and over 85 in three (see Table 1 forfurther details). Only four studies provided details of thedementia subtypes of their samples (Aguirre et al., 2013;Cove et al., 2014; Hall, Orrell, Stott, & Spector, 2013¸ Pad-dick et al., 2017) (see Table 1).

Procedure

In all 12 studies, all participants attended individual assess-ment sessions before and immediately after the interven-tion (i.e., pretest and posttest).

CST Treatment GroupsThe CST groups were conducted by various professionals(clinical psychologists, graduate specialists in aging, occupa-tional therapists, care workers, nurses, or researchers). Ele-ven studies adopted the standard protocol or adapted theprotocol to the local culture, with 14 twice-weekly groupsessions (see Spector et al., 2006 for a detailed descriptionof the CST program), while the CST sessions were sched-uled once a week in one study (Cove et al., 2014).2

Control GroupsIn seven of the eight RCTs and in Paddick et al. (2017), theCST treatment group was compared with an active controlgroup involved for the same number of sessions in the usualactivities organized at the centers, such as group games,music and singing, arts and crafts, and low-impact exercise.In one RCT (Cove et al., 2014), the control group was onlyinvolved in the pre- and posttest sessions. Three pretest–posttest studies did not include a control group (seeTable 1).

CaregiversIn the three studies that involved caregivers, they attendedtwo individual assessment sessions, before and immedi-ately after the intervention (see Table 1). In one study (Coveet al., 2014), caregivers were asked to engage in similarCST activities with their relative with dementia at home(for a detailed description, see Cove et al., 2014). In another

study (Wong, Yek, Zhang, Lum, & Spector, 2017), care-givers and facilitators were involved in focus groups andinterviews to conduct qualitative assessments on theobserved acceptance and response of the person withdementia.

Outcome Measures

All 12 studies assessed general cognitive functioning as theprimary outcome. Two studies ascertained the impact ofthe CST by considering subscales of the cognitive function-ing measure used (ADAS-Cog subscales). Two studies alsoincluded other measures for assessing specific cognitivedomains, that is, language, memory, executive functioningand attention, praxis, and orientation (see Table 2).

As for the secondary outcomes, nine studies includedmeasures of quality of life, nine considered behavioraland psychological functioning (depression, anxiety, social-emotional loneliness, and behavioral disorders), fiveassessed everyday life functioning, and two examined com-munication skills (see Table 2).

Three studies included outcome measures on familycaregivers’ general health status and quality of life, thequality of their relationship with the individual with demen-tia, the burden of care, and symptoms of depression andanxiety (see Table 2).

CST Outcomes

People With DementiaPrimary OutcomesNine of the 12 studies (see Table 3) found that CST had apositive impact on the general cognitive functioning ofthe individuals with dementia. Of these nine studies, fivewere of medium-to-high-quality (level of evidence 1+, gradeof recommendation B), one was low-quality (level of evi-dence 1�, grade of recommendation D), another washigh-quality (level of evidence 2+, grade of recommenda-tion B), and the other two were low-quality (level of evi-dence 2�, grade of recommendation D). Of the threestudies that found no such improvement in general cogni-tive functioning, two were high-quality (level of evidence1�, grade of recommendation D), and one was low-quality(level of evidence 2�, grade of recommendation D�) (seeTable 3).

1 Other additional criteria, adopted only by some studies, were as follows: (i) absence of severe behavioral symptoms of dementia (Capotostoet al., 2017; Coen et al., 2011; Paddick et al., 2017; Spector et al., 2001; Yamanaka et al., 2013); (ii) absence of severe psychological symptoms ofdementia (Capotosto et al., 2017; Coen et al., 2011; Paddick et al., 2017; Yamanaka et al., 2013); (iii) a score from 0.5 (or 1) to 2 on the ClinicalDementia Rating Scale (CDR; Aguirre et al., 2013; Capotosto et al., 2017; Hughes et al., 1982); (iv) English as the first language forcommunicating efficiently (Aguirre et al., 2013; Hall et al., 2013); (v) could engage in group activity for at least 45 min (Apóstolo, Cardoso, Rosa, &Paúl, 2014; Cove et al., 2014; Stewart et al., 2017).

2 Any adaptation of the protocol was approved by Spector.



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Table2.

Primaryan

dse

cond

aryou

tcom

emea

suresforpe

ople

withde

men

tia,

andou

tcom

emea

suresforfamily

caregivers

involved

inthenine

stud

iesreview

ed.

Outco

memea

sures

No.

ofstud

ies

Primaryou

tcom

es–pe

ople

withde

men

tia

Gen

eral

cogn

itivefunc

tion

ing

MMSE;ADAS-C

og(Ros

enet

al.,19

84);COGNISTA

T(N

orthernCaliforniaNeu

robe

havioral

Group

,19

95);MoC

A;

SLU

MS(Tariq

etal.,20

06)

12

Cog

nitive

func

tion

ingin

spec

ific

cogn

itivedo

mains

4^

Lang

uage

Toke

ntest

(Strau

sset

al.,20

06);Narrative

Lang

uage

Test

(Carlomag

noet

al.,20

13);BNT-2(Kap

lanet

al.,20

01);

D-K

EFS

(Delis

etal.,20

01)

2

Mem

ory

WMS-IIILo

gica

lMem

ory(W

echs

ler,19

97);DigitSpa

n(DeBen

ietal.,20

08)

2

Execu

tive

func

tion

san

dattention

TMT(Reitan&

Wolfson

,199

2);D-K

EFS

(Delis

etal.,20

01)

1

Praxis

WMS-IIIVisu

alRep

rodu

ction(W

echs

ler,19

97)

1

Orien

tation

WMS-IIIInform

ationan

dOrien

tation

(Wec

hsler,19

97)

1

Sec

onda

ryou

tcom

es–pe

ople

withde

men

tia

Qua

lityof

life

QoL

-AD(Log

sdon

etal.,19

99);Dem

entiaSpe

cificHea

lthRelated

Qua

lityof

Life

Mea

sures(Smithet

al.,20

05);EQ-

5D(EuroQ

olGroup

,19

90);WHOQOL-BREF(The

WHOQOLGroup

,19

98)

9

Psych

olog

ical

andbe

havioral

func

tion

ing

9

Moo

d:de

pres

sion

Corne

llSca

le(Alexo

poulos

,Abram

s,Yo

ung,

&Sha

moian

,19

88);Geriatric

Dep

ress

ionSca

le-15(She

ikh&

Yesa

vage

,198

6);Fa

ceSca

le(Lorish&

Maisiak

,198

6;Ta

bira

etal.,20

02);Hos

pitalAnx

iety

andDep

ress

ionSca

le(Zigmon

d&

Sna

ith,

1983

)

8

Moo

d:an

xiety

RAID

(Sha

nkar

etal.,19

99);Hos

pitalAnx

iety

andDep

ress

ionSca

le(Zigmon

d&

Sna

ith,

1983

)4

Moo

d:so

cial-emotiona

llone

lines

sSoc

ialan

dEmotiona

lLo

nelin

essSca

le(ada

pted

from

DeJo

ng&

VanTilburg,

2006

)1

Beh

avior

CAPE-B

RS(Pattie&

Gillea

rd,19

79);NPI(Cum

mings

etal.,19

94)

6

Everyda

ylifefunc

tion

ing

Alzhe

imer’s

Disea

seCo-op

erativeStudy

-Activitiesof

Daily

Living

Inventory(Galas

koet

al.,19

97);CAPE-B

RS

(Pattie&

Gillea

rd,19

79);DAD(Gélinas

,Gau

thier,McIntyre,

&Gau

thier,19

99)

5

Com

mun

ication

Holde

nCom

mun

icationSca

le(Holde

n&

Woo

ds,19

95)

2

Careg

iver

outcom

es3

Gen

eral

health

status

GHQ-12(Goldb

erg,

1978

)1

Qua

lityof

caregiveran

dpa

tien

trelation

ship

QCPR(Spruy

tteet

al.,20

02)

1

Qua

lityof

life

WHOQOL-BREF(The

WHOQOLGroup

,19

98)

1

Careg

iver

burden

Relative’sStres

sSca

le(Green

eet

al.,19

82);ZaritBurde

nInventory(Zaritet

al.,19

80).

2

Moo

d:de

pres

sion

Hos

pitalAnx

iety

andDep

ress

ionSca

le(Zigmon

d&

Sna

ith,

1983

)1

Moo

d:an

xiety

Hos

pitalAnx

iety

andDep

ress

ionSca

le(Zigmon

d&

Sna

ith,

1983

)1

Notes

.^Tw

ostud

ies(Pad

dick

etal.,20

17;Spe

ctor

etal.,20

10)a

sses

sedCSTeffectiven

essin

spec

ific

cogn

itivedo

mains

byco

nsideringthesu

bsca

lesof

theADAS-C

og.B

NT-2=Bos

tonNam

ingtest-2;CAPE-

BRS

=Clifton

Ass

essm

entProce

dures

Forthe

Elderly-B

ehav

iorRating

Sca

le;COGNISTA

T=

Neu

robe

havioral

Cog

nitive

Status

Exa

mination;

Corne

llSca

le=

Corne

lsc

ale

ofDep

ress

ion

inDem

entia;

DAD=Disab

ility

Ass

essm

entforDem

entia;

D-K

EFS

=Delis–Kap

lanExecu

tive

func

tion

system

;GDS-15=Geriatric

Dep

ress

ionSca

le-15;

GHQ-12=Gen

eral

Hea

lthQue

stionn

aire-12;

HAD=Hos

pitalA

nxiety

and

Dep

ress

ionSca

le;H

olde

nSca

le=Holde

nCom

mun

icationSca

le;IQR=interqua

rtile

rang

e;MMSE=Mini-Men

talS

tate

Exa

mination;

MoC

A=Mon

trea

lCog

nitive

Ass

essm

ent;NPI=

Neu

rops

ychiatricInventory;

QCPR=Qua

lityof

Careg

iver

andPatient

Relations

hip;

QoL

-AD=Qua

lityof

Life-A

lzhe

imer’sDisea

se;R

AID

=RatingAnx

iety

inDem

entia;

SLU

MS=Saint

LouisUniversityMen

talS

tatusExa

m;T

MT=TrailM

aking

Test;WMS-III=

Wec

hslerMem

orySca

le3rded

.;WHOQOL-BREF=

Brief

WHOQua

lityof

Life.



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Table3.

Reviewed

stud

iesrepo

rtingsign

ifican

tversus

nons

ignifica

ntresu

lts,

byou

tcom

edo

main,

inpe

ople

withde

men

tiaan

dfamily

caregivers,a

ndsu

mmaryof

theJa

dadSca

lean

dtheSPREAD

qualityrating

sby

stud

y

Significa

ntresu

lts

Non

sign

ifican

tresu

lts

No.

ofstud

ies

Study

Qua

lityrating

No.

ofstud

ies

Study

Qua

lityrating

Primaryou

tcom

es–pe

ople

with

demen

tia

Jada

dSPREAD

Jada

dSPREAD

Gen

eral

cogn

itivefunc

tion

ing

9Agu

irre

etal.(201

3)Med

ium

1+,B

3Coveet

al.(201

4)High

1�,D

Apó

stoloet

al.(201

4)High

1+,B

Hallet

al.(201

3)Lo

w2�

,D

Cap

otos

toet

al.(201

7)Med

ium

1+,B

Spe

ctor

etal.(200

1)High

1�,D

Coe

net

al.(201

1)Lo

w1�

,D

Pad

dick

etal.(201

7)High

2+,B

Spe

ctor

etal.(200

3)Med

ium

1+,B

Stewartet

al.(201

7)Lo

w2�

,D

Won

get

al.(201

7)Lo

w2�

,D

Yaman

akaet

al.(201

3)High

1+,B

Cog

nitive

func

tion

ingin

spec

ific

cogn

itivedo

mains

Lang

uage

4Cap

otos

toet

al.(201

7)Med

ium

1+,B

Hallet

al.(201

3)Lo

w2�

,D

Pad

dick

etal.(201

7)[ADAS-C

ogsp

oken

lang

uage

subs

cale]

High

2+,B

Spe

ctor

etal.(200

3;20

10)

[ADAS-C

ogco

mman

dsan

dsp

oken

lang

uage

subs

cales]

Med

ium

1+,B

Mem

ory

2Hallet

al.(201

3)Lo

w2�

,D

1Cap

otos

toet

al.(201

7)Med

ium

1+,B

Pad

dick

etal.(201

7)[m

emoryan

dlearning

subs

cale

ofthe

ADAS-C

og]

High

2+,B

Execu

tive

func

tion

ingan

dattention

1Hallet

al.(201

3)Lo

w2�

,D

Praxis

1Pad

dick

etal.(201

7)[praxissu

bsca

leof

theADAS-C

og]

High

2+,B

1Hallet

al.(201

3)Lo

w2�

,D

Orien

tation

1Hallet

al.(201

3)Lo

w2�

,D

Sec

onda

ryou

tcom

es–pe

ople

with

demen

tia

Qua

lityof

life

6Agu

irre

etal.(201

3)Med

ium

1+,B

5Coveet

al.(201

4)High

1�,D

Cap

otos

toet

al.(201

7)Med

ium

1+,B

Pad

dick

etal.(201

7)[psych

olog

ical,so

cial,

environm

entalas

pectsof

QoL

]

High

2+,B

(Con

tinu

edon

next

page

)



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Table3.

(Con

tinu

ed)

Significa

ntresu

lts

Non

sign

ifican

tresu

lts

No.

ofstud

ies

Study

Qua

lityrating

No.

ofstud

ies

Study

Qua

lityrating

Coe

net

al.(201

1)Lo

w1�

,D

Stewartet

al.(201

7)Lo

w2�

,D

Pad

dick

etal.(201

7)[phy

sica

lhe

alth

domain]

High

2+,D

Won

get

al.(201

7)[QoL

-AD

totalsc

ore]

Low

2�,D

Spe

ctor

etal.(200

3)Med

ium

1+,B

Yaman

akaet

al.(201

3)[but

improvem

ents

inthe

EQ-5Dan

datren

dtoward

anim

provem

entin

theQoL

-ADratedby

prox

ies]

High

1+,B

Won

get

al.(201

7)[onlyforthefamily

relation

ship

item

oftheQoL

-AD]

Low

2�,D

Psych

olog

ical

andbe

havioral

func

tion

ing

Moo

d:de

pres

sion

4Cap

otos

toet

al.(201

7)Med

ium

1+,B

4Apó

stoloet

al.(201

4)High

1+,B

Spe

ctor

etal.(200

1)High

1�,D

Coe

net

al.(201

1)Lo

w1�

,D

Stewartet

al.(201

7)Lo

w2�

,D

Pad

dick

etal.(201

7)High

2+,B

Yaman

akaet

al.(201

3)High

1+,B

Spe

ctor

etal.(200

3)Med

ium

1+,B

Moo

d:an

xiety

4Coe

net

al.(201

1)Lo

w1�

,D

Pad

dick

etal.(201

7)High

2+,B

Spe

ctor

etal.(200

1)High

1�,D

Spe

ctor

etal.(200

3)Med

ium

1+,B

Moo

d:so

cial-emotiona

llone

lines

s1

Cap

otos

toet

al.(201

7)Med

ium

1+,B

Beh

avior

2Agu

irre

etal.(201

3)Med

ium

1+,B

4Cap

otos

toet

al.(201

7)Med

ium

1+,B

Pad

dick

etal.(201

7)[onlyforse

verity

ofde

pres

sive

symptom

s,nigh

ttim

edisturba

nce,

chan

gesin

appe

tite

ofNPI]

High

2+,B

Coe

net

al.(201

1)Lo

w1�

,D

Spe

ctor

etal.(200

1)High

1�,D

Spe

ctor

etal.(200

3)Med

ium

1+,B

Everyda

ylifefunc

tion

ing

5Agu

irre

etal.(201

3)Med

ium

1+,B

Cap

otos

toet

al.(201

7)Med

ium

1+,B

Coe

net

al.(201

1)Lo

w1�

,D

Spe

ctor

etal.(200

1)High

1�,D

Spe

ctor

etal.(200

3)Med

ium

1+,B

Com

mun

ication

1Spe

ctor

etal.(200

3)Med

ium

1+,B

1Spe

ctor

etal.(200

1)High

1�,D

(Con

tinu

edon

next

page

)



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Four studies examined whether CST could lead to gainsin specific cognitive domains (Capotosto et al., 2017; Hallet al., 2013; Paddick et al., 2017; Spector et al., 2010, whichfurther examined the results by Spector et al., 2003). InPaddick et al. (2017) – a high-quality study (level of evi-dence 2+, grade of recommendation B) – and in Spectoret al. (2010) – a medium-quality study (level of evidence1+, grade of recommendation B) – the focus was on theADAS-Cog subscales, and benefits were found for the “spo-ken language” subscale. Spector et al. (2010) also foundimprovements in the “commands” subscale, while Paddicket al. (2017) found them in the praxis and memory sub-scales. As for the other two studies (see Table 2 fordetails), one by Hall et al. (2013) was a low-quality study(level of evidence 2�, grade of recommendation D) thatfound improvements in language comprehension and pro-duction, verbal and visual short-term memory, and orienta-tion, but not in executive functioning, attention or praxis,and the other by Capotosto et al. (2017) was a medium-quality study (level of evidence 1+, grade of recommenda-tion B) that found benefits in language comprehensionand production, but not in short-term memory (seeTable 3).

Secondary OutcomesQuality of life. Of the nine studies that measured the qualityof life perceived by the participants with dementia, fourstudies (Aguirre et al., 2013; Capotosto et al., 2017; Coenet al., 2011; Spector et al., 2003) found significant improve-ments in this domain. One was a low-quality study (level ofevidence 1�, grade of recommendation D) by Coen et al.(2011), while the other three were rated as medium-quality(level of evidence 1+, grade of recommendation B) (seeTable 3).

The high-quality study by Paddick et al. (2017) (level ofevidence 2+, grade of recommendation B) found benefitsin the physical health domain, but not in the psychological,social, and environmental aspects of quality of life. The low-quality study by Wong et al. (2017) (level of evidence 2�,grade of recommendation D) only found benefits in thefamily relationship domain, not in the overall quality oflife score (see Table 3). Three studies found no improve-ments in perceived quality of life, including two high-qualitystudies, one by Cove et al. (2014) (level of evidence 1�,grade of recommendation D), and one by Yamanakaet al. (2013) (level of evidence 1+, grade of recommenda-tion B); and one low-quality study by Stewart et al.(2017) (level of evidence 2�, grade of recommendationD). Yamanaka et al. (2013) did find improvements in care-givers’ ratings of quality of life in people with dementia,though these improvements depended on the measureconsidered.

Table3.

(Con

tinu

ed)

Significa

ntresu

lts

Non

sign

ifican

tresu

lts

No.

ofstud

ies

Study

Qua

lityrating

No.

ofstud

ies

Study

Qua

lityrating

Careg

iver

outcom

es

Gen

eral

health

status

1Spe

ctor

etal.(200

1)High

1�,D

Qua

lityof

life

1Pad

dick

etal.(201

7)High

2+,B

Qua

lityof

therelation

ship

1Coveet

al.(201

4)High

1�,D

Careg

iver

burden

2Pad

dick

etal.(201

7)Spe

ctor

etal.(200

1)High

High

2+,B

1�,D

Moo

d:de

pres

sion

1Pad

dick

etal.(201

7)High

2+,B

Moo

d:an

xiety

1Pad

dick

etal.(201

7)High

2+,B

Note.

ADAS-C

og=

Alzhe

imer’s

Disea

seAss

essm

entSca

le-C

ognition

;NPI=

Neu

rops

ychiatricInventory;

QoL

-AD

=Qua

lityof

Life-A

lzhe

imer’s

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Psychological and behavioral functioning. Eight studiesmeasured mood (i.e., depression, anxiety, social and emo-tional loneliness) in people with dementia (see Table 3).Four found a significant reduction in depressive symptomsafter CST: two were medium-to-high-quality (level of evi-dence 1+, grade of recommendation B); one was high-qual-ity (level of evidence 1�, grade of recommendation D); onewas low-quality (level of evidence 2�, grade of recommen-dation D) (see Table 3). The other four studies found nosuch improvement, including two rated as medium-to-high-quality (level of evidence 1+, grade of recommenda-tion B); one rated as low-quality (level of evidence 1�,grade of recommendation D); and one rated as high-quality(level of evidence 2+, grade of recommendation B) (seeTable 3).

Four studies (Coen et al., 2011; Paddick et al., 2017; Spec-tor et al., 2001, 2003) measured anxiety, and none foundCST effective in reducing this symptom. The first two ofthese studies were one of low-quality and one of high-qual-ity, respectively (both with a level of evidence 1�, grade ofrecommendation D); the one by Spector et al. (2003) was amedium-quality study (level of evidence 1+, grade of rec-ommendation B); and the one by Paddick et al. (2017)was a high-quality study (level of evidence 2+, grade of rec-ommendation B) (see Table 3).

Only the medium-quality study by Capotosto et al.(2017) (level of evidence 1+, grade of recommendation B)included a self-reported measure of social and emotionalloneliness and found that participants reported less per-ceived social and emotional loneliness after the CST (seeTable 3).

Six of the 12 studies included behavioral symptomsamong the outcome measures, but only Aguirre et al.(2013) and Paddick et al. (2017) found CST effective inreducing behavioral disorders in participants with dementiaimmediately after completing the intervention. The formerof these two studies was of medium-quality (level of evi-dence 1+, grade of recommendation B), and the latterwas of high-quality (level of evidence 2+, grade of recom-mendation B). Of the other four that found no improve-ments in behavioral symptoms, two – Capotosto et al.(2017) and Spector et al. (2003) – were medium-qualitystudies (level of evidence 1+, grade of recommendationB); Coen et al. (2011) was low-quality; and Spector et al.(2001) was high-quality (both with a level of evidence 1�,grade of recommendation D) (see Table 3).

Everyday life functioning.None of the five studies (Aguirreet al., 2013; Capotosto et al., 2017; Coen et al., 2011; Spectoret al., 2001, 2003) that included measures of everyday lifefunctioning found any improvement in this domain. Thesestudies included one of low-quality (Coen et al., 2011) andone of high-quality (Spector et al., 2001), both with a levelof evidence 1�, grade of recommendation D, and three

medium-quality studies (level of evidence 1+, grade of rec-ommendation B) (see Table 3).

Communication skills. Of the two studies that measuredcommunication skills, the medium-quality one by Spectoret al. (2003) (level of evidence 1+, grade of recommenda-tion B) reported an improvement, albeit with only a trendtoward significance, while the high-quality study by Spectoret al. (2001) (level of evidence 1�, grade of recommenda-tion D) found no such benefit (see Table 3).

CaregiversOf the three studies that involved caregivers, the high-qual-ity study by Spector et al. (2001) (level of evidence 1�,grade of recommendation D) found improvements in theirgeneral health status (albeit with only a trend toward signif-icance), but not a reduction of their burden of care. Paddicket al. (2017) conducted a high-quality study (level of evi-dence 2+, grade of recommendation B) and found benefitsin caregivers’ anxiety symptoms, but not in their quality oflife or symptoms of depression, nor any significant reduc-tion in caregivers’ burden. The high-quality study by Coveet al. (2014) (level of evidence 1�, grade of recommenda-tion D) found no improvements in the quality of the rela-tionship between the caregiver and the person withdementia.

Discussion

Summary of Findings

The aim of the present review was to assess the quality ofall the studies published to date on the effectiveness ofone of the most often used and evidence-based programsof cognitive stimulation: the CST protocol devised by Spec-tor et al. (2003, 2006). Judging from the quality rating ofthe studies reviewed, there is moderate evidence for theCST being effective in improving general cognitive func-tioning, and a specific cognitive domain: language. Thebenefits in language seem to be due to the nature of theactivities and to the general structure of the CST sessions.Participants are involved in several activities (e.g., wordassociations, object categorization, and word games)designed to stimulate their verbal skills, and broadly toencourage them to express themselves verbally, interactwith the other group members (and the facilitator), and findways to use language creatively (Spector et al., 2003, 2010).These specific features of the CST seem to sustain their lan-guage comprehension and production abilities (Capotostoet al., 2017; Hall et al., 2013). This result is in line withthe findings from psychosocial interventions, which haverevealed no major impact on cognition (see McDermott



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et al., 2018) due to the degenerative nature of dementia. Itis worth adding though, that – just because of the degener-ative nature of such a disease – even no change in cognitiveperformance after the intervention (i.e., no further deterio-ration 2 months after the pretest assessment) should beseen as important, as it suggests that the intervention sus-tains cognitive functioning and helps to contrast the individ-ual’s cognitive decline.

A moderate level of evidence was also found for studiesthat identified a gain in the quality of life of people withdementia, in line with the findings of previous reviews oncognitive stimulation programs (see McDermott et al.,2018).

The evidence was weaker for the effectiveness of CST inimproving other specific cognitive domains (i.e., memory,praxis, and orientation), behavioral and psychological func-tioning (i.e., depression, emotional and social loneliness), orcommunication skills in people with dementia. The CSTseemed to have no impact on measures of everyday lifefunctioning or anxiety symptoms, in line with Woodset al. (2012). These results should be considered withcaution, however, as they might be due to the studies inves-tigating more specific cognitive domains being underpow-ered and to their use of different measures, as discussedbelow. Further studies are needed and should use the samemeasures more systematically.

As for caregivers, there was only limited evidence of CSTbenefiting their general health and anxiety symptoms. Thiswould mean that more “direct” interventions are needed tosustain caregivers in terms of their cognitive and everydaylife functioning (e.g., Sörensen, Pinquart, & Duberstein,2002).

Limitations

Despite the novelty of the present review, it suffers fromthe limitation of having included only 12 studies (compris-ing only 8 RCTs and with three pretest–posttest studies thatdid not include a control condition). The fact that some ofthe studies only reported changes in general functioningscores made it difficult to thoroughly appraise the strengthof CST effect on specific cognitive domains. There is also alack of evidence of CST being effective for caregivers, sinceonly three studies explored this aspect, and the use of dif-ferent measures led to inconsistent results.

The small number of studies reviewed and the variety ofmeasures used to assess the benefits of CST may be amongthe reasons for the moderate and low evidence of the CSTprogram’s efficacy. These factors also prevented us fromattempting any meta-analysis to ascertain the dimensionof the gains for the CST group. It is worth mentioning that,although all the studies that we reviewed had adopted strictinclusion/exclusion criteria, the samples involved were

heterogeneous in terms of severity, duration, and etiologyof dementia. The different influence on the efficacy ofCST of these and other individual characteristics of peoplewith dementia remains to be ascertained (but see Piraset al., 2017).

In addition, although our quality assessment was per-formed following internationally adopted criteria, it wasrather broad and did not investigate such factors as poten-tial sampling and selection biases. Moreover, bearing inmind that double blinding cannot be done in rehabilitativetrials, and that this was one

the efficacy of cognitive stimulation therapy (cst) for people...

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