The Efficacy of Cognitive Stimulation Therapy (CST) For People With Mild-to-Moderate Dementia: A Review

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The Efﬁcacy of Cognitive Stimulation Therapy (CST) for People With Mild-to-
Moderate Dementia: A Review
Article in European Psychologist · November 2018

DOI: 10.1027/1016-9040/a000342
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${protocol}://econtent.hogrefe.com/doi/pdf/10.1027/1016-9040/a000342 - Erika Borella <erika.borella@unipd.it> - Tuesday, November 20, 2018 5:21:52 AM - Università degli Studi di Padova IP Address:147.162.126.240
Original Articles and Reviews
The Efficacy of Cognitive Stimulation

Therapy (CST) for People With
Mild-to-Moderate Dementia
A Review
Alessandra Lobbia,1 Elena Carbone,1 Silvia Faggian,2 Simona Gardini,3 Federica Piras,4
Aimee Spector,5 and Erika Borella1
1
Department of General Psychology, University of Padova, Italy
2
Centro Servizi Anni Sereni, Scorzè (VE), Italy
3
Department of Medicine, University of Parma, Italy
4
Department of Clinical and Behavioral Neurology, Neuropsychiatry Laboratory, IRCCS Santa Lucia Foundation, Rome, Italy
5
Research 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 evidence
obtained 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 qualitative
analysis 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 cognitive
functioning, 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 their
caregivers’ health status and anxiety symptoms. Albeit with the limited quality of reviewed evidence, and the need for more studies on CST, the
present review highlights the value of this program as part of dementia care services to sustain the cognitive functioning and quality of life of
people with dementia.
Keywords: dementia, Cognitive Stimulation Therapy, cognitive functioning, quality of life
Dementia is the most prevalent cognitive degenerative dis- produced questionable results to date (e.g., Galimberti &
ease in the aging population and considered one of the Scarpini, 2012), so interest in psychosocial approaches to
greatest global public health challenges (WHO, 2012). dementia has increased considerably in recent years. Vari-
Dementia can have various etiological factors, but Alzhei- ous programs (e.g., cognitive, multi-strategy, behavioral,
mer’s disease is considered the primary cause, accounting and environmental interventions) have been suggested for
for around 60% of all cases (Thies & Bleiler, 2011). Given people with dementia, and those based on cognitive stimu-
that the costs of care for dementia will be $1 trillion by lation seem the most effective (e.g., Cooper et al., 2012).
2018, and $2 trillion by 2030 (Alzheimer’s Disease Interna- Cognitive stimulation programs, generally implemented
tional, 2015), it is imperative for the neuroscientific in groups, aim to improve the cognitive and social function-
approach to dementia care to implement evidence-based, ing of individuals with dementia, and consequently their
effective interventions to manage the cognitive and behav- quality of life, by providing a stimulating environment that
ioral symptoms of dementia, and improve the quality of life prompts individual engagement in a range of activities and
for people with dementia and their carers. discussions (Woods, Aguirre, Spector, & Orrell, 2012). A
Treatment options for dementia include pharmacological systematic review (Woods et al., 2012) of studies on pro-
therapies and psychosocial interventions (or non-pharma- grams based on reality orientation and cognitive stimula-
cological treatments). Pharmacological therapies have tion confirmed the benefits of the latter in various areas.
Ó 2018 Hogrefe Publishing European Psychologist (2018)

https://doi.org/10.1027/1016-9040/a000342
2 A. Lobbia et al., Efficacy of Cognitive Stimulation Therapy
In particular, while mood, behavioral functioning, or every- Since CST is becoming increasingly popular, the aim of
day life functioning did not change, the general cognitive the present review was specifically to examine the reliability
functioning of people with dementia as well as their quality of the findings and the strength of the evidence obtained in
of life and well-being clearly improved, based on staff studies on the CST protocol in terms of cognitive function-
ratings of participants’ communication skills and social ing, perceived quality of life, psychological, behavioral, and
interaction abilities (Woods et al., 2012). A recent synthesis everyday life functioning for people with dementia; per-
of 22 systematic reviews, covering 197 studies on a huge ceived health status, quality of life, and burden of care for
variety of psychosocial interventions, also highlighted that family caregivers after their relatives attended the rehabili-
group cognitive stimulation improved cognitive functioning, tative protocol were also taken into consideration.
social interaction, and quality of life for people with demen- To this main aim we considered the soundness of the
tia (McDermott et al., 2018). However, these findings were included papers’ experimental design (randomization,
based on different stimulation programs and protocols, and blinding, details of number of participants, and dropouts)
the procedures varied in terms of content, frequency, dura- based on standardized rating criteria, that is, the Jadad
tion, format, delivery mode, and number of sessions. Scale (Jadad et al., 1996) and the Stroke Prevention and
An exception among the cognitive intervention protocols Educational Awareness Diffusion (SPREAD) method (Iniz-
is the “Cognitive Stimulation Therapy” program (CST, itari & Carlucci, 2006).
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 Method
(Spector et al., 2003). Its published and readily available
standardized protocol has enabled the CST to become the Criteria for Inclusion of Studies in This
only program widely used in various countries and across Review
different cultures (in Italy, China, etc.) for the cognitive
stimulation of people with mild-to-moderate dementia The review focused on CST studies conducted with a quan-
(Aguirre, Spector, & Orrell, 2014). titative design, for which adequate information was pro-
The CST protocol consists of 14 twice-weekly themed vided or could be obtained from the authors of the study.
and structured group sessions lasting about 45 min each. The literature search was limited to studies published in
The activities are based on the features of psychosocial English in peer-reviewed journals from 2001 – that is, after
interventions proving effective in previous studies and the pilot study by Spector, Orrell, Davies, and Woods
reviews. The CST incorporates elements of reality orienta- (2001) – to 2017 that (i) adopted the original CST program,
tion (RO; Taulbee & Folsom, 1966), such as the use of or adapted the materials of the original protocol to different
whiteboards for temporal orientation, but overcomes some cultural backgrounds; (ii) involved participants diagnosed
of the limits of this approach (see Woods et al., 2012). It with mild-to-moderate dementia according to the Diagnos-
also includes aspects of reminiscence therapy, multisensory tic and Statistical Manual of Mental Disorders (DSM) –
stimulation, and implicit learning principles. Innovatively, Fourth or Fifth edition – criteria, and further classified as
the CST protocol adopts the principles of the person-cen- cases of Alzheimer’s disease, vascular dementia, mixed Alz-
tered care approach as its frame of reference, focusing on heimer’s and vascular dementia, or other types of demen-
the “personhood” of people with dementia (see Kitwood, tia, who attended the intervention in various settings (e.g.,
1997). During CST, people are involved in activities that at home, in day care, in nursing homes); (iii) possibly
place the emphasis on their emotional, relational, and social involved family caregivers too, either directly or by collect-
skills (Woods et al., 2012), and a respectful and sensitive ing data on the person–caregiver relationship.
approach to the individual is essential for the success of this The outcome measures (CST outcomes) were analyzed
intervention. separately for people with dementia and their family care-
The aim of combining a cognition-based approach with givers. For the former, since CST is supposed to act on cog-
psychosocial and relational features is to stimulate cogni- nitive functioning and also more generally, on quality of life
tion, and particularly language and executive functioning, the outcome measures were classified as primary and sec-
spatial and temporal orientation, reminiscence, and the ondary, depending on the aspect considered: those assess-
retrieval of personal information, but also to determine a ing improvements in general cognitive functioning and
broader impact on dementia-related symptoms (e.g., behav- specific cognitive domains (memory, executive functioning,
ioral disorders, depression, impaired communication) and language, attention, as detailed below) were primary
thus on the overall quality of life and well-being of people outcome measures; those pertaining to quality of life,
with dementia. behavioral and psychological functioning, everyday life
European Psychologist (2018) Ó 2018 Hogrefe Publishing

A. Lobbia et al., Efficacy of Cognitive Stimulation Therapy 3
functioning, and communication skills were secondary out- (d) 2+ for good-quality cohort studies with small CIs and/
come measures (see below). For the family caregivers, any or highly significant results.
change in measures of health status, quality of life, and bur-
den of care were considered as outcomes (see below). A study with large CIs and/or scarcely significant results
was classified with a minus ( ) sign. The related strength
of evidence (grade of recommendation) was rated as
Search Strategy follows:
(a) grade B for studies with levels of evidence 1++ or 1+;
The following databases were searched systematically: Web
(b) grade C for studies with levels of evidence 2++ or 2+;
of Science, PubMed, Psychology and Behavioral Science,
(c) grade D for studies with level of evidence 2+, or stud-
PsycINFO (Ovid), SCOPUS, SocINDEX with Full Text
ies classified with a minus ( ) sign, regardless of the
(EBSCO). Literature search was limited to studies published
level of evidence.
in English in peer-reviewed journals from 2001 to 2017.
Terms describing the target sample (i.e., Alzheimer’s dis-
The final ratings were reached by consensus between the
ease, dementia, people with dementia) were combined (us-
three judges.
ing the Boolean term “AND” to get more hits) with terms
defining the type of treatment (i.e., non-pharmacological
therapy, Cognitive Stimulation Therapy, CST, psychosocial
intervention) and sought in the full-text field. Titles and Results
abstracts were checked to ascertain whether each study
met our inclusion criteria. Reference lists, especially of pre- A total of 238 records were initially identified, but after
vious reviews on non-pharmacological interventions for reviewing the titles and abstracts, 197 were excluded
dementia, were also reviewed to identify additional publica- because they were duplicates, not in English, or unrelated
tions. The literature search was run from November 2015 to to the topic of our review. Of the 41 records included in
March 2017 to include all studies adopting the CST pro- the analysis of the full texts, the review considered 14 stud-
gram and meeting the inclusion criteria. ies published from July 2001 to March 2017, comprising 10
RCTs and four pretest–posttest studies (see Figure 1 for
details). Three of the 10 RCTs (Spector, Orrell, & Woods,
Evaluation Process 2010; Spector et al., 2003; Woods, Thorgrimsen, Spector,
Royan, & Orrell, 2006) examined different aspects of the
Three judges independently rated the quality of the
efficacy of CST in the same sample as Spector et al.
selected studies, describing them in tabular form, and con-
(2003) and were consequently considered as a single study.
sidering the following different key aspects: design and pro-
Thus, 12 studies were examined, 8 RCTs and 4 pretest–
cedure; characteristics of the sample, and activities of the
posttest studies. Table 1 summarizes the design, sample
control group; inclusion/exclusion criteria; outcome mea-
and setting, outcomes measures, results, and quality ratings
sures considered; and outcomes of the intervention.
of these studies.
The overall methodological quality of each study was
examined using the Jadad Scale (Jadad et al., 1996), which
allows researchers to monitor the likelihood of bias in Description of the Studies Reviewed
research reports by awarding up to 5 points, based on
whether the study was randomized and/or blinded, and Experimental Design
whether details were provided regarding the randomization Apart from Aguirre et al. (2013) and Spector et al. (2001),
and double blinding methods, and dropouts. A study was the other six RCTs were single-blind studies, and three of
“high-quality” if it scored from 3 to 5, “medium-quality” them were multicenter studies (see Table 1). Of the four
if it scored 2, and “low-quality” if it scored 0 or 1. pretest–posttest studies, only Paddick et al. (2017) included
The level of evidence derived from each study was clas- a control group (see Table 1).
sified using the SPREAD method (Inizitari & Carlucci,
2006) as follows: Sample
(a) 1++ for high-quality individual RCTs with small confi- The participants with dementia were enrolled at residential
dence intervals (CIs) and highly significant results; care homes, nursing homes, day centers, hospitals, or
(b) 1+ for good-quality individual RCTs with small CIs and dementia care services, except for three studies that also
highly significant results; included at least some people with dementia who were liv-
(c) 2++ for high-quality cohort studies with small CIs and/ ing at home (Cove et al., 2014; Paddick et al., 2017; Spector
or highly significant results; et al., 2001).

Identification
Records identified through database Additional records identified

searching through reference list
(n = 234) (n = 4)
Records screened
(n = 238)
Screening
Records removed because they were duplicates, not

published in English, or unrelated to the topic
(n = 197)
Full-text articles assessed Full-text articles excluded:

Eligibility
for eligibility - not CST protocol by Spector

(n = 41) 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)*
Included
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 were
consequently considered as a single study. Thus, 12 studies were examined in all.
The inclusion/exclusion criteria adopted generally and 25 on the Montreal Cognitive Assessment (Nasreddine
reflected those of Spector et al. (2003, 2006). The inclusion et al., 2005), indicating a mild-to-moderate cognitive
criteria were thus (a) a diagnosis of dementia of any sub- impairment. The exclusion criteria were (c) inability to
type according to the fourth edition of the Diagnostic and understand and communicate adequately; (d) sensory abil-
Statistical Manual of Mental Disorders (DSM-IV); (b) a ities inadequate to participate in group activities and make
score of 10 or more on the Mini-Mental State Examination use of most of the material in the program; (e) neurodevel-
(Folstein, Folstein, & McHugh, 1975), or a score between 10 opmental disorders, premorbid intellectual disabilities,

Table 1. Description of the 12 studies on the CST protocol by Spector et al. (2006). For each study, the Jadad Scale and the SPREAD quality ratings are given in the last column
Authors Experimental design Sample Outcomes of intervention for the CST group Quality rating and comments
Randomized controlled trials
1. Spector RCT 35 PWD Improvements in: general cognition (ADAS-Cog; MMSE); JADAD
et al. Pilot study CST group: n = 21 depressive and anxiety symptoms (Cornell Scale; RAID). High (3/5)
(2001) CST treatment group versus Control group^: n = 14 Severity of dementia (CDR) increased for controls. SPREAD
control group Dropout: n = 8 Marginal decline in Behavior (CAPE-BRS) and commu- Level of evidence: 1
Carers: n = 10 nication (Holden Scale) in both the CST and control Grade of recommendation: D
Ó 2018 Hogrefe Publishing

Mean age: 85.7 years groups-. Pos: described as randomized, description of the
(SD = 6.7). FC method of randomization included, description of drop-
Dementia diagnosis sub- Improvement in carers’ general psychological distress outs included.
type: not specified. (GHQ-12). Neg*: Small sample size, assessors not blinded.
Living situation: at home Caregivers’ stress (RS) increased slightly in the CST
(12); in residential home group and more substantially for controls.
(23).
Setting:
3 residential homes; 1 day
care center.
2. Spector RCT 201 PWD Improvements in: general cognition (MMSE; ADAS-Cog), JADAD
A. Lobbia et al., Efficacy of Cognitive Stimulation Therapy
et al. Multicenter CST group: n = 115 quality of life (QoL-AD), communication (Holden Scale – Medium (2/5)
(2003) Single blind Control group^: n = 86 trend toward significance). SPREAD
CST treatment group versus Dropout: n = 34 No sig. improvements in functional ability (CAPE–BRS), Level of evidence: 1+
control group Mean age: 85.3 years anxiety (RAID), or depression (Cornell Scale). Grade of recommendation: B
(SD = 7.0). Pos: described as randomized, good description of the
Female: 158 method of randomization, blind assessor, intention-to-
Male: 43 treat analysis used, number needed to treat calculated.
Dementia diagnosis sub- Neg*: no description of withdrawals and dropouts.
type: not specified.
Setting:
18 residential homes;
5 day care centers.
3. Woods See Spector et al. (2003) See Spector et al. (2003) Sig. correlations between improvement in quality of life See Spector et al. (2003)
et al. (QoL-AD) and: improvement in general cognition (MMSE; Pos: described as randomized, good description of the
(2006) ADAS-Cog); reduction of depression symptoms (Cornell method of randomization, blind assessor.
Scale); improvement in communication abilities (Holden Neg*: no description of withdrawals and dropouts.
Scale)-improved-(only for the sample as a whole).
Sig. improvements in quality of life (QoL-AD) mediated by
improvement in general cognition (MMSE, ADAS-Cog).
4. Spector See Spector et al. (2003) See Spector et al. (2003) Improvements in: the total ADAS-Cog score; the See Spector et al. (2003)
et al. commands and spoken language subscales of the Pos: described as randomized, good description of
(2010) ADAS-Cog. method of randomization, blind assessor.
Neg*: no description of withdrawals and dropouts.
(Continued on next page)
European Psychologist (2018)

5
Table 1. (Continued)
5. Coen et al. RCT 27 PWD Improvements in: general cognition (MMSE). JADAD
(2011) Single blind CST group: n = 14 Qualitative ratings: average scores on communication, Low (1/5)
CST treatment group versus Control group^: n = 13 enjoyment, and mood of participants improved between SPREAD

control group Dropout: not specified. the first and last sessions. CST participants demon- Level of evidence: 1
Mean age of CST group: strated good interaction and enthusiasm. Grade of recommendation: D
78.4 years (SD = 5.0). Pos: described as randomized,blind assessor, included
Mean age of control group: observational measures.
81.3 years (SD = 6.2). Neg*: no details provided of randomization method, no
Female: 14 description of withdrawals and dropouts, small sample
Male: 13 size.
Dementia severity: mild to
moderate.
Dementia diagnosis sub-
Setting:
2 long-term care facilities;
1 private nursing home.
6. Aguirre RCT 272 PWD Improvement in: general cognition (MMSE; ADAS-Cog). JADAD
et al. CST treatment group versus Dropout: n = 36 No sig. improvement in: quality of life (QoL-AD). Medium (2/5)
(2013) control group Mean age: 82.6 years (Benefits of CST were independent of the use of AChEIs). SPREAD
(SD = 8.1). Level of evidence: 1+
Female: 177 Grade of recommendation: B
Male: 95 Pos: described as randomized, description of with-
Control group^: Spector drawals and dropouts included.
study control group (see Neg*: no details provided on randomization method for
Spector et al., 2003) – but CST groups within each center, assessors not blinded.
only for three measures.
type: Alzheimer’s disease
(n = 93); vascular dementia
(n = 68); other (Lewy body
dementia, mixed type
dementia, Korsakov’s dis-
ease) (n = 23); unspecified
dementia (n = 88).
Setting:
9 residential homes;
9 community mental health.

7. Yamanaka RCT 56 PWD Improvements in: general cognition (COGNISTAT; MMSE); JADAD
et al. Single blind CST group: n = 26 mood (Face Scale) (both self-reported ratings and proxy High (3/5)
(2013) CST treatment group versus Control group^: n = 30 ratings); quality of life (EQ-5D) rated by proxies. SPREAD
control group Dropout: n = 9 No sig. improvements in: quality of life (QoL-AD; EQ-5D) Level of evidence: 1+
Mean age: 83.91 years rated by participants themselves. Grade of recommendation: B

(SD = 5.98). Trend toward an improvement in: quality of life (QoL-AD) Pos: described as randomized, description of method of
Female: 44 rated by proxies. randomization included, good description of withdrawals
Male: 12 and dropouts, blind assessor, intention-to-treat model
Dementia diagnosis sub- used.
type: not specified. Neg*: therapist and care workers who rated the QOL and
Setting: mood of PWD were not blinded, statistical power not
3 residential homes; examined.
1 nursing home in the Tokyo
metropolitan area.
8. Cove et al. RCT 68 PWD No sig. improvements in: general cognition (MMSE; JADAD
(2014) Single-blind CST plus carer training ADAS-Cog); quality of life (QoL-AD); Quality of Caregiver High (3/5)
CST plus carer training ver- group: n = 21 and Patient Relationship (QCPR). SPREAD
sus CST only versus control CST only group: n = 24 Level of evidence: 1
group Waiting list control group: Grade of recommendation: D
n = 23 Pos: described as randomized,description of method of
Dropout: n = 18 randomization included, good description of withdrawals
Carers: n = 21 and dropouts, blind assessor, three-group design.
Mean age of CST plus carer Neg*: no monitoring of treatment fidelity, relatively small
training group: sample size.
75.4 years (SD = 5.56).
Mean age of CST group:
76.8 years (SD = 6.62).
Mean age of control group:
77.8 years (SD = 7.47).
Female: 32
Male: 36
type: Alzheimer’s dementia
– early onset
(n = 1), late onset
(n = 36), atypical/mixed
(n = 9); vascular dementia
(n = 4); subcortical vascular
dementia (n = 5); dementia
in Parkinson’s disease
(n = 5); unspecified demen-
tia (n = 7).
Living situation:
63 private accommodations;
1 sheltered housing;

7
4 supported living.

9. Apóstolo RCT 56 PWD Improvements in: general cognition (MoCA). JADAD
et al. Multicenter CST group: n = 27 No sig. decrease in the depressive symptoms (GDS-15). High (3/5)
(2014) Single blind Control group^: n = 29 SPREAD
CST treatment group versus Dropout: n = 8 Level of evidence: 1+
control group Mean age: 81.65 years Grade of recommendation: B
(SD = 5.64). Pos: described as randomized,description of method of
Female: 33 randomization included, good description of withdrawals
Male: 15 and dropouts, blind assessor.
Dementia diagnosis sub- Neg*: no intention-to-treat analysis.
Setting:
Portuguese nursing homes
(NHs).
10. Capotosto RCT 39 PWD Improvements in: general cognition (ADAS-Cog); mood JADAD
et al. Multicenter CST group: n = 20 (Cornell Scale, Social and Emotional Loneliness Scale – Medium (2/5)
(2017) Single blind Control group^: n = 19 with a decrease in reported loneliness); quality of life SPREAD
CST treatment group versus Dropout: n = 5 (QoL-AD). Level of evidence: 1+
control group Mean age of CST group: CST group maintained the MMSE score at posttest, while Grade of recommendation: B
88.25 years (SD = 5.15). control group displayed deterioration. Pos: described as randomized, description of with-
Mean age of control group: No sig. improvements in: short-term memory (Backward drawals and dropouts included, blind assessor, active
86.52 years (SD = 5.55). Digit Span), behavior (NPI), everyday functioning (DAD). control group used.
Female: 27 Neg*: no description of the method of randomization,
Male: 12 small sample size.
Setting:
2 residential homes.

Pre–post studies
11. Hall et al. Pretest–posttest design 41 PWD Improvements in orientation (WMS-III Information and JADAD
(2013) CST treatment group Dropout: n = 7 Orientation test); memory (immediate and delayed the- Low (1/5)
(no control group) matic recall variable of the WMS-III Logical Memory test; SPREAD
Mean age: 80.3 years delayed recall variable of the WMS-III Visual Reproduc- Level of evidence: 2

(SD = 8.8). tion test); language comprehension (Token Test); Grade of recommendation: D
Female: 20 No sig. improvements in general cognition (MMSE); Pos: description of withdrawals and dropouts included.
Male: 14 memory (immediate recall or recognition variables of the Neg*: No planned control group, no randomization, no
Dementia diagnosis sub- WMS-III Visual Reproduction test); attention (TMT-A); control for the use of antidementia medication.
type: not specified (n = 12); language expression (BNT-2; verbal fluency – D-KEFS);
Alzheimer’s disease (n = 8); executive functions (D-KEFS verbal fluency switching
Vascular dementia (n = 7); task; TMT-B); praxis (“copy” component of the WMS-III
Mixed dementia (n = 5); Visual Reproduction test); working memory (WAIS-III
frontotemporal dementia Digit Span subtest – trends toward sig.).
(n = 1);
Dementia with Lewy bodies
(n = 1).
Setting:
2 National Health Service
(NHS) memory clinics;
3 NHS day hospitals;
3 local authority day
centers.
12. Paddick Stepped wedge design/ 34 PWD Improvements in general cognition (ADAS-Cog); specific JADAD
et al. pretest–posttest design CST group: n = 16 cognitive domains of language, memory, praxis (ADAS- High (3/5)
(2017) Single blind Waiting list control group: Cog subscales); quality of life (but only in the physical SPREAD
CST treatment group versus n = 18 health domain of the WHOQOL-BREF); behavioral Level of evidence: 2+
control group Dropouts = none symptoms (only NPI severity of depressive symptoms, Grade of recommendation: B
Carers: unspecified nighttime disturbance, changes in appetite as rated by Pos: described as randomized, description of method of
Mean age: 80.00 years primary carers); anxiety symptoms for primary carers randomization included, description of withdrawals and
(IQR = 76.5–85.3). (HAD) dropouts included, blind assessors, number needed to
Female: 29 No sig. improvements in psychological, social, and treat calculated.
Male: 5 environmental aspects of quality of life (WHOQOL-BREF Neg*: generally low levels of education.
Dementia diagnosis subscales); anxiety and depression (HAD) for PWD, and
subtype: quality of life (WHOQOL-BREF), caregiver burden (Zarit
Alzheimer’s disease (n = 16); Burden Inventory) and depression (HAD) for primary
Vascular dementia (n = 10); carers.
Parkinson’s disease
dementia (n = 2);
Possible Lewy bodies
dementia (n = 2);
Mixed (n = 4).
Setting:
Community buildings in 6
rural villages of the Hai dis-

9
trict of Kilimanjaro region in

northern Tanzania.
10
13. Stewart Pretest–posttest design 40 PWD Improvements in general cognition (SLUMS); depression JADAD
et al. CST treatment group Dropout = 2 (Cornell scale) Low (1/5)

(2017) (no control group) No sig. improvements in quality of life (QoL-AD). SPREAD
Mean age: 78.08 years Level of evidence: 2
(SD = 11.10). Grade of recommendation: D
Female: 24 Pos: description of withdrawals and dropouts included
Male: 16 Neg*: No planned control group, no randomization,no
Dementia diagnosis sub- control for the use of antidementia medication.
Setting: community and
long-term care community.
14. Wong Pretest–posttest design 30 PWD Improvements in quality of life (QoL-AD – but only in the JADAD
et al., Pilot study Dropout = 4 family relationship) Low (1/5)
2017 (no control group) No sig. improvements in general cognition (ADAS-Cog), SPREAD
Trained CST-HK facilitators: quality of life (total QoL-AD). Level of evidence: 2
n = 12 Grade of recommendation: D
Family caregivers: n = 13 Pos: description of withdrawals and dropouts included,
Mean age: 81.5 years number needed to treat calculated.
(SD = 5.9). Neg*: No planned control group, no randomization, small
Female: 22 sample size.
Male: 8
Setting:
Hospital dementia care
services in Hong Kong.
Notes. ^Care-as-usual control group. *The maximum score (5) requires double blinding and appropriate of double blinding method, but only single blinding is possible in psychological research, so studies in this
review could only be awarded a maximum score of 3.
AChEIs = Acetylcholinesterase inhibitors; ADAS-Cog = Alzheimer’s Disease Assessment Scale-Cognition; ADL = Activities of daily living; BNT-2 = Boston Naming test-2; CAPE-BRS = Clifton Assessment
Procedures For the Elderly-Behavior Rating Scale; CDR = Clinical Dementia Rating Scale (Hughes, Berg, Danziger, Coben, & Martin, 1982); COGNISTAT = Neurobehavioral Cognitive Status Examination; Cornell
Scale = Cornel scale of Depression in Dementia; CST = Cognitive Stimulation Therapy; CST-HK = Cognitive Stimulation Therapy Hong Kong; DAD = Disability Assessment for Dementia; D-KEFS = Delis–Kaplan
Executive function system; EQ-5D = health-related quality of life; FC = Family caregivers; GDS-15 = Geriatric Depression Scale-15; GHQ-12 = General Health Questionnaire-12; HAD = Hospital Anxiety and
Depression Scale; Holden Scale = Holden Communication Scale; IQR = interquartile range; JADAD = Jadad Scale; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment;
Neg = negative points; NPI = Neuropsychiatric Inventory; Pos = positive points; PWD = People with dementia; QCPR = Quality of Caregiver and Patient Relationship; QoL-AD = Quality of Life-Alzheimer’s Disease;
RAID = Rating Anxiety in Dementia; RCT = Randomized controlled trial; RS = Relatives’ Stress; SD = Standard Deviation; Sig. = significant; SLUMS = Saint Louis University Mental Status Exam; SPREAD = Stroke
Prevention and Educational Awareness Diffusion scale; TMT = Trail Making Test; WMS-III = Wechsler Memory Scale 3rd ed.; WHOQOL-BREF = Brief WHO Quality of Life.

and/or current physical illness/disability that might affect study (Wong, Yek, Zhang, Lum, & Spector, 2017), care-
participation.1 Four of the 12 studies also considered caregivers and facilitators were involved in focus groups and
givers, but only Cove et al. (2014) specified the criteria interviews to conduct qualitative assessments on the
for their eligibility (see Table 1). observed acceptance and response of the person with
The average age of participants was over 70 years in all dementia.
studies, over 80 in five, and over 85 in three (see Table 1 for
further details). Only four studies provided details of the
dementia subtypes of their samples (Aguirre et al., 2013;
Outcome Measures
Cove et al., 2014; Hall, Orrell, Stott, & Spector, 2013¸ Pad- All 12 studies assessed general cognitive functioning as the
dick et al., 2017) (see Table 1). primary outcome. Two studies ascertained the impact of
the CST by considering subscales of the cognitive function-
ing measure used (ADAS-Cog subscales). Two studies also
Procedure included other measures for assessing specific cognitive
domains, that is, language, memory, executive functioning
In all 12 studies, all participants attended individual assess-
and attention, praxis, and orientation (see Table 2).
ment sessions before and immediately after the interven-
As for the secondary outcomes, nine studies included
tion (i.e., pretest and posttest).
measures of quality of life, nine considered behavioral
and psychological functioning (depression, anxiety, social-
CST Treatment Groups
emotional loneliness, and behavioral disorders), five
The CST groups were conducted by various professionals
assessed everyday life functioning, and two examined com-
(clinical psychologists, graduate specialists in aging, occupa-
munication skills (see Table 2).
tional therapists, care workers, nurses, or researchers). Ele-
Three studies included outcome measures on family
ven studies adopted the standard protocol or adapted the
caregivers’ general health status and quality of life, the
protocol to the local culture, with 14 twice-weekly group
quality of their relationship with the individual with demen-
sessions (see Spector et al., 2006 for a detailed description
tia, the burden of care, and symptoms of depression and
of the CST program), while the CST sessions were sched-
anxiety (see Table 2).
uled once a week in one study (Cove et al., 2014).2
Control Groups
In seven of the eight RCTs and in Paddick et al. (2017), the CST Outcomes
CST treatment group was compared with an active control People With Dementia
group involved for the same number of sessions in the usual Primary Outcomes
activities organized at the centers, such as group games, Nine of the 12 studies (see Table 3) found that CST had a
music and singing, arts and crafts, and low-impact exercise. positive impact on the general cognitive functioning of
In one RCT (Cove et al., 2014), the control group was only the individuals with dementia. Of these nine studies, five
involved in the pre- and posttest sessions. Three pretest– were of medium-to-high-quality (level of evidence 1+, grade
posttest studies did not include a control group (see of recommendation B), one was low-quality (level of evi-
Table 1). dence 1 , grade of recommendation D), another was
high-quality (level of evidence 2+, grade of recommenda-
Caregivers tion B), and the other two were low-quality (level of evi-
In the three studies that involved caregivers, they attended dence 2 , grade of recommendation D). Of the three
two individual assessment sessions, before and immedi- studies that found no such improvement in general cogni-
ately after the intervention (see Table 1). In one study (Cove tive functioning, two were high-quality (level of evidence
et al., 2014), caregivers were asked to engage in similar 1 , grade of recommendation D), and one was low-quality
CST activities with their relative with dementia at home (level of evidence 2 , grade of recommendation D ) (see
(for a detailed description, see Cove et al., 2014). In another Table 3).
1
Other additional criteria, adopted only by some studies, were as follows: (i) absence of severe behavioral symptoms of dementia (Capotosto
et al., 2017; Coen et al., 2011; Paddick et al., 2017; Spector et al., 2001; Yamanaka et al., 2013); (ii) absence of severe psychological symptoms of
dementia (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 Clinical
Dementia Rating Scale (CDR; Aguirre et al., 2013; Capotosto et al., 2017; Hughes et al., 1982); (iv) English as the first language for
communicating 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.

12
Table 2. Primary and secondary outcome measures for people with dementia, and outcome measures for family caregivers involved in the nine studies reviewed.
Outcome measures No. of studies
Primary outcomes – people with dementia
General cognitive functioning MMSE; ADAS-Cog (Rosen et al., 1984); COGNISTAT (Northern California Neurobehavioral Group, 1995); MoCA; 12
SLUMS (Tariq et al., 2006)
Cognitive functioning in specific cognitive domains 4^

Language Token test (Strauss et al., 2006); Narrative Language Test (Carlomagno et al., 2013); BNT-2 (Kaplan et al., 2001); 2
D-KEFS (Delis et al., 2001)
Memory WMS-III Logical Memory (Wechsler, 1997); Digit Span (De Beni et al., 2008) 2
Executive functions and attention TMT (Reitan & Wolfson,1992); D-KEFS (Delis et al., 2001) 1
Praxis WMS-III Visual Reproduction (Wechsler, 1997) 1
Orientation WMS-III Information and Orientation (Wechsler, 1997) 1
Secondary outcomes – people with dementia
Quality of life QoL-AD (Logsdon et al., 1999); Dementia Specific Health Related Quality of Life Measures (Smith et al., 2005); EQ- 9
5D (EuroQol Group, 1990); WHOQOL-BREF (The WHOQOL Group, 1998)
Psychological and behavioral functioning 9
Mood: depression Cornell Scale (Alexopoulos, Abrams, Young, & Shamoian, 1988); Geriatric Depression Scale-15 (Sheikh & 8
Yesavage, 1986); Face Scale (Lorish & Maisiak, 1986; Tabira et al., 2002); Hospital Anxiety and Depression Scale
(Zigmond & Snaith, 1983)
Mood: anxiety RAID (Shankar et al., 1999); Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) 4
Mood: social-emotional loneliness Social and Emotional Loneliness Scale (adapted from De Jong & Van Tilburg, 2006) 1
Behavior CAPE-BRS (Pattie & Gilleard, 1979); NPI (Cummings et al., 1994) 6
Everyday life functioning Alzheimer’s Disease Co-operative Study-Activities of Daily Living Inventory (Galasko et al., 1997); CAPE-BRS 5
(Pattie & Gilleard, 1979); DAD (Gélinas, Gauthier, McIntyre, & Gauthier, 1999)
Communication Holden Communication Scale (Holden & Woods, 1995) 2
Caregiver outcomes 3
General health status GHQ-12 (Goldberg, 1978) 1
Quality of caregiver and patient relationship QCPR (Spruytte et al., 2002) 1
Quality of life WHOQOL-BREF (The WHOQOL Group, 1998) 1
Caregiver burden Relative’s Stress Scale (Greene et al., 1982); Zarit Burden Inventory (Zarit et al., 1980). 2
Mood: depression Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) 1
Mood: anxiety Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) 1
Notes. ^Two studies (Paddick et al., 2017; Spector et al., 2010) assessed CST effectiveness in specific cognitive domains by considering the subscales of the ADAS-Cog. BNT-2 = Boston Naming test-2; CAPE-
BRS = Clifton Assessment Procedures For the Elderly-Behavior Rating Scale; COGNISTAT = Neurobehavioral Cognitive Status Examination; Cornell Scale = Cornel scale of Depression in Dementia;
DAD = Disability Assessment for Dementia; D-KEFS = Delis–Kaplan Executive function system; GDS-15 = Geriatric Depression Scale-15; GHQ-12 = General Health Questionnaire-12; HAD = Hospital Anxiety and
Depression Scale; Holden Scale = Holden Communication Scale; IQR = interquartile range; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; NPI = Neuropsychiatric Inventory;
QCPR = Quality of Caregiver and Patient Relationship; QoL-AD = Quality of Life-Alzheimer’s Disease; RAID = Rating Anxiety in Dementia; SLUMS = Saint Louis University Mental Status Exam; TMT = Trail Making
Test; WMS-III = Wechsler Memory Scale 3rd ed.; WHOQOL-BREF = Brief WHO Quality of Life.

Table 3. Reviewed studies reporting significant versus nonsignificant results, by outcome domain, in people with dementia and family caregivers, and summary of the Jadad Scale and the SPREAD
quality ratings by study
Significant results Nonsignificant results
No. of Study Quality rating No. of studies Study Quality rating
studies
Primary outcomes – people with Jadad SPREAD Jadad SPREAD

dementia
General cognitive functioning 9 Aguirre et al. (2013) Medium 1+, B 3 Cove et al. (2014) High 1 ,D
Apóstolo et al. (2014) High 1+, B Hall et al. (2013) Low 2 ,D
Capotosto et al. (2017) Medium 1+, B Spector et al. (2001) High 1 ,D
Coen et al. (2011) Low 1 ,D
Paddick et al. (2017) High 2+, B
Spector et al. (2003) Medium 1+, B
Stewart et al. (2017) Low 2 ,D
Wong et al. (2017) Low 2 ,D
Yamanaka et al. (2013) High 1+, B
Cognitive functioning in specific

cognitive domains
Language 4 Capotosto et al. (2017) Medium 1+, B
Hall et al. (2013) Low 2 ,D
[ADAS-Cog spoken language subscale]
Spector et al. (2003; 2010) Medium 1+, B
[ADAS-Cog commands and spoken
language subscales]
Memory 2 Hall et al. (2013) Low 2 ,D 1 Capotosto et al. (2017) Medium 1+, B
[memory and learning subscale of the
ADAS-Cog]
Executive functioning and attention 1 Hall et al. (2013) Low 2 ,D
Praxis 1 Paddick et al. (2017) High 2+, B 1 Hall et al. (2013) Low 2 ,D
[praxis subscale of the ADAS-Cog]
Orientation 1 Hall et al. (2013) Low 2 ,D
Secondary outcomes – people with
dementia
Quality of life 6 Aguirre et al. (2013) Medium 1+, B 5 Cove et al. (2014) High 1 ,D
Capotosto et al. (2017) Medium 1+, B Paddick et al. (2017) High 2+, B
[psychological, social,
environmental aspects of
QoL]

13
14
Significant results Nonsignificant results

No. of Study Quality rating No. of studies Study Quality rating
studies
Coen et al. (2011) Low 1 ,D Stewart et al. (2017) Low 2 ,D
Paddick et al. (2017) High 2+, D Wong et al. (2017) [QoL-AD Low 2 ,D
[physical health domain] total score]
Spector et al. (2003) Medium 1+, B Yamanaka et al. (2013) High 1+, B

[but improvements in the
EQ-5D and a trend toward
an improvement in the QoL-
AD rated by proxies]
Wong et al. (2017) Low 2 ,D
[only for the family relationship
item of the QoL-AD]
Psychological and behavioral
functioning
Mood: depression 4 Capotosto et al. (2017) Medium 1+, B 4 Apóstolo et al. (2014) High 1+, B
Spector et al. (2001) High 1 ,D Coen et al. (2011) Low 1 ,D
Stewart et al. (2017) Low 2 ,D Paddick et al. (2017) High 2+, B
Yamanaka et al. (2013) High 1+, B Spector et al. (2003) Medium 1+, B
Mood: anxiety 4 Coen et al. (2011) Low 1 ,D
Spector et al. (2001) High 1 ,D
Mood: social-emotional loneliness 1 Capotosto et al. (2017) Medium 1+, B
Behavior 2 Aguirre et al. (2013) Medium 1+, B 4 Capotosto et al. (2017) Medium 1+, B
Paddick et al. (2017) High 2+, B Coen et al. (2011) Low 1 ,D
[only for severity of depressive
symptoms, nighttime disturbance,
changes in appetite of NPI]
Everyday life functioning 5 Aguirre et al. (2013) Medium 1+, B
Capotosto et al. (2017) Medium 1+, B
Coen et al. (2011) Low 1 ,D
Communication 1 Spector et al. (2003) Medium 1+, B 1 Spector et al. (2001) High 1 ,D

1 ,D
1 ,D
2+, B
2+, B
2+, B
Four studies examined whether CST could lead to gains
Quality rating
in specific cognitive domains (Capotosto et al., 2017; Hall
et al., 2013; Paddick et al., 2017; Spector et al., 2010, which
further examined the results by Spector et al., 2003). In
High
High
High
High
High
Paddick et al. (2017) – a high-quality study (level of evi-
Note. ADAS-Cog = Alzheimer’s Disease Assessment Scale-Cognition; NPI = Neuropsychiatric Inventory; QoL-AD = Quality of Life-Alzheimer’s Disease; EQ-5D = Health-Related Quality of Life.
dence 2+, grade of recommendation B) – and in Spector
et al. (2010) – a medium-quality study (level of evidence
Nonsignificant results
1+, grade of recommendation B) – the focus was on the

Paddick et al. (2017)

Spector et al. (2001)
ADAS-Cog subscales, and benefits were found for the “spo-
Cove et al. (2014)
Study
ken language” subscale. Spector et al. (2010) also found

improvements in the “commands” subscale, while Paddick
et al. (2017) found them in the praxis and memory sub-
scales. As for the other two studies (see Table 2 for
details), one by Hall et al. (2013) was a low-quality study
(level of evidence 2 , grade of recommendation D) that
No. of studies
found 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-
1
1
2
quality study (level of evidence 1+, grade of recommenda-

tion B) that found benefits in language comprehension
1 ,D
2+, B
Quality rating
and production, but not in short-term memory (see

Table 3).
High
High
Secondary Outcomes
Quality of life. Of the nine studies that measured the quality
of life perceived by the participants with dementia, four
studies (Aguirre et al., 2013; Capotosto et al., 2017; Coen
Significant results
et al., 2011; Spector et al., 2003) found significant improve-

ments in this domain. One was a low-quality study (level of
evidence 1 , grade of recommendation D) by Coen et al.
Study

Spector et al. (2001)
(2011), while the other three were rated as medium-quality

(level of evidence 1+, grade of recommendation B) (see
Table 3).
The high-quality study by Paddick et al. (2017) (level of
evidence 2+, grade of recommendation B) found benefits
in 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 ,
studies
No. of
grade of recommendation D) only found benefits in the

family relationship domain, not in the overall quality of
1
life score (see Table 3). Three studies found no improve-

ments in perceived quality of life, including two high-quality
studies, one by Cove et al. (2014) (level of evidence 1 ,
grade of recommendation D), and one by Yamanaka
Quality of the relationship
et al. (2013) (level of evidence 1+, grade of recommenda-

General health status
tion B); and one low-quality study by Stewart et al.

Caregiver outcomes
(2017) (level of evidence 2 , grade of recommendation

Mood: depression
Caregiver burden
D). Yamanaka et al. (2013) did find improvements in care-

Mood: anxiety
Quality of life
givers’ ratings of quality of life in people with dementia,

though these improvements depended on the measure
considered.

Psychological and behavioral functioning. Eight studies medium-quality studies (level of evidence 1+, grade of rec-
measured mood (i.e., depression, anxiety, social and emo- ommendation B) (see Table 3).
tional loneliness) in people with dementia (see Table 3). Communication skills. Of the two studies that measured
Four found a significant reduction in depressive symptoms communication skills, the medium-quality one by Spector
after CST: two were medium-to-high-quality (level of evi- et al. (2003) (level of evidence 1+, grade of recommenda-
dence 1+, grade of recommendation B); one was high-qual- tion B) reported an improvement, albeit with only a trend
ity (level of evidence 1 , grade of recommendation D); one toward significance, while the high-quality study by Spector
was low-quality (level of evidence 2 , grade of recommen- et al. (2001) (level of evidence 1 , grade of recommenda-
dation D) (see Table 3). The other four studies found no tion D) found no such benefit (see Table 3).
such improvement, including two rated as medium-to-
high-quality (level of evidence 1+, grade of recommenda- Caregivers
tion B); one rated as low-quality (level of evidence 1 , Of the three studies that involved caregivers, the high-qual-
grade of recommendation D); and one rated as high-quality ity study by Spector et al. (2001) (level of evidence 1 ,
(level of evidence 2+, grade of recommendation B) (see grade of recommendation D) found improvements in their
Table 3). general health status (albeit with only a trend toward signif-
Four studies (Coen et al., 2011; Paddick et al., 2017; Spec- icance), but not a reduction of their burden of care. Paddick
tor et al., 2001, 2003) measured anxiety, and none found et al. (2017) conducted a high-quality study (level of evi-
CST effective in reducing this symptom. The first two of dence 2+, grade of recommendation B) and found benefits
these studies were one of low-quality and one of high-qual- in caregivers’ anxiety symptoms, but not in their quality of
ity, respectively (both with a level of evidence 1 , grade of life or symptoms of depression, nor any significant reduc-
recommendation D); the one by Spector et al. (2003) was a tion in caregivers’ burden. The high-quality study by Cove
medium-quality study (level of evidence 1+, grade of rec- et al. (2014) (level of evidence 1 , grade of recommenda-
ommendation B); and the one by Paddick et al. (2017) tion D) found no improvements in the quality of the rela-
was a high-quality study (level of evidence 2+, grade of rec- tionship between the caregiver and the person with
ommendation B) (see Table 3). dementia.
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 emotional
loneliness and found that participants reported less per-
ceived social and emotional loneliness after the CST (see
Discussion
Table 3).
Summary of Findings
Six of the 12 studies included behavioral symptoms
among the outcome measures, but only Aguirre et al. The aim of the present review was to assess the quality of
(2013) and Paddick et al. (2017) found CST effective in all the studies published to date on the effectiveness of
reducing behavioral disorders in participants with dementia one of the most often used and evidence-based programs
immediately after completing the intervention. The former of cognitive stimulation: the CST protocol devised by Spec-
of these two studies was of medium-quality (level of evi- tor et al. (2003, 2006). Judging from the quality rating of
dence 1+, grade of recommendation B), and the latter the studies reviewed, there is moderate evidence for the
was of high-quality (level of evidence 2+, grade of recom- CST being effective in improving general cognitive func-
mendation B). Of the other four that found no improve- tioning, and a specific cognitive domain: language. The
ments in behavioral symptoms, two – Capotosto et al. benefits in language seem to be due to the nature of the
(2017) and Spector et al. (2003) – were medium-quality activities and to the general structure of the CST sessions.
studies (level of evidence 1+, grade of recommendation Participants are involved in several activities (e.g., word
B); Coen et al. (2011) was low-quality; and Spector et al. associations, object categorization, and word games)
(2001) was high-quality (both with a level of evidence 1 , designed to stimulate their verbal skills, and broadly to
grade of recommendation D) (see Table 3). encourage them to express themselves verbally, interact
Everyday life functioning. None of the five studies (Aguirre with the other group members (and the facilitator), and find
et al., 2013; Capotosto et al., 2017; Coen et al., 2011; Spector ways to use language creatively (Spector et al., 2003, 2010).
et al., 2001, 2003) that included measures of everyday life These specific features of the CST seem to sustain their lan-
functioning found any improvement in this domain. These guage comprehension and production abilities (Capotosto
studies included one of low-quality (Coen et al., 2011) and et al., 2017; Hall et al., 2013). This result is in line with
one of high-quality (Spector et al., 2001), both with a level the findings from psychosocial interventions, which have
of evidence 1 , grade of recommendation D, and three revealed no major impact on cognition (see McDermott

et al., 2018) due to the degenerative nature of dementia. It heterogeneous in terms of severity, duration, and etiology
is worth adding though, that – just because of the degener- of dementia. The different influence on the efficacy of
ative nature of such a disease – even no change in cognitive CST of these and other individual characteristics of people
performance after the intervention (i.e., no further deterio- with dementia remains to be ascertained (but see Piras
ration 2 months after the pretest assessment) should be et al., 2017).
seen as important, as it suggests that the intervention sus- In addition, although our quality assessment was per-
tains cognitive functioning and helps to contrast the individ- formed following internationally adopted criteria, it was
ual’s cognitive decline. rather broad and did not investigate such factors as poten-
A moderate level of evidence was also found for studies tial sampling and selection biases. Moreover, bearing in
that identified a gain in the quality of life of people with mind that double blinding cannot be done in rehabilitative
dementia, in line with the findings of previous reviews on trials, and that this was one of the assessment criteria, our
cognitive stimulation programs (see McDermott et al., ratings were lower even though the experimental method
2018). was flawless.
The evidence was weaker for the effectiveness of CST in
improving other specific cognitive domains (i.e., memory,
praxis, and orientation), behavioral and psychological func-
Implications for Future Research
tioning (i.e., depression, emotional and social loneliness), or Future research on CST needs to adopt a robust method-
communication skills in people with dementia. The CST ological approach and to ensure an adequate statistical
seemed to have no impact on measures of everyday life power, balanced sampling, clear adherence to the protocol,
functioning or anxiety symptoms, in line with Woods appropriate randomization methods and blindness at the
et al. (2012). These results should be considered with assessment point, and multiple indicators of the same con-
caution, however, as they might be due to the studies inves- struct of interest. The impact of CST on specific cognitive
tigating more specific cognitive domains being underpow- domains, behavioral functioning, and other aspects related
ered and to their use of different measures, as discussed to quality of life – including psychological well-being or
below. Further studies are needed and should use the same social support (e.g., Bowling, 2005) – warrants further
measures more systematically. investigation.
As for caregivers, there was only limited evidence of CST A more thorough understanding, potentially extended
benefiting their general health and anxiety symptoms. This using neuroimaging techniques, of CST’s mechanisms of
would mean that more “direct” interventions are needed to action would also be very useful as it might generate evi-
sustain caregivers in terms of their cognitive and everyday dence of any associated neuronal changes. Cost-effective-
life functioning (e.g., Sörensen, Pinquart, & Duberstein, ness was only formally examined in CST studies
2002). conducted in the UK, and it would be useful to investigate
whether the costs and benefits of the protocol generalize
across cultures. It would also be worth investigating the effi-
Limitations cacy and cost-effectiveness of CST combined with pharma-
Despite the novelty of the present review, it suffers from cological interventions, and the longer-term effects of CST.
the limitation of having included only 12 studies (compris- Given that caring for a person with dementia has an
ing only 8 RCTs and with three pretest–posttest studies that enormous impact on the lives of family caregivers, further
did not include a control condition). The fact that some of research is also warranted on whether and to what extent
the studies only reported changes in general functioning formal or family caregivers might benefit from the CST pro-
scores made it difficult to thoroughly appraise the strength gram in terms of a better quality of life, and less stress. This
of CST effect on specific cognitive domains. There is also a latter aspect has yet to be thoroughly analyzed.
lack of evidence of CST being effective for caregivers, since
only three studies explored this aspect, and the use of dif- Implications for Practice
ferent measures led to inconsistent results.
The small number of studies reviewed and the variety of One of the pressing needs in clinical practice for the treat-
measures used to assess the benefits of CST may be among ment of people with dementia is to be able to use a shared
the reasons for the moderate and low evidence of the CST protocol for cognitive stimulation after diagnosis. In this
program’s efficacy. These factors also prevented us from sense, the CST may be a promising solution.
attempting any meta-analysis to ascertain the dimension Research has shown the benefits of CST in a variety of
of the gains for the CST group. It is worth mentioning that, settings, including hospitals, day centers, and care homes.
although all the studies that we reviewed had adopted strict The method can easily be adapted to other languages and
inclusion/exclusion criteria, the samples involved were different cultures. It has the benefit of being cost-effective,

requiring no specialized medical knowledge or equipment, randomized controlled trial. Journal of Nursing Scholarship, 46,
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Bowling, A. (2005). Ageing well: Quality of life in old age. London,
workers following a simple manual. In some countries (like UK: McGraw-Hill Education.
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brain-damaged adults with communicative deficits. Rivista di
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(2014). Effectiveness of weekly cognitive stimulation therapy
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enhancing cognitive stimulation therapy with a carer training
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of the clinical relevance of CST are needed to corroborate
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therapy as a sustainable intervention for dementia in sub- Oxford University Press.

Tabira, Y., Yasunaga, M., Nagamoto, N., Matsushita, H., Fukunaga, Alessandra Lobbia is psychologist,
Y., Ihara, T., & Kawasuji, M. (2002). Quality of life after 2nd Level Short Specialization’s de-
esophagectomy for cancer: An assessment using the ques- gree in Psychology of Aging at the
tionnaire with the face scale. Surgery Today, 32, 213–219. University of Padova, Italy. She is a
https://doi.org/10.1007/s005950200 member of the CST-IT group and
Tariq, S. H., Tumosa, N., Chibnall, J. T., Perry, H. M., & Morley, collaborates with the Fidenza Alz-
J. E. (2006). Comparison of the Saint Louis University Mental heimer Support Association, Italy.
Status examination and the Mini-Mental State Examination for Her fields of interest include psy-
detecting dementia and mild neurocognitive disorder – A pilot chosocial interventions for people
study. American Journal of Geriatric Psychiatry, 14, 900–910. with dementia, and caregivers sup-
https://doi.org/10.1097/01.JGP.0000221510.33817.86 port; prevention of cognitive impair-
Taulbee, L. R., & Folsom, J. C. (1966). Reality orientation for ment and active aging.
geriatric patients. Hospital and Community Psychiatry, 17, 133–
135. https://doi.org/10.1176/ps.17.5.133
The WHOQOL Group. (1998). Development of the World Health Elena Carbone is PhD student in
Organization WHOQOL-BREF Quality of Life Assessment. Psy- Psychological Sciences at the
chological Medicine, 28, 551–558. University of Padova, Italy. Her re-
Thies, W., & Bleiler, L. (2011). Alzheimer’s disease facts and search interest focuses on age-re-
figures. Alzheimer’s Dementia, 7, 208–244. https://doi.org/ lated differences in cognitive
10.1016/j.jalz.2011.02.004 processes and complex cognitive
Wechsler, D. (1997). Wechsler Memory Scale (3rd ed.). San abilities, cognitive interventions/
Antonio, TX: Psychological Corporation. stimulation programs to sustain old-
*Wong, G. H., Yek, O. P., Zhang, A. Y., Lum, T., & Spector, A. (2017). er adults’ cognitive functioning.
Cultural adaptation of Cognitive Stimulation Therapy (CST) for
Chinese people with dementia: Multicentre pilot study. Inter-
national Journal of Geriatric Psychiatry, 33, 841–848. https:// Silvia Faggian is psychologist at the
doi.org/10.1002/gps.4663 Public Hospital of Dolo, Italy, where
*Woods, B., Aguirre, E., Spector, A. E., & Orrell, M. (2012). she conducts diagnostic assessment
Cognitive stimulation to improve cognitive functioning in people and psychotherapy interventions for
with dementia. The Cochrane Database of Systematic Reviews, young and older adults with acute
15, CD005562. https://doi.org/10.1002/14651858.CD005562.pub2 and chronic moderate-to-severe
*Woods, B., Thorgrimsen, L., Spector, A., Royan, L., & Orrell, M. mental health disorders. She is a
(2006). Improved quality of life and cognitive stimulation member of the CST-IT group. Her
therapy in dementia. Aging and Mental Health, 10, 219–226. fields of interest include neuropsy-
https://doi.org/10.1080/13607860500431652 chological assessment, cognitive
World Health Organization. (2012). Dementia: A public health rehabilitation/stimulation programs,
priority. Retrieved from http://www.who.int/mental_health/ careers distress.
publications/dementia_report_2012/en/
*Yamanaka, K., Kawano, Y., Noguchi, D., Nakaaki, S., Watanabe,
N., Amano, T., & Spector, A. (2013). Effects of cognitive Simona Gardini is research assistant
stimulation therapy – Japanese version (CST-J) for people with at the Department of Medicine,
dementia: A single-blind, controlled clinical trial. Aging and University of Parma, Italy, and col-
Mental Health, 17, 579–586. https://doi.org/10.1080/ laborates with the Fidenza Alzheimer
13607863.2013.777395 Support Association. She is a mem-
Zarit, S. H., Reever, K. E., & Back-Peterson, J. (1980). Relatives of ber of the CST-IT group. Her research
the impaired elderly: Correlates of feelings of burden. The interest includes neuropsychological
Gerontologist, 20, 649–655. https://doi.org/10.1093/geront/ and neuroimaging markers of
20.6.649 dementia; psychosocial interventions
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and for person with dementia; well-being
Depression scale. Acta Psychiatrica Scandinavica, 67, 361–370. and positive psychology.
https://doi.org/10.1111/j.1600-0447.1983.tb09
Federica Piras, Speech Pathologist,
Received May 4, 2017 Psychologist (PhD), is Junior PI at
Revision received May 1, 2018 IRCCS Santa Lucia Foundation, Neu-
Accepted May 10, 2018 ropsychiatry Laboratory, Clinical and
Published online November 19, 2018 Behavioral Neurology Department
(Italy). Her fields of interest include
Erika Borella time perception, temporal predictions
Department of General Psychology and sense of agency in healthy sub-
University of Padova jects and neuropsychiatric samples;
35131 Padova cognitive rehabilitation in psychiatric
Italy samples; neuropsychological and
erika.borella@unipd.it neuroimaging markers of dementia.

Aimee Spector is Professor of Old Erika Borella is Associate Professor

Age Clinical Psychology, University and jointly responsible for the Sec-
College London. Her research fo- ond Level Short Specialization degree
cuses on the development and eval- course in Psychology of Aging at the
uation of psychosocial interventions University of Padova (Italy). She is a
and outcome measures for people member of the CST-IT group. Her
with dementia. She was an original research interest focuses on aging
developer of Cognitive Stimulation and particularly on training/cognitive
Therapy (CST) and has authored over stimulation programs to sustain old-
90 peer-reviewed papers. er adults functioning at cognitive and
emotional levels, age-related differ-
ences in basic cognitive mechanisms
and on complex aspects of cognition.
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Article in European Psychologist · November 2018

Elena Carbone Federica Piras

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Original Articles and Reviews

The Efficacy of Cognitive Stimulation

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

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Records identified through database Additional records identified

Records removed because they were duplicates, not

Full-text articles assessed Full-text articles excluded:

for eligibility - not CST protocol by Spector

Studies for the

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European Psychologist (2018)

European Psychologist (2018)

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European Psychologist (2018)

European Psychologist (2018)

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trict of Kilimanjaro region in

European Psychologist (2018)

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European Psychologist (2018)

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Cognitive functioning in specific

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Significant results Nonsignificant results

European Psychologist (2018)

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1+, grade of recommendation B) – the focus was on the

Paddick et al. (2017)

Paddick et al. (2017)

ken language” subscale. Spector et al. (2010) also found

found improvements in language comprehension and pro-

quality study (level of evidence 1+, grade of recommenda-

and production, but not in short-term memory (see

et al., 2011; Spector et al., 2003) found significant improve-

Paddick et al. (2017)

(2011), while the other three were rated as medium-quality

grade of recommendation D) only found benefits in the

life score (see Table 3). Three studies found no improve-

et 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 recommendation

D). Yamanaka et al. (2013) did find improvements in care-

givers’ ratings of quality of life in people with dementia,

Ó 2018 Hogrefe Publishing European Psychologist (2018)

European Psychologist (2018) Ó 2018 Hogrefe Publishing

Ó 2018 Hogrefe Publishing European Psychologist (2018)

European Psychologist (2018) Ó 2018 Hogrefe Publishing