Aging & Mental Health, May 2006; 10(3): 207–210
EDITORIAL
Cognitive stimulation and dementia
E. MONIZ-COOK
Department of Clinical Psychology, Post Graduate Medical Institute, Hertford Building, University of Hull, Hull, UK
The ageing society has stimulated interest in the
‘use it or lose it’ approach to memory decline, where
aspects of lifestyle such as mental activity (Wilson
et al., 2002) or exercise (Larson et al., 2006) are
thought to act as protective factors in delaying the
onset of dementia. The current drive towards early
detection and diagnosis in many western health care
systems has precipitated a parallel interest in
psychological treatments for dementia, since many
people and families often want to know what
they should do about memory difficulties, following
a diagnosis of dementia. Some governments have
reflected this public interest in their policies—for
example, in the UK, the National Service Framework
for Older People, recommends that ‘mental exercise’ is
offered (Department of Health [DoH], 2001, p. 98).
There is confusion about what ‘mental exercise’
as a treatment for dementia might mean. Cognitive
stimulation (Breuil et al., 1994; Woods et al., this
issue) or its precursor, reality orientation (Woods,
2001), is one type of mental ‘therapy’ for dementia
but other approaches such as memory training
(Zarit, S. H., Zarit, J. M., & Reever, 1982),
memory rehabilitation (Clare 1999; De Vreese,
Neri, Fioravanti, Belloi, & Zanetti, 2001), pro-
cedural memory stimulation (Zanetti et al.,
1995), cognitive rehabilitation (Clare & Woods,
2001), cognitive training (Hofmann, Hock,
Kuhler, & Muller-Spahn, 1996), psychosocial
rehabilitation (Bird, 2000) and memory stimulation
(Grandmaison & Simard, 2003) can also be found in
the literature on interventions that target cognition
in people with dementia. These wide ranging
terminologies and definitions can give rise to
misunderstandings in the practice of cognition-
focussed treatment in dementia. This is seen for
example, in a recent national guideline for the
management of dementia (Scottish Intercollegiate
Guidelines network [SIGN], 2006), where cognitive
stimulation describing home-based individual
cognitive training carried out with minimal training
by families is recommended (SIGN, 2006, p. 8).
Correspondence: Professor Esme Moniz-Cook, PhD, Clinical Psychology & Ageing, Post Graduate Medical Institute,
Hertford Building, University of Hull, Hull, UK. E-mail: E.D.Moniz-cook@hull.ac.uk
ISSN 1360-7863 print/ISSN 1364-6915 online ß 2006 Taylor & Francis
DOI: 10.1080/13607860600725268
This guideline further suggests that individual
24-hour reality orientation therapy applied by skilled
therapists is better than group classroom reality
orientation (SIGN, 2006, p. 11), that is usually
applied by staff in care settings, but it overlooks
the developing evidence base for group reality
orientation therapy or group cognitive stimulation
(Breuil et al., 1994; Holden & Woods, 1995;
Spector, Davies, Woods, & Orrell, 2001; Spector
et al., 2003). Provision of individually tailored
home-based programmes involving both the person
with dementia and the family caregiver reflects the
zeitgeist of dementia care practice (Vernooij-Dassen
& Moniz–Cook, 2005), but this does not have to
imply that there is no place for group intervention
within a given set of circumstances, for some
people with dementia. The paper by Woods and
his colleagues (this issue) describes the effect of
a group cognitive stimulation programme on quality
of life. Given the aforementioned problems with
terminology, definitions and practice, we will now
turn to the context of group cognitive stimulation by
examining its history and development as a psycho-
social intervention for dementia.
Cognitive stimulation: Connecting the past to
the present
Mental activity as a psychological ‘therapy’ for
dementia has a long history, dating to the
development of reality orientation (RO), where
Taulbee and Folsom (1966) noticed that it allowed
a change from hopelessness to hopefulness for some
people with dementia. It also appeared to provide
hope for care staff, with reports of improved morale
(Merchant & Saxby, 1981; Powell-Proctor & Millar,
1982), perhaps because it helped combat the
hopelessness and therapeutic nihilism that was at
the time associated with dementia (Holden, 1987).
Reality orientation was a method of presenting
information that reoriented people with dementia
208 E. Moniz-Cook
throughout the day (i.e., 24-hour RO) including
developing a ‘prosthetic’ environment, but its more
common use in research and practice remained
within group ‘classroom’ sessions (Holden &
Woods, 1995). By the 1980s, concerns about its
potential to become an insensitive experience for
people with dementia (Dietch, Hewett, & Jones,
1989; Gubrium & Ksander, 1975), resulted in a fall
in its popularity, with exceptions in some countries
such as in Italy, where group reality orientation
therapy (ROT) continues to be embraced
(Zanetti et al., 1995; 2002). By the turn of the
century a systematic review of classroom RO
(Spector et al., 2000) reported positive effects on
cognition and in some cases, behaviour, in people
with dementia. The most influential study at the
time (Breuil et al., 1994) described a ‘cognitive
stimulation’ group and it also became clear that the
content of groups were not all the same (see review
by Spector, Orrell, Davies, & Woods, 2001). Many
RO groups included aspects of reminiscence or other
stimulating activity and there were culture-specific
differences in application across some countries
(Holden & Woods, 1995). What followed was the
development of a global Cognitive Stimulation
Therapy (CST) group programme lasting seven
weeks (Spector et al., 2001), for people in
care settings, a randomised controlled trial which
demonstrated short-term positive outcomes on both
cognition and quality of life (Spector et al., 2003)
and persuasive arguments for the redefinition of RO
as ‘cognitive stimulation’ (Woods, 2002).
This issue contains two papers on cognition-
orientated group interventions for people
with dementia. One study evaluates the CST
programme (Woods et al., this issue), whilst the
other compares global cognitive stimulation training
and cognitive—specific cognitive training (Farina
et al., this issue). The problem with definition and
terminology described previously has been recently
addressed by Clare and Woods (2004), who outline
a conceptual basis for classifying the range of
cognition-focussed interventions into three broad
but distinct categories, which they describe as
cognitive stimulation, cognitive training and cogni-
tive rehabilitation. Within this framework, cognitive
stimulation therapy (Woods et al., this issue) and
global cognitive stimulation training (Farina et al.,
this issue) may be seen as ‘cognitive stimulation’
interventions, since both target global cognitive
functions which are interrelated and therefore
cannot be treated in isolation. In contrast, the
cognitive-specific training group, described by
Farina and her colleagues, is an example of cognitive
training, since it involves repeated practice on
specific tasks such as analogues of activities of daily
living (washing hands, laying tables making tea) or
paper exercises for enhancing attention, short–term
memory language, visuo-spatial abilities and cate-
gorization. This type of repeated practice or
‘exercise’ runs the risk of undermining the person’s
sense of competence and the finding that global
cognitive stimulation in the form of group recrea-
tional activity has better outcomes for both person
and family (Farina et al., this issue), is therefore
reassuring.
A cognition-orientated intervention that achieves
improvements on measures of cognition may not
have any practical effect on the everyday situations
that people with dementia and their families might
face (Bird, 2000). Therefore, in addition to cogni-
tion other outcomes such as emotion and behaviour
(Woods, 2001), the impact on family caregivers
(Richards, Duggan, Carr, Wang & Moniz-Cook,
2003) and the relationship between the person and
their family caregiver (Charlesworth, 2001), are
also now seen as important outcomes for research
on the cognitive management of dementia. For
example, studies of memory training have reported
positive changes in the person’s memory perfor-
mance, but a negative effect on family caregiver
mood (Zarit et al., 1982), or positive outcomes for
cognition with no negative effect on caregiver mood
(Onder et al., 2005) or improvements in memory
with initial family distress, followed by positive
outcome in mood and family burden a year later
(Moniz-Cook, Agar, Gibson, Win, & Wang, 1998).
The papers on cognition-orientated group interven-
tions for people with dementia in this issue cannot be
criticised for ignoring real life situations for people
and families, since they specifically measure the
effects on quality of life of people with dementia
(Woods et al., this issue), their mood, behaviour and
their family’s burden (Farina et al., this issue).
However teasing out the important components of
a group cognition-orientated programme is not easy,
since a benefit of group work is the opportunity for
social interaction. For people with dementia who
engage in cognitive management groups, social
interaction can act as one of the ‘active ingredients’
(Bird, 2000) that contribute to positive outcomes
on mood and quality of life. The study from Italy by
Farina and her colleagues is disappointing in its
failure to measure the quality of life of patients since
it is not possible to use its findings to further evaluate
the contribution of social interaction as a component
of global cognitive stimulation therapy on positive
quality of life outcomes (Spector et al., 2003; Woods
et al., this issue). The study by Woods and his
colleagues did not include a placebo social activity or
passive recreational group. Pleasurable activity
and social interaction may have contributed to the
positive quality of life outcomes, since patients
reported improvements in their relationships as
well as in their memory function, energy and in
managing everyday chores, following cognitive
stimulation therapy (Woods et al., this issue).
In the Italian study, improved trends on measures
of behaviour for both cognitive stimulation and
cognitive training groups were, according to the

authors, associated with non-specific psychological
support and socialisation. An in-home programme,
where family caregivers delivered cognitive training,
also reported positive outcomes on cognition and
interaction against a control group, but positive gains
were also seen in a placebo condition of passive
social activity (Quayhagen, M. P., Quayhagen, M.,
Corbeil, Roth, & Rodgers, 1995; 1996). Knowing
the precise contribution of cognition and social
interaction to the positive reported outcomes of
cognitive stimulation may well be an interesting
pursuit for researchers (see Clare and Woods, 2004,
p. 387), but given that many care staff struggle to
find positive pleasurable activity for people with
dementia, CST, like its precursor ‘classroom’ RO
may well become one way of providing mental
exercise and pleasant social activity in care home
settings.
If group reality orientation is conceptually the
same as cognitive stimulation (Clare & Woods,
2004), is there a place for other forms of RO, that
are not based on group activity, within the range of
cognition-focussed intervention in dementia? A
recent randomised trial from Italy, used an adapted
24-hour in-home version of RO, where families were
taught to apply ROT, which essentially stimulated
global cognition by using graded guided practice in
a range of cognitive tasks (Onder et al., 2005).
Whilst this programme enhanced the effects of
donezepil on cognitive function, there were few
equivalent outcomes on social functioning. In con-
trast, home-based cognitive training for everyday
problems using families to carry out the programmes
has shown promise for cognition, spousal
communication, and interaction outcomes (see
Quayhagen et al., 1995; 1996). Again, these positive
outcomes may be strongly influenced by social
engagement in meaningful activity with a caregiver
(Bird, 2000).
What type of mental activity is needed to
achieve the outcomes described in the studies
reported in this issue, or in related systematic reviews
(see Clare, Woods, Moniz-Cook, Orrell, &
Spector, 2003; Spector et al., 1998)? Clearly
cognitive training in the form of mechanistic
repeated paper and pencil ‘exercise’ continues
to lack credibility, whilst a meaningful and pleasur-
able programme content remains important.
The framework provided by Clare and Woods
(2004) for the range of cognition-orientated psycho-
social interventions in dementia is a step towards
clarification of concepts, content and practice and
has the potential to bridge the gap between
research and practice. Cognitive stimulation in the
twenty-first century reflects a modernisation of
reality orientation, where cognition-focussed
programmes are set in a social context and aim to
enhance cognitive and social function in people with
dementia. Even in countries where the traditional
name has been retained, it is fair to note that the
Cognitive stimulation and dementia 209
content is similar (see for example Zanetti et al.,
2002). Traditional RO group therapy may have
found new avenues for application in early
stage dementia, within ongoing in-home individual
programmes provided by family caregivers, in
conjunction with an acetylcholinesterase inhibitor
(Onder et al., 2005). However this type of individual
24-hour in-home RO needs to show its efficacy on
quality of life measures for people with dementia.
The relative merits of 24-hour cognitive stimulation,
cognitive training and cognitive rehabilitation also
require further investigation.
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