RESEARCH ARTICLE

Cognitive stimulation therapy (CST) for people with

dementia—who benefits most?†
E. Aguirre1,4, Z. Hoare2, A. Streater1,4, A. Spector5, B. Woods3, J. Hoe1,4 and M. Orrell1,4
1
Mental Health Sciences Department, University College London, Charles Bell House, 67–73 Riding House Street, London, UK
2
North Wales Organisation for Randomised Trials in Health & Social Care, Institute of Medical & Social Care Research (IMSCaR), Bangor
University, Bangor, Wales, UK
3
DSDC Wales, Bangor University, Bangor, Wales, UK
4
Research & Development Department, North East London NHS Foundation Trust, London, UK
5
Department of Clinical, Educational and Health Psychology, University College London, 1–19 Torrington Place, London, UK
Correspondence to: E. Aguirre, E-mail: e.aguirre@ucl.ac.uk

†
Trial registration number: ISRCTN 26286067

Background: The efficacy of cognitive stimulation therapy (CST) has been demonstrated, but little is
known about the characteristics of people with dementia, which may predict a more positive response
to CST. This study sought to investigate which factors may predict response to CST.
Methods: Two hundred and seventy-two participants with dementia took part in a 7-week CST
intervention. Assessments were carried out pre-treatment and post-treatment. The results were
compared with those of a previous comparable CST randomised control trial. A comparison of mean
scores pre-CST and post-CST groups was undertaken, and contributing factors that predicted change
in outcomes were examined.
Results: CST improved cognition and quality of life, and the results showed that the benefits of CST
were independent of whether people were taking acetylcholinesteraseinhibitor (AChEI) medication. In-
creasing age was associated with cognitive benefits, as was female gender. Care home residents
improved more than community residents on quality of life, but the community sample seemed to
benefit more in relation to behaviour problems.
Conclusions: These results demonstrate that CST improves cognition and quality of life for people with
dementia including those already on AChEIs. Older age and being female were associated with
increased cognitive benefits from the intervention. Consideration should be given to aspects of CST,
which may enhance the benefits for people with dementia who are male and those younger than
80 years. Copyright # 2012 John Wiley & Sons, Ltd.
Key words: dementia; Alzheimer’s disease; cholinesterase inhibitors (AChEIs); cognitive stimulation; cognition; quality of life
History: Received 25 November 2011; Accepted 11 April 2012; Published online in Wiley Online Library
(wileyonlinelibrary.com).
DOI: 10.1002/gps.3823

Introduction address general stimulation of cognitive abilities

Cognitive stimulation has been described as a cognitive-
based non-pharmacological intervention that targets
cognitive and social functioning (Clare et al., 2003).
The intervention is usually undertaken in a group
setting or with the family caregiver (e.g. Onder et al.,
2005), and the activities included in the programme
(Clare and Woods, 2004). A recent Cochrane Review
on cognitive stimulation combined the data from 15
randomised controlled trials (RCTs) showing that
the treatment group significantly benefited in cogni-
tion when compared with those receiving usual care
or an alternative activity (Woods et al., 2012). The re-
view also showed that cognitive stimulation improved

Copyright # 2012 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (2012)

communication, social interaction and quality of life
of people with dementia (Woods et al., 2012).
Recent studies have also explored the combined
effect of cognitive stimulation programmes with or
without acetyl cholinesterase inhibitor (AChEI) treat-
ment (e.g. Chapman et al., 2004; Onder et al., 2005).
Chapman et al. (2004) showed slower rates of decline
in discourse, functional abilities, emotional well-being
and global functioning for those participants receiving
cognitive stimulation and donepezil compared with
those taking donepezil only.
Cognitive stimulation therapy (CST) (Spector et al.,
2003) is a version of cognitive stimulation that was
developed on the basis of theory and evidence from
a Cochrane review of reality orientation (RO) and
subsequently evaluated in a pilot trial (Spector et al.,
2001), followed by a full RCT (Spector et al., 2003).
A cost-effective analysis of CST (Knapp et al., 2006)
showed that CST was cost effective and had benefits
comparable with those of AChEI treatment. This led
to a national recommendation that cognitive stimula-
tion programmes should be generally available for
people with mild to moderate dementia (NICE-SCIE,
2006). However, factors that might impact on the
effectiveness of this intervention are not known. Woods
et al. (2006) found that improvement in quality of life
was associated with being female, lower levels of
depression and improved cognitive function. This study
investigated whether sociodemographic characteristics
and the use of antidementia drugs in people with
dementia predict a positive response to CST.
Method
Participants
Community participants represented 50% of the total
sample and were recruited from day centres, commu-
nity mental health teams and voluntary sector. The
other 50% of the sample was recruited from care homes
in the participating areas London, Essex and Bedfordshire.
This provided a sample broadly representative of the
population and at the same time comparable with the
potential differences in effectiveness between people living
in care homes and community settings. The inclusion
criteria were that participants (1) met DSM-IV criteria
for dementia (American Psychiatric Association, 1994);
(2) scored from 0.5 to 2 on Clinical Dementia Rating
(Hughes et al., 1982); (3) had adequate ability to
communicate/understand to participate in the group;
(4) were able to see and hear well enough to participate
in the group; (5) had no major physical illness or
Copyright # 2012 John Wiley & Sons, Ltd.
E. Aguirre et al.
disability, which could affect their participation; (6)
did not have a learning disability; and (7) were able to
communicate in English.
A total of 18 centres (nine residential and nine
community) were included in the study, and assess-
ments were conducted in the weeks prior to and
following the intervention. Within the 18 centres,
354 participants were screened and 272 (77.1%)
recruited. Participants were randomised into two differ-
ent CST groups per centre (group A or B) with both
groups receiving 7 weeks of CST. The aim of the rando-
misation was to reduce the intra-class correlation coeffi-
cient, increase the variability within the two CST groups
and ensure that any potential change was due to the in-
tervention. The study was approved by the Local NHS
Research Ethics Committee (ref. 08/H0702/68).
Intervention
The CST programme followed that described in the
Spector et al. (2003) study, which has since been
published as a manual (Spector et al., 2006). The
programme consisted of fourteen, 45-min sessions
over 7 weeks. The sessions incorporated the use of an
‘RO board’, displaying both personal and orientation
information, including the group name (as chosen
by participants). The guiding principles of CST were
adopted, which involved using new ideas, thoughts
and associations; using orientation (both sensitively
and implicitly); a focus on opinions rather than facts;
using reminiscence as an aid to the here-and-now;
providing triggers to aid recall; creation of continuity
and consistency between sessions; focus on implicit
(rather than explicit) learning; stimulating language;
stimulating executive functioning; and being person
centred. Each group had one main facilitator, from
the research team and a co-facilitator who was a staff
member from the centre. The use of two facilitators
enabled effective de-briefing and reflection to occur
at the end of each session. Facilitators from the
research team had ongoing clinical supervision by a
clinical psychologist experienced in CST. After each
session, facilitators completed an adherence to treat-
ment form as well as a participant record form in order
to maximise intervention fidelity.
Assessment measures
(a) We measured cognition using the Alzheimer’s
Disease Assessment Scale–Cognitive subscale
(ADAS-Cog) (Rosen et al., 1984) and the mini
mental state examination (MMSE) (Folstein
Int J Geriatr Psychiatry (2012)
CST for people with dementia—who benefits most?
et al., 1975). The ADAS-Cog consists of 11 tasks
assessing memory, language, praxis, attention
and other cognitive abilities. The MMSE is a brief,
widely used screening test of cognitive function.
Both measures have proven good reliability and
validity.
(b) We measured quality of life using the Quality of
Life—Alzheimer’s Disease (QoL-AD) (Logsdon
et al., 2002) and the DEMQOL (Smith et al.,
2005). The QoL-AD covers 13 items encompass-
ing physical and mental health, personal relation-
ships, finance and overall life quality. It has good
internal consistency, validity and reliability. The
DEMQOL has five domains of health, well-being,
cognitive functioning, social relationships and
self-concept and uses self-rated reports of QoL
administered by a trained interviewer.
( c) We assessed behavioural disturbances using the
total score (frequency  severity) of the neuropsy-
chiatric inventory (NPI) (Cummings et al., 1994).
The NPI assesses 10 behaviours commonly occur-
ring in dementia and has good validity and
reliability.
(d) We assessed activities of daily living using the
Alzheimer’s Disease Co-operative Study—Activities
of Daily Living Inventory (ADCS-ADL) (Galasko
et al., 1997) a structured questionnaire, which
assesses functional capacity across the range of
dementia severity. The sensitivity and reliability
have been established.
Proxy reports of the measures were completed by the
members of the staff for the residential sample and
family caregivers for the community sample. When
family caregivers were not available, a care staff member
completed the proxy measures for the participant.
Analysis
Assessments were scored and data were entered into
MACRO, an electronic data capture system that
produces a fully auditable trail for data from input to
extraction for analysis. For cleaning and analysis
purposes, SPSS syntax was written to extract the relevant
data from MACRO. No changes were made to the SPSS
files. The randomisation was stratified according to use
of AChEIs and living situation (living in the community
or in care homes).
The analysis followed a repeated-measures linear
model to allow various variables to be taken into
account. We fitted the model using post score as the
dependent variable with living situation, marital
status, gender and AChEI medication as factors and
Copyright # 2012 John Wiley & Sons, Ltd.
age as a covariate. Complete case data analysis was
used initially to establish the results, followed by the
analysis with imputations. We imputed missing data
using a linear regression model incorporating the
variables included in the repeated-measures model
and the other outcome scores at the relevant time
points. All variables were assessed for normality in
accordance with the assumptions of the tests applied.
Cornell and RAID outcome measures were found to
have non-normal tendencies and transformations were
applied in these cases, and the results assessed with
untransformed data presented as little variation between
the sets were found. This analysis was followed by a
two-sample independent t-test to compare the results
seen in this study group with a well-matched control
group from the Spector et al. (2003) study.
Results
In total, 272 people met the inclusion criteria and 236
(87%) participants were assessed at follow-up. The
reasons for withdrawal included health problems
(15: 41.5%), moving to a different care home (2: 5.5%)
and refusal to continue in the study (18: 53%). Of the
participants who dropped out, 71.4% were women,
64% living in the community and 64% older than
80 years. The average attendance for the CST programme
was 10.3 sessions (range 0–14), and 81% of participants
attended seven or more sessions of the programme.
The mean age was 82.6 (SD 8.1, range 52 to 100), and
177 (61%) were women; 113 (42%) lived in care homes
and 159 (58%) in the community. Participants were
mainly White (245, 90.1%), and nearly half were
widowed (127, 46.7%). All the participants met the
diagnostic criteria for dementia. There were 93 (34.2%)
with Alzheimer’s, 68 (25%) with vascular dementia and
23 (8.5%) with other dementias (Lewy body dementia,
mixed type dementia, Korsakov’s disease), and 88 partici-
pants (29%) had unspecified type dementia. A total of 82
(31%) participants were receiving AChEIs with only 16
(14%) of these in care homes.
Table 1 compares community and care home
participant characteristics in terms of age, sex,
AChEIs and gender. Most of the sample had moder-
ate dementia with a mean MMSE score of 16.7 (SD
5.5) and a mean ADAS-Cog score of 34.4 (SD 13.3).
The community group were less cognitively impaired
at baseline (MMSE 18.9, SD 5.7) and had a higher
mean ADAS-Cog of 30.5 (SD 13.1); this compared with
a mean MMSE of 16.2 (SD 5.1) and ADAS-Cog of 40.6
(SD 11.4) for the care home sample. The total sample
scored in the mid-range on the QoL-AD (mean 36.3,
Int J Geriatr Psychiatry (2012)
 E. Aguirre et al.

Table 1 Baseline characteristics according to living condition
Characteristics Community Residential
Number of 159 113
participants
Number prescribed 67 (42%) 16 (14%)
AChEI
Mean age, SD 81.6 (7.6) 84.7 (8.5)
(range)
Gender ratio, F [%] 96 [60%] 81 [72%]
SD 5.03) and DEMQOL (mean 92.9, SD 11.4). Mean
scores were in the mid-range on the measures of
dependency (ADCL 42.1, SD 17.4) and behavioural
symptoms (NPI 15.1, SD 12.3).
Predictors of change in cognition and quality
of life between baseline and follow-up
A repeated-measures linear model explored the
impact of other variables. We fitted the model using
post score as the dependent variable and age, living
situation (community/care home), gender, marital
status and AChEIs as factors or covariates. In fitting
the models this way, the results showed that age and
gender variables were important factors for the
effectiveness of CST. For MMSE, age was a significant
predictor of effectiveness of CST with older partici-
pants appearing to benefit more. At the mean age of
82 years, there is little difference between the pre and
post score, but participants older than this appear to
benefit more with a possible increase in MMSE score.
For ADAS-Cog, age again is a significant predictor of
the effectiveness of CST with older participants benefiting
more on the MMSE. Gender showed to be a significant
variable in the complete case study analysis and showed
a strong correlation with cognitive improvement,
with female ADAS-Cog scores improving more than
male scores.
Living situation was also shown to be an important
All
variable for some of the staff-completed outcome mea-
sures (Table 2). For the NPI, a decrease in score was
272 seen for the community sample from 18.1 (SE 2.2) to
13.9 (SE 2.2) whereas there was a small increase in
82 (31%)
NPI score for the care home-based participants from
82.6 (8.1) 11.3 (SE 2.4) to 13.4 (SE 2.4). This indicates a potential
benefit for the community sample. For the DEMQOL
177 [61%]
(proxy), both community-based and care home-based
participants saw a mean increase. However, the care
home group increased from 94.2 (SE 3.6) to 100.9
(SE 3.3), which was larger than the community change
from 99.3 (SE 3.4) to 100.2 (SE 3.2). In fact, this can be
seen as the community sample remaining steady
whereas the care home sample have been brought into
alignment with what was observed in the community.
In summary, we have identified benefits for the com-
munity sample on NPI scores, and there is a benefit
for care home sample for the proxy DEMQoL.
Change when comparing the results with
those of a similar control group
Independent sample t-tests were used to compare the
complete case dataset results with the Spector study
control group (Spector et al., 2003) who had used the
same inclusion criteria and so formed a comparable
sample. The Spector study sample had a mean age of
84.7 years and a 3:1 female : male ratio. For the ADAS-
Cog, the Spector control group showed a mean reduction
of 0.3 whereas the CST group showed a mean reduction
of 2.7, a mean difference of 2.4 (t = 2.27, df = 240,
p = 0.024) with confidence intervals of 0.33 to 4.51. For
the MMSE, the Spector control group reduced by an
average of 0.4 points, whereas the CST group saw a mean
increase of 0.9 points, so there was a mean difference of
1.3 points (t = 2.76, df = 293, p = 0.006) with a confidence
interval of 0.38 to 2.22 (Table 3). At follow-up, the CST
group had demonstrated significantly better results on

Table 2 Differences before and after CST (people with dementia completed measures)

Measure Estimated marginal mean Estimated marginal mean F value p value Other variable significant
before CST (SE) after CST (SE) in the model

MMSE 15.8 (0.99) 18.5 (0.89) 20.7 <0.001 Age F = 5.5, p = 0.019
ADAS-Cog 35.0 (2.0) 30.6 (2.3) 16.8 <0.001 Age F = 12.5, p < 0.001
QoL-AD 35.7 (0.9) 36.3 (0.9) 0.001 0.97 None
DEMQoL 93.4 (2.0) 92.4 (1.9) 8.38 0.004 None
ADCS-DL 44.0 (2.8) 44.6 (2.8) 0.24 0.32 Age F = 8.64, p = 0.004
NPI 14.7 (2.2) 13.6 (2.2) 4.11 0.044 Type F = 6.25, p = 0.013
Proxy QoL-AD 33.3 (1.0) 32.8 (1.0) 2.91 0.089 None
Proxy DEMQOL 96.7 (3.4) 100.6 (3.2) 27.24 <0.001 Type F = 8.39, p = 0.004

Statistics are given for the repeated-measures models.

Copyright # 2012 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry (2012)
CST for people with dementia—who benefits most?
Table 3 Meta-analysis comparison of mean change in CST groups versus control group of the Spector et al. (2003) study
Measure Spector et al. (2003) control
Mean change (SD) [N]
MMSE 0.4 (3.5) [70]
ADAS-Cog 0.3 (5.5) [70]
QoL-AD 0.8 (5.6) [70]
both MMSE and ADAS-Cog than the Spector et al.
(2003) control group. There was no difference between
the CST group and the Spector et al. (2003) control
group on the QoL-AD.
Discussion
The benefits of cognitive stimulation on cognitive
function are now well documented (Woods et al.,
2012; Orrell et al., 2012), and the results of this study
provide additional evidence for the effectiveness of
the programme developed by Spector et al. (2003).
The study showed that CST has cognitive benefit for
people with dementia evident in comparisons of
change scores and in comparisons with the changes
shown by the control group from the previous trial.
Unlike the Spector et al. (2003) study and the recent
Cochrane Review (Woods et al., 2012), this study
found a positive change in behaviour following the
CST intervention as did the first Cochrane review on
RO (Spector et al., 2000). There was also a significant
improvement in quality of life as measured by the
DEMQOL but not on the QoL-AD. Previous studies
have identified the need for quality of life measures
in dementia that are able to detect any changes in
quality of life in response to both interventions and
the progression of the disease (Hoe et al., 2009), so that
they can be used to establish the benefits of treatment
for people with dementia. This analysis suggests the
two measures may be measuring different aspects of
quality of life. These findings need to be explored
further in future trials.
Who benefits most?
The benefits of CST were found to be independent of
the use of AChEIs, and this is in line with the Cochrane
review findings and other studies (Woods et al., 2012;
Chapman et al., 2004; Onder et al., 2005; Bottino
et al., 2005) that suggest that cognitive stimulation
Copyright # 2012 John Wiley & Sons, Ltd.
Current study Values
Mean change (SD) [N]
0.93 (3.3) [225] t = 2.76
p = 0.006
2.72 (8.3) [172] t = 2.26
p = 0.024
0.08 (4.9) [225] t = 0.92
p = 0.357
is effective irrespective of whether AChEIs are pre-
scribed, and any effects of the intervention are
additional to those associated with the medication
(Woods et al., 2012).
The greater effect for the very old people in this
study (older than 80 years) is an unexpected finding.
It may suggest that these older participants are experi-
encing more excess disability, showing impairment
beyond that resulting directly from the dementia. It
may be that they receive less stimulation in general
than the less old participants and so benefit more from
the intervention. When designing cognitive-based
interventions for dementia, it’s important to be aware
of the cognitive changes that occur with age even
without a dementia diagnosis. It might be that the
design of cognitive-based interventions for dementia
needs to take this variable into account, so that the
activities match the cognitive requirements of the
participants and one aspect might be the differences
found between ‘fluid’ abilities (novel problem solving)
and ‘crystallised’ abilities (existing ‘world knowledge’).
Research evidence suggests that crystallised abilities
follow a markedly slower trajectory of decline in very
old adults (specially older than 80 years) (Backman,
Small, Wahlin & Larsson, 2000). It might be that
CST programmes for very old adults might benefit
more from the use of reminiscence strategies as an aid
to orientation to the here-and-now (using crystallised
abilities) and less of activities designed to use their
fluid intelligence focusing on stimulation of the
senses and cognitive exercises.
In the complete case analysis, greater improvements
in cognition were associated with female gender
(F = 5.1, p = 0.025). The female : male ratio for this
study was 4:1, with the result that the average group
contained two men out of seven participants. Men
might be more reluctant to communicate as they are
usually in the minority in most groups with women
generally outnumbering men in the groups (Spector
et al., 2003; Woods et al., 2006). It may be that the gen-
der majority dictates the style in which the groups are
Int J Geriatr Psychiatry (2012)

run; for example, more ‘talking’ in female-dominated
groups and more ‘doing’ in male-dominated groups.
However, experience from one all-male group from this
study suggested that the dynamics of the group were
completely different, the group appeared to be less
conversational, not as free flowing, and there was less
interaction between group members. Further work is
needed in order to explore these gender differences in
response to CST and to develop interventions more
geared towards the preferences of men.
Finally, in relation to the differences we found
between those living in the community and those
living in care homes, it needs to be mentioned that
these differences arise from measures completed by
different proxies such as a family member in the
community or a member of staff in the care home.
For example, the community sample was associated
with an improvement in behavioural outcomes that
might be affected by the fact that family carers ratings
are influenced by their level of strain, whereas residen-
tial participants had greater improvements in quality
of life, which might be associated with how increased
hope in staff is linked with improved quality of life
(Spector et al., 2006). Further work is needed to
explore these differences in perspectives.
Limitations
This research study was part of a larger trial of CST
compared with maintenance CST (Aguirre et al., 2010).
The CST intervention was the first stage of the trial and
was given to all the participants who were randomised
after the CST treatment phase to receive either mainte-
nance CST or treatment as usual. Therefore, as part of
the inclusion criteria for the full-scale RCT, participants
with severe dementia, severe mental or physical illness,
significant hearing or visual problems and learning dis-
abilities were excluded. These exclusions are made on
pragmatic grounds to ensure that effective groups can be
run, but this may limit the generalisability of the findings.
It could be useful to know whether people with a
particular type of dementia benefit more or less than
other types of dementia; however, the sample of our
study did not allow this exploration as nearly a third
of the participants had an unspecified dementia.
Conclusion
The results provide further evidence that CST benefits
cognition and quality of life for people with dementia
and is potentially more beneficial for women and
people older than 80 years. Results suggest that the
Copyright # 2012 John Wiley & Sons, Ltd.
E. Aguirre et al.
CST approach, which follows the principles of
person-centred care (Kitwood and Bredin, 1991)
and has been defined as being grounded in a strong
value base of respecting individuality and personhood
(Woods et al., 2006; Woods, 2002), has the potential
for improving cognition and well-being in many people
with dementia in addition to any potential benefits
from antidementia medication. Future research and
practice need to investigate the use of CST delivered
by family carers and for other cultural and ethnic
minority groups.
Conflict of interest
Aimee Spector runs the CST training course on a com-
mercial basis.
Key points
• CST improves cognition and quality of life for
people with dementia including those already on
antidementia medication. - Older age and being
female are associated with increased cognitive
benefits from CST intervention.
• Future studies should evaluate which aspects of
CST may enhance the benefits for people with
dementia who are male and those under 80 year
old.
Acknowledgements
Maintenance Cognitive Stimulation Programme
(ISRCTN26286067) is part of the Support at Home—
Interventions to Enhance Life in Dementia (SHIELD)
project (Application No. RP-PG-0606-1083) awarded
to Prof. Orrell (UCL/NELFT), based in North East
London Foundation Trust, and funded by the NIHR
Programme Grants for Applied Research funding
scheme. Other grant holders include Woods (Bangor),
Challis (Manchester), Moniz-Cook (Hull), Russell
(Swansea), Knapp (LSE) and Dr Charlesworth (UCL).
This report/article presents independent research
commissioned by the National Institute for Health
Research (NIHR) under its Programme Grants for
Applied Research scheme (RP-PG-060-1083). The views
expressed in this publication are those of the authors and
not necessarily those of the NHS, the NIHR or the
Department of Health.
Int J Geriatr Psychiatry (2012)
CST for people with dementia—who benefits most?
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