Cognitive Stimulation Therapy - a new therapy for dementia
Submitting InstitutionUniversity College London
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Cognitive Stimulation Therapy (CST) is an evidence-based, brief, group
therapy for people with mild to moderate dementia. It was developed and
evaluated by UCL in collaboration with Bangor University. Our research
showed significant benefits in cognition and quality of life plus
cost-effectiveness. Cognitive Stimulation for people with mild/moderate
dementia of all types is recommended by NICE and is now in widespread use
across the UK and the rest of the world in a variety of settings including
care homes, hospitals and the community. A recent audit by the Memory
Services National Accreditation Programme reported that 66% of UK memory
clinics surveyed were using CST.
Dementia is a common condition that affects about 800,000 people in the
UK. Our research over the last 15 years has led to the development of an
evidence-based group therapy for people with dementia, which is now in
widespread use across the UK and beyond.
The key underpinning research was a multi-centre, single-blind RCT which
ran between 1998 and 2001. It was led by Professor Martin Orrell (UCL
Mental Health Sciences) and Professor Bob Woods (University of Bangor),
with Dr Aimee Spector being the lead researcher/PhD student (now Senior
Lecturer in Clinical, Educational & Health Psychology at UCL). It aims
to improve cognitive skills and quality of life for people with dementia
through activities such as categorisation, word association and discussion
of current affairs. The `key principles' of CST seem to be the main
mechanisms of change — these include stimulation of language and executive
functioning, encouraging implicit learning and a focus on opinions rather
201 participants were randomised to receive CST over 7 weeks, compared to
a `treatment as usual' control group. There were significant improvements
in cognition and quality of life following CST. The cognitive benefits
were of a similar magnitude to those found using anti-dementia drugs .
An economic analysis conducted in collaboration with partners at the
London School of Economics (LSE) showed CST to be cost-effective .
A pilot study of longer-term CST showed that cognitive function can
continue to improve for a six-month period using weekly CST sessions
following from the initial programme . Subsequent analysis of
the trial data showed that CST benefits memory, language and executive
functioning in dementia, with the most marked impact on language .
A study using complex neuropsychological tests showed significant changes
in verbal memory, non-verbal memory, language comprehension and
orientation . Qualitative interviews with service-users and
staff showed that changes generalised into everyday life such as
improvements in mood and concentration . Our recent Cochrane
review has confirmed the effectiveness of cognitive stimulation approaches
Research into CST has continued at UCL. As part of the NIHR-funded SHIELD
Programme (led by Orrell) a 26-week maintenance CST programme has been
evaluated as an RCT, showing continued benefits in quality of life. The
SHIELD programme is also supporting a trial looking at implementation of
CST in practice, which is currently underway. The individual CST trial
(led by Orrell and supported by the Health Technology Assessment grants
programme), involves the development and evaluation of a one-to-one,
carer-led CST programme and has just completed recruitment.
References to the research
 Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M,
Orrell M. Efficacy of an evidence-based cognitive stimulation therapy
programme for people with dementia: randomised controlled trial. Br J
Psychiatry. 2003 Sep;183:248-54. http://doi.org/b664td
 Knapp M, Thorgrimsen L, Patel A, Spector A, Hallam, A, Woods B,
Orrell M. Cognitive Stimulation Therapy for dementia: is it cost
effective? Br J Psychiatry.2006 Jun;188:574-80. http://doi.org/fcs8qz
 Orrell M, Spector A, Thorgrimsen L, Woods B. A pilot study examining
the effectiveness of maintenance Cognitive Stimulation Therapy (MCST) for
people with dementia. Int J Geriatr Psychiatry. 2005 May;20(5):446-51. http://doi.org/bkrnqb
 Spector A, Orrell M and Woods B. Cognitive Stimulation Therapy (CST):
effects on different areas of cognitive function for people with dementia.
Int J Geriatr Psychiatry. 2010 Dec;25(12):1253-8. http://doi.org/dwwm33
 Hall L, Orrell M, Stott J, Spector A. Cognitive stimulation therapy
(CST): neuropsychological mechanisms of change. Int Psychogeriatr. 2013
 Spector A, Gardner C & Orrell M. The impact of Cognitive
Stimulation Therapy groups on people with dementia: views from
participants, their carers and group facilitators. Aging Ment Health. 2011
 Woods B, Aguirre E, Spector A, Orrell M. Cognitive Stimulation to
improve cognitive functioning in people with dementia. Cochrane Database.
2012 Feb 15;2:CD005562. http://doi.org/cmb9pb
Grants (M Orrell — lead)
1997-9. Developing a psychological therapy package for dementia
(M Orrell, B Woods, H Cayton, S Davies). North Thames NHS Executive
Project Grant, £47,000.
1999-2002. A randomised controlled trial of psychological therapies
in dementia (M Orrell, L Royan). BHB Community Healthcare NHS Trust,
1999-2001. A randomised controlled trial of psychological therapies
in dementia (M Orrell, B Woods, S Davies, A Spector, M Butterworth,
M Knapp). NHS Executive London Region, Responsive Funding, £85,000.
2007-12. Support at Home — Interventions to Enhance Life in Dementia
(SHIELD) (M Orrell, B Woods, I Russell, D Challis, E Moniz-Cook, M
Knapp, G Charlesworth, J Wilson). National Institute of Health Research —
Programme Grant, £1,981,952.
2010-14. Individual Cognitive Stimulation Therapy for dementia (iCST
Trial) (M Orrell, B Woods, I Russell, E Moniz-Cook, M Knapp, A
Spector, A Burns). Health Technology Assessment — Trials Grant,
Details of the impact
CST involves 14 or more sessions of themed activities which aim to
actively stimulate and engage participants, whilst providing an optimal
learning environment and the social benefits of a group. CST can be
administered by any suitably-trained person working with people with
dementia, such as care workers, occupational therapists or nurses. CST
groups take place in settings including residential homes, hospitals and
Dissemination of CST
Following our development of the CST treatment programme, we have
facilitated its dissemination through the publication of three training
manuals [a], and the development of a training programme [b].
Sales of the manuals in 2008-13 amounted to 5,143 copies [c], and
in the same period we trained over 2,000 people. Courses took place across
the UK and in Italy and Spain, including attendees from as far afield as
Australia and South Africa. In 2010 and 2011 we conducted training
workshops at Alzheimer's Disease International conferences in Toronto and
Malaysia, and for the 0/66 international dementia group which organised a
training workshop in Cuba. We also run a CST website (www.cstdementia.com),
which has c.8,000 hits per month.
In 2006, NICE recommended that "people with mild/moderate dementia of all
types should participate in group Cognitive Stimulation which should be
commissioned and provided by a range of health and social care workers
with training and supervision. This should be delivered irrespective of
any anti-dementia drug received by the person with dementia" [d].
CST was the only non-drug intervention recommended to treat cognitive
symptoms of dementia. Our study was referenced as supporting evidence
which underpinned the decision to recommend CST.
Use of CST in the UK
Many people with dementia in the UK and beyond are now benefitting from
CST. It is routinely offered in many NHS trusts — for example, in the Isle
of Wight, our CST protocol has been followed since 2009, with one
practitioner reporting that "CST is the gold standard because the
evidence is that it does produce an improvement in people's memory
scores, and certainly in their quality of life" [e]. The
following NHS Trusts are known to be offering CST as at July 2013:
Berkshire; Birmingham and Solihull; Camden and Islington; Cornwall;
Gloucestershire; Greater Glasgow and Clyde; Isle of Wight; Kent and
Medway; Milton Keynes; Norfolk and Suffolk; North East London;
Northamptonshire; Nottinghamshire; Rotherham, Doncaster and South Humber;
Sussex; South Essex, Tees, Esk and Wear Valley and West London [f].
CST is also used in other settings such as care homes. For example, the
London Borough of Redbridge recently implemented CST in 11 care homes
across the borough [g]. Through use of our manual and training
courses, it is also possible for individuals to set up groups themselves.
In an article in the Mail on Sunday in 2011, one carer gives her account
of setting up a CST group herself, which has now developed into a local
programme [e, h]
The impact on the lives of people who undertake such programmes is
considerable. One patient reported that "I noticed people becoming more
fluent and you could see people trying to express themselves more."
Similarly, the positive impacts are valued by carers. One reported that "There
is no argument that my wife's brighter" and another said "she's
started remembering things since coming to the group" [i].
The carer who set up local groups herself concluded that "I want more
people to have access to CST, which helps people to start living again"
CST is beginning to be recommended more widely in government policy. In
2011, the NHS Institute for Innovations concluded that CST can save the
NHS £54.9 million a year through reduced use of antipsychotic medication [j].
In 2012, the Memory Services National Accreditation Programme (MSNAP) (run
by the Royal College of Psychiatrists) included CST as one of their key
standards for accreditation [k]. They now report that as a result,
CST is used in 66% of memory clinics [l]. Also in 2011, the
National Clinical Director for Dementia for England drew attention to our
Cochrane Review, highlighting the positive benefits of CST and its use in
community, care home and hospital settings [m].
In 2011, the World Alzheimer's Report stated that CST should routinely be
given to people with early stage dementia [n]. It advocates using
CST to provide an effective low cost intervention to help improve
cognition for people with dementia in developing countries. The CST manual
has been translated into several languages including Japanese, Spanish,
Italian, German, Portuguese, Dutch and Swahili. Since 2008 CST is being
used in Australia, USA, South Africa, New Zealand, Germany, Canada, Chile,
Italy, Japan, Nepal, the Philippines, the Netherlands, Tanzania, Brazil,
China, Hong Kong, Indonesia, India, Ireland, Nigeria, Singapore, South
Korea, Turkey and Portugal [o].
Sources to corroborate the impact
[a] CST training manuals (available on request):
- Spector A, Thorgrimsen L, Woods B and Orrell M (2005). Our Time: An
evidence-based programme to offer cognitive stimulation to people with
dementia. Freiberg Press: USA.
- Spector A, Thorgrimsen L, Woods B and Orrell M (2006). Making a
difference: An evidence-based group programme to offer Cognitive
Stimulation therapy (CST) to people with dementia. Hawker Publications:
- Aguirre E, Spector A, Streater A, Hoe J, Woods B and Orrell M (2011).
Making a Difference 2. Hawker Publications: UK.
[c] Publisher's data — copy of emails available on request
[d] National Institute for Health and Clinical Excellence and the Social
Care Institute for Excellence (NICE-SCIE): Dementia: supporting people
with dementia and their carers in health and social care. Clinical
Guideline 42. http://www.nice.org.uk/cg042
[e] The Daily Mail: "A little-known drug-free treatment can have an
amazing effect on Alzheimer's sufferers. So why does a top charity refuse
to endorse it?" (Dec 2011) http://dailym.ai/sprcz9
[f] Full details and links to each trust can be found here: http://www.cstdementia.com/page/cst-in-practice
[g] Email from Research Assistant, North East London Foundation Trust.
Available on request.
[h] Cognitive Help and Therapy (CHAT) — local group set up in Horsham
which now offers programmes across the local area: http://www.cognitivehelpandtherapy.org/index.html
[i] Presentation on CST, Dementia UK networks:
[j] NHS Institute for Innovation and Improvement. An economic evaluation
of alternatives to antipsychotic drugs for individuals living with
dementia. The NHS Institute for Innovation and Improvement, Coventry
House, University of Warwick Campus, Coventry, UK; 2011.
[k] MSNAP standards:
[l] Email from Project Worker, Memory Clinics Audit, MSNAP. Copy
available on request.
[m] National Clinical Director for Dementia for England highlights our
Also discussed on the Dementia News blog:
[n] World Alzheimer report (2011) http://www.alz.co.uk/research/WorldAlzheimerReport2011.pdf