Efficacy Of A Cognitive Stimulation Therapy Programme For People With Dementia

Transcription

1 Efficacy Of A Cognitive Stimulation Therapy Programme For People With Dementia Presenter: Bronagh Flynn Senior OT St James Hospital B. Flynn, E. Rigney, E. O Connor, L. Fitzgerald, C. Murray, C. Dunleavy, M. Mc Donnald, D. Delaney, C. Cunningham, N. Pender, N. Merriman, J. Edgeworth, R.F. Coen. Occupational Therapy Dept, St James s Hospital, Psychology Dept, Beaumont Hospital, Tara Wintrop Private Nursing Home

2 What is Cognitive Stimulation Therapy (CST)? CST is a non-invasive, psychological intervention for those with a cognitive impairment which focuses on the improvement and strengthening of spared cognitive functions and resources as well as on the maintenance of social and interaction skills, with the potential to improve mood and quality of life.

3 Evidence Based CST Programme For People With Dementia - Spector et al 2003, Br Jr Psychiatry! UK Randomised Control Trial (n=201) found that ADAS-cog scores, MMSE scores & QOL improved following a specific set cognitive stimulation programme! Spector et al (2003) study completed randomised control trial which was single-blinded

4 CST Study (Spector et al 2003)! 14 sessions programme ran twice a week for 45mins per sessions in residential homes & day centres! Study measured group intervention programme against usual activities which was described as usually nothing.! Results showed CST improved cognition, QOL, with effects similar to acetyl cholinesterase inhibitors

5 Reasoning and Ethical Approval for Research! Limited studies to date! Replicate study by Spector et al (2003)! Joint study by St. James s O.T. Department with Mercers Institute Research (MIRA) St James Hospital, Beaumont Hospital Psychology Dept and Tara Winthrop Private Nursing Home! Ethical Approval from Adelaide & Meath Children s Hospital & St James s Ethics Committee for St James s & Cherry Orchard Hospital and Beaumont Ethics Committee! Participants selected using inclusion criteria, & written consent from participants and next of kin.

6 Aims of Study! Small scale replication of Spector et al s study (2003) to investigate potential efficacy of CST Current sample much smaller Control condition = standard activities

7 Locations of Participants! St James s Hospital Long Term Care Units! - Cherry Orchard Hospital (LTC)! - Hospital 4 (LTC) - Bru Caoimhin (Rehab Ward)! Tara Winthrop Private Nursing Home through Psychology Dept. Beaumont Hospital with programme run by Tara Winthrop s activity coordinator.

8 Inclusion Criteria for Study A. Mild to moderate cognitive impairment B. Score of in MMSE C. Some ability to communicate and understand communication; a score of 1 or 0 on the BRS-CAPE "#Able to see & hear well enough to participate in the group and make the most of the material in the programme, as determined by researcher $# No major physical illness or disability %# No diagnosis of an intellectual disability

9 ! 1. Physical games! 2. Sound! 3. Childhood! 4. Food! 5. Current Affairs! 6. Faces/Scenes! 7. Word Association CST Programme! 8. Being Creative! 9. Categorising objects! 10. Orientation! 11. Using Money! 12. Number Games! 13. Word Games! 14. Team Quiz Intervention & control individuals also attended other usual activities e.g. bingo, U/L groups, Balance (PT Groups) music, art.

10 Pre and Post Methods of Assessment! Mini-Mental State Examination (MMSE)! Clinical Dementia Rating (CDR, sum of box score)! Rating Anxiety in Dementia (RAID)! Geriatric depression Scale (GDS15 with one inappropriate item omitted, = GDS14 )! Quality of Life in Alzheimer s disease (QoL-AD, participant version)! Behavior Rating Scale (BRS) from the CAPE! Alzheimer s Disease Assessment Scale (ADAS-cog) Test selection based on battery used by Spector et al 03.

11 Description of Assessments MMSE Global screening tool 5 sub-areas to assess Normal, Mild, Moderate & Severe score BRS from CAPE 4 sub-areas Completed by nursing staff by observation. A, B, C, D & E dependency level score GDS-15 with 1 item omitted 14 questions Yes/ No response Triggered emotions RAID 6 sub-areas Completed by participant, leader of group and nurse unable, 0, 1, 2 & 3 score Triggered emotions

12 Description of Assessments QOL-AD 13 questions (1 omitted from original) Poor, Fair, Good, & Excellent response ADAS-Cog Battery of 11 sub-test Index of global cognition Sensitive to change CDR (dementia staging) 6 sub-areas None, questionable, mild, moderate & severe score Completed by assessor Word list recall Commands Name objects / fingers Visuoconstruction Ideational praxis Orientation Recognition Memory Spoken Language Ability Comprehension of spoken language Remembering test instructions Word finding difficulties in spontaneous speech

13 Statistical analysis! Data analysis completed by MIRA using DataDesk! MMSE, CDR(sum of box score), RAID, GDS14, QOL-AD, BRS and ADAS-cog total score were analyzed.! Mann-Whitney U test was used to evaluate statistical significance due to small sample size.

14 Statistical analysis! The pre-intervention scores for both the intervention and control groups were compared.! For both the intervention and control groups, change from pre- to post-intervention was calculated for each variable.!! Between group difference scores were compared.

15 Demographics of Participants! Beaumont - Tara Winthrop Private Nursing Home 5 Intervention participants - 4 male - - mean age = 83.4 (67-98) - - mean pre mmse = Controls - 2 male - mean pre mmse = 13.5 mostly primary level education! St James s & Cherry Orchard 9 intervention participants - 5 male - mean age = 79.1 (70-89) - mean pre mmse = Controls 2 males Mean pre mmse = 19.1 mostly primary level education

16 Results 1 Pre-intervention (mean ± sd) Intervention Group Control Group MMSE 16.7 ± ± 5.1 P=0.66 CDR(sum of box) 10.2 ± ± 2.6 P=0.04 RAID 8.4 ± ± 5.4 P=0.12 GDS ± ± 3.8 P=0.28 QoL-AD 31.6 ± ± 7.2 P=0.48 BRS 15.1 ± ± 5.6 P=0.59 ADAS total 29.0 ± ± 9.3 P=0.55 Controls a little worse on CDR. Groups did not differ besides.

17 Results 2 between group pre to post change Intervention Group change Control Group change Between Gp comparison MMSE 0.8 ± ± 2.5 P=0.013 significant CDR(sum of box) 0.5 ± ± 2.1 P=0.68 RAID -1.1 ± ± 6.4 P=0.27 GDS ± ± 1.9 P=0.29 QoL-AD 3.6 ± ± 4.4 P=0.055, just short of significant BRS 0.0 ± ± 5.4 P=0.45 ADAS total -0.2 ± ± 4.1 P=0.39 Intervention group MMSE improved while control MMSE declined. Intervention group rated QoL as better (p=0.055).

18 Results 3 MMSE: number in each group who increased or decreased on MMSE Intervention Group Control Group MMSE increase n=9 n=2 MMSE decrease n=3 n=9 MMSE no change n=2 * MMSE differences are evident in groups (not just an effect due to a couple of individuals). * 4 controls and 2 intervention participants were on cholinesterase inhibitor.

19 Qualitative Data Results from St James s s & Cherry Orchard Supports statistical data Improvements in areas of - Interest - Communication - Enjoyment - Mood Difference in 1 st session attended & last session of the average scores for all members improved for all of the above areas.

20 Group sessions of CST programme with most! 1) Number Games Engagement! 2) Orientation! 3) Word Games

21 Summary Comparison Between Spector et al and Current Study! Spector et al 2003 Randomised Control Trial! Mild-moderate cognitive impairment & diagnoses of dementia! Large scale study over large number of sites! Results shows improvement in Cognition, QOL, and ADAS-cog scores! Controls usual activity was usually nothing

22 Summary Comparison Between Spector et al and Current Study! Single Blinded Control Trial.! Moderate to severe cognitive impairment! No dementia specific diagnosis! Interventions & controls attended other usual activities e.g. Bingo, Balance (PT groups) SALT, Music, Art! Small numbers in study; still showed significant improvements in cognition (improved MMSE score)! QOL was almost statistically significant, and supported in qualitative data

23 SUMMARY! Significant increases in MMSE Scores post CST Programme (similar to Spector et al, 2003)! Improvements in QOL observed (similar to Woods, 2006)! Further research into measuring QOL in person s with dementia & cognitive impairment (2006, E. Moniz-Cook)! O.T. s involved in study found that standardised assessments may exclude participants who would benefit from programme due to inability to complete outcome measures

24 Limitations of the Study! Small sample size! No change in ADAS-cog assessment! Time/Staff resources! Ability for participants to complete Standardised Assessments leading to exclusion of participants that could benefit

25 Staff Involved in Research! St James s Hospital Dr. R.F Coen - Psychologist MIRA N. Merriman - Occupational Therapy Manager B. Flynn - Senior OT, Cherry Orchard E. Rigney - Senior OT L. Fitzgerald - Basic grade OT E. O Connor - Basic grade OT C. Murray - OTA Dr. C. Cunningham - Consultant! Beaumont Hospital Dr. J. Edgeworth Psychologist C. Dunleavy Tara Winthrop M. Mc Donald Activity Co-ordinator, Tara Winthrop D. Delaney Psychology PHD Student Dr. N. Pender - Psychologist

26 Acknowledgements! Nursing Staff on all the wards involved with the study in facilitation of groups & assistance with screening & completion of objective pre/post Rating Scales.! Families of participants of the study for their interest & support during programme.

27 Questions?

28 References! Acevedo A. & Lowenstein D.A. (2007) Nonpharmacological Cognitive Interventions in Aging and Dementia Journal of Geriatric Psychiatry and Neurology; (20)4, ! Douglas s. James I, & Ballard C (2004) Non-pharmacological interventions in dementia Advances in Psychiatric Treatment; 2004 (10), ! Farinamd E, Mantovani F, Fioravanti R, Pignatti R, Chiavari L, Imbornone E, Ovilotto F, Alberoni M, Marani C & Nemni R (2006) Evaluating two group programmes of cognitive training in mild - to-moderate AD: Is there any difference between a global stimulation and a cognitive-specific one? Aging & Mental Health, May 2006; 10(3): ! Hoe J, Hancock G. Livingston G, & Orrell M. (2006) Quality of life of people with dementia in residential care homes British Journal of Psychiatry 188, ! HIQUA (Aug, 2007); Draft National Quality Standards for Residential Care Settings for Older People A consultation Document ; Aug 2007 Health Information and Quality Authority (AntUdaras Um Fhaisneis agus Cailiocht Slainte.! Leach L (2004) Cognitive Stimulation therapy improves cognition and quality of life in older people with dementia ; Evidence-Based Mental health; 7 (1):19

29 References! Matsuda O. (2007) Cognitive stimulation therapy for Alzheimer s disease: the effect of cognitive stimulation therapy on the progression of mild Alzheimer's disease in patients treated with donepezil; International Pschogeriatrics: 2007:19: ! Moniz-Cook E.(2006). Cognitive stimulation and dementia; Aging & Mental Health, May 2006; 10(3): ! NHS National Institute for Clinical Excellence (NICE) Guidelines & Social Care Institute for Excellence (SCIE) (November 2006) Dementia: Supporting people with dementia and their carers in health and social care: guideline 42 pg 14 Interventions for cognitive symptoms and maintenance of function! Onder G, Zanetti O, Giacobini E, Frisoni G.B, Bartorelli L, Carbone G, Lambertucci P, Silveri M.C & Bernamei R. (2005) Reality orientation therapy combined with cholinesterase inhibitors in Alzheimer s Disease: randomised control trial: British Journal of Psychiatry; 2005(187) ! Orrell M, Spector A, Thorgrimsen L, and Woods B (2005); A Pilot Study examining the effectiveness of maintenance Cognitive Stimulation Therapy (MCST) for people with dementia ; International Journal of Geriatric Psychiatry; (20)

30 References! Spector A, Thorgrimsen L, Woods B, Royan, Davies S, Butterworth M and Orrell M (2003) Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia : randomised control trial; British Journal of Psychiatry (2003), 183, ! Spector A, Orrell M, Davies S and Woods B (2000) Reality Orientation for Dementia: A review of the evidence of effectiveness from randomised controlled trails. The Gerontologist, 40 (2), ! Spector A, Orrell M, Davies S, and Woods (2001) Can Reality orientation be rehabilitate? Development & piloting an evidence-based programme of cognitive based therapies for people with dementia; Neuropsychological Rehabilitation; 11(3/4): ! Spector A. and Orrell M (2006) A Review of the use of cognitive stimulation therapy in dementia management ; British Journal of Neuroscience Nursing; 2 (8):

31 References! Spector A. Thorgrimsen L. Woods B. Orrell M. Making a difference: An evidencebased group programme to offer cognitive stimulation therapy (CST) to people with dementia The manual for group leaders; Pub The Journal for Dementia Care! Woods B, Thorgrimsen L, Spector A, Royan A. & Orrell M(2006) Improved quality of life and cognitive stimulation therapy in dementia Aging & Mental Health 10(3):